She brought a list. Three pages, handwritten in blue ink, folded into the back of the spiral notebook she carried to every appointment. The list included her current medications — lisinopril, metformin, sertraline, naproxen as needed — her qualifying condition, her questions about drug interactions, and a sentence she had practiced in the car: “I want to talk about whether cannabis might be appropriate for my situation.” The physician had fourteen minutes. He spent two of them reading her list. He spent eleven of them having the most productive clinical conversation she could remember.
The woman was fifty-eight, a school administrator from West Fargo, and she was not unusual in her preparation — she was unusual in that she had prepared at all. Most patients walking into a conversation about medical cannabis bring their anxiety and their hope. Few bring the clinical details that transform a tentative discussion into a useful one.
This is what to bring, what to say, and what to do when the conversation does not go the way you expected.
Start with your medication list. Not “I take a blood pressure pill” — the name, the dose, how long you've been on it. Cannabis interacts with the cytochrome P450 enzyme system, the same metabolic pathway that processes a significant number of common pharmaceuticals. A 2020 review by Nasrin and colleagues at Washington State University, published in Clinical Pharmacology & Therapeutics, identified THC and CBD as inhibitors of CYP3A4 and CYP2C19, enzymes involved in metabolizing drugs including certain blood thinners, anti-epileptics, and immunosuppressants. Your physician needs to evaluate these potential interactions before certifying you — but only if they know what you take.
Sertraline, the SSRI the woman from West Fargo had been on for three years, was relevant. CBD can increase serum levels of certain SSRIs by slowing their metabolism. The interaction is not dangerous for most patients at low cannabis doses, but it is worth monitoring, and it is worth knowing about before you start rather than after you notice increased side effects and cannot identify the cause.
Disclose your full history, not your curated one. Patients often omit details they consider embarrassing or irrelevant — a history of substance use disorder, a prior psychiatric hospitalization, a family history of psychosis. These are not reasons a provider will refuse certification. They are reasons a provider might recommend a different cannabinoid ratio, a lower starting dose, or additional monitoring. A 2019 position statement from the Canadian Psychiatric Association, published in The Canadian Journal of Psychiatry, noted that patients with a personal or family history of psychotic disorders face elevated risk from high-THC cannabis and should be counseled accordingly. Your physician can only counsel you on risks they know about.
Ask about your qualifying condition specifically. North Dakota's medical cannabis program requires a qualifying condition — the list includes PTSD, chronic pain, cancer, epilepsy, Crohn's disease, and others. But having a qualifying condition does not mean cannabis is equally supported by evidence for every condition on that list. The evidence base for cancer-related nausea, for instance, is decades deep. The evidence for some other conditions is thinner. Asking your provider “What does the evidence look like for my specific condition?” is not a challenge — it is a collaboration.
Know what “certification” means in North Dakota. Your provider is not writing a prescription. They are issuing a written certification that you have a qualifying condition and that, in their clinical judgment, you might benefit from medical cannabis. The certification goes to the North Dakota Department of Health and Human Services, which processes your application and issues a registry card. Your provider does not choose your product, your dose, or your method of consumption. That conversation happens at the dispensary, and the gap between those two conversations is one that patients frequently find disorienting.
If your provider says no — or says nothing useful — you have options. Some physicians in North Dakota remain uncomfortable with cannabis certification, whether due to insufficient training, institutional restrictions, or personal reservations. A 2021 survey by Philpot and colleagues at the University of North Dakota found that while most physicians acknowledged cannabis had therapeutic potential, a significant number felt unprepared to discuss it clinically. If your provider declines, ask why. If the reason is policy rather than medicine, seek a provider who certifies cannabis patients. This is not doctor-shopping. It is navigating a healthcare system that has not yet caught up with the law it operates under.
The woman in West Fargo left her appointment with a certification, a follow-up in six weeks, and a shorter list than the one she'd walked in with. Most of her questions had been answered. The ones that remained were the kind that only experience could address — and she knew, at least, what to watch for.
The list was the easy part. The harder part was deciding that her questions deserved fourteen minutes of a physician's time.
They did.