Health care providers have been slow to embrace the medical marijuana industry even though July 15 was the legal opening date for the state’s first dispensaries.

The number of doctors certifying medical cannabis patients only climbed slightly over the past six months. There were 88 physicians who certified 14,492 patients as of June 30, up from 79 doctors and 13,150 patients on Dec. 31, according to the state Health Department.

Despite a nationwide push to legalize pot, Hawaii doctors are still reluctant to join the movement, said Dr. Chris Flanders, executive director of the Hawaii Medical Association, representing 1,100 physicians.

“According to the federal government, it’s illegal. For years we were threatened with the possibility of losing Medicare privileges for recommending or certifying medical marijuana patients,” he said. “The possibility always existed that a federal agency could come into your office and prosecute a physician criminally for activities related to the use of marijuana. Although they never really did that, a lot of the physicians feel like it’s not worth the risk.”

The U.S. Drug Enforcement Administration lists marijuana as one of the most dangerous drugs, along with heroin, with a high potential for abuse, though there has been a major push to change that as more states legalize the drug.

Persuading more physicians to buy into the medical marijuana program also is difficult because of a lack of research to prove the efficacy of cannabis treatment, said HMA President Dr. Scott McCaffrey.

“The majority of doctors are viewing this cautiously. We don’t have enough good clinical research and more needs to be done,” he said. “There’s hesitation because there’s just not enough clinical research and we don’t know what we’re recommending in terms of potency and purity of cannabis when it’s bought illegally on the streets. For those reasons doctors are holding back.”

Hawaii legalized medical marijuana 16 years ago, but patients did not have a legal way to obtain the drug. Act 241, passed in 2015, allowed the state to issue eight licenses for a total of 16 medical marijuana dispensaries statewide. The law allowed dispensaries to open July 15, but licensees have said they will not be ready to open until late this year or early next year.

“Doctors are waiting until dispensaries are really established before they will be comfortable writing more certifications for medical marijuana use,” McCaffrey added. “There is considerable interest in this area from a lot of doctors, but I think they’ve taken a wait-and-see stance until dispensaries actually come into being. Once the dispensaries are open, there will at least be some level of quality control on medical cannabis and … I believe doctors will be more comfortable on coaching and advising their patients on this matter.”

Dr. Scott Miscovich, a primary care doctor who certifies medical marijuana patients, said educating physicians and patients is crucial to legitimizing the industry.

“The hesitation is pure education. Doctors are still fearful to certify patients. They’re not prescribing or putting their Medicare license or federal DEA license at risk. It’s kind of an urban myth,” he said. “We are not telling them what to buy or how much to use. It’s a big confusion that doctors don’t understand. To a lot of people it’s taboo to even ask their patients if they’re using medical marijuana.”

Gov. David Ige signed a bill into law earlier this month that allows nurses to certify patients for medicinal marijuana, a move advocates say is necessary because of a shortage of doctors willing to join the program.

Change is difficult in the constantly evolving health care community, so it may take awhile for providers to become comfortable with marijuana as medicine, Flanders said.

“The majority are going to wait and see what happens. And make sure it’s safe, easy and doesn’t cause problems for their practice,” he said. “We see that with a lot of different things: new technology, new procedural issues, new policy issues. A lot of physicians, they’ll wait and see how new things work out for the people that are using them before they start using those technologies or those procedures. They’re a conservative bunch. They want to keep the risks as low as possible.”