Politics

In an article published in the August 9, 2016 edition of JAMA, Dr. Humayun Chaudry, chief executive officer of the FSMB, describes the guidelines “as a reasonable effort to offer best practices for clinicians to follow when considering marijuana in patient care” (10,11). In general, the guidelines encourage healthcare providers to employ the same professional practices they employ when prescribing an FDA-approved medication, but with a few additional steps.

Below are the salient points from the “Model Guidelines for the Recommendation of Marijuana in Patient Care.” (11,12):

• There should be an established and documented provider-patient relationship before the clinician considers making a recommendation for the use of medical marijuana.
• A clinical history, including previous therapies used, and a personal or family history of substance abuse, mental illness or psychotic disorders should be obtained and documented in the patient’s chart. Also, an in-person physical examination should be performed and documented in the patient’s chart before deciding whether or not to recommend marijuana for medical use.
• The clinician should review the known risks and benefits of marijuana therapy with the patient. In addition, other treatment options along with the risks and benefits associated with those alternative options should be presented.
• The patient should be warned that, unlike with FDA-approved drugs, there is variability and a lack of standardization in medical marijuana preparations, and medical marijuana has not undergone the Food and Drug Administration’s (FDA) drug approval process. (See the FDA question in this section for further details on this point.)
• Patients should be instructed not to drive or operate heavy machinery while under the influence of marijuana.
• In cases where the patient is a minor or without decision-making capacity, the clinician must involve the patient’s parent/ legal guardian or surrogate as instructed by the state laws.
• The recommending provider should create a written treatment plan similar to an opioid agreement plan. As stated in the “Report of the Federation of State Medical Boards (FSMB) Workgroup on Marijuana and Medical Regulation,” the treatment agreement should include documentation of:
  • A review of other measures attempted to ease the suffering
  • Advice about other options for managing the condition
  • How the patient may benefit from the marijuana therapy
  • Advice about the potential risks of the medical use of marijuana, including: the variability of quality and concentration of marijuana; the risk of cannabis use disorder; exacerbation of psychotic disorders and adverse cognitive effects for children and young adults; and other risks, including falls or fractures
  • Advice about the potential risks of the medical use of marijuana during pregnancy or breastfeeding
  • Informing the patient about the need to safeguard all marijuana and marijuana-infused products from children and pets
  • Informing the patient that the marijuana is for the patient’s use only and the marijuana should not be given to another individual (even if the other individual is also a medical marijuana patient)
  • The length of time for which the medical marijuana recommendation is valid
  • Additional therapies and diagnostic evaluations
  • A treatment plan
• Each state has its own qualifying conditions.
• Some states require healthcare providers who recommend medical marijuana to register with the state or with the specific oversight agency, and provide the registry with information each time a recommendation, authorization, or reauthorization is issued. (Note: Some states require healthcare providers to notify the oversight agency about the occurrence of any serious adverse effects that may be related to medical marijuana.)
• Prior to recommending marijuana to a patient, the healthcare provider should refer to the Prescription Drug Monitoring Program (PDMP) each time a recommendation is given.
• A patient who has a history of substance abuse or a mental health disorder may require specialized assessment and treatment. The clinician should seek a consultation with, or refer the patient to, a pain management, psychiatric or addiction specialist, as needed.
• Information that should appear in the medical record includes, but is not necessarily limited to the following: medical history; physical examination; diagnostic, therapeutic, and laboratory results; other treatments and prescribed medications; date of marijuana recommendation along with expiration date of recommendation; instructions to the patient, including discussions of risks and benefits, side effects and variable effects; results of ongoing assessment and monitoring of patient’s response to the use of marijuana; a copy of the signed Treatment Agreement, with instructions on safekeeping and not sharing.