MEDICAL CANNABIS

Medical Cannabis Guidelines

The Pinellas County Medical Association has adopted a set of guidelines (adapted from the Federation of State Medical Boards) for the recommendation of marijuana in patient care. Read the guidelines here.

Physician-Patient Relationship: The health and well-being of patients depends upon a collaborative effort between the physician and the patient. The relationship between a patient and a physician is complex and based on the mutual understanding of the shared responsibility for the patient’s health care. The physician-patient relationship is fundamental to the provision of acceptable medical care. Therefore, physicians must have documented that an appropriate physician-patient relationship has been established,7 prior to providing a recommendation, attestation, or authorization for marijuana to the patient. Consistent with the prevailing standard of care, physicians should not recommend, attest, or otherwise authorize marijuana for themselves or family member.

Patient Evaluation: A documented in-person medical evaluation and collection of relevant clinical history commensurate with the presentation of the patient must be obtained before a decision is made as to whether to recommend marijuana for medical use. At minimum, the evaluation should include the patient’s history of present illness, social history, past medical and surgical history, alcohol and substance use history, family history with emphasis on addiction or mental illness/ psychotic disorders, physical exam, documentation of therapies with inadequate response, and diagnosis requiring the marijuana recommendation.

Informed and Shared Decision Making: The decision to recommend marijuana should be a shared decision between the physician and the patient. The physician should discuss the risks and benefits of the use of marijuana with the patient. Patients should be advised of the variability and lack of standardization of marijuana preparations and the effect of marijuana. Patients should be reminded not to drive or operate heavy machinery while under the influence of marijuana. If the patient is a minor or without decision-making capacity, the physician should ensure that the patient’s parent, guardian or surrogate is involved in the treatment plan and consents to the patient’s use of marijuana.

Treatment Agreement: A health care professional should document a written treatment plan that includes:

  • Review of other measures attempted to ease the suffering caused by the terminal or debilitating medical condition that do not involve the recommendation of marijuana.
  • Advice about other options for managing the terminal or debilitating medical condition.
  • Determination that the patient with a terminal or debilitating medical condition may benefit from the recommendation of marijuana.
  • Advice about the potential risks of the medical use of marijuana to include:
    • 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;
    • Adverse events, exacerbation of psychotic disorder, adverse cognitive effects for children and young adults, and other risks, including falls or fractures;
    • Use of marijuana during pregnancy or breast feeding;
    • The need tsafeguard all marijuana and marijuana-infused products from children and pets or domestic animals; and
    • The need tnotify the patient that the marijuana is for the patient’s use only and the marijuana should not be donated or otherwise supplied tanother individual.
  • Additional diagnostic evaluations or other planned treatments.
  • A specific duration for the marijuana authorization for a period no longer than twelve months.
  • A specific ongoing treatment plan as medically appropriate.

 

Qualifying Conditions: At this time, there is a paucity of evidence for the efficacy of marijuana in treating certain medical conditions. Recommending marijuana for certain medical conditions is at the professional discretion of the physician. The indication, appropriateness, and safety of the recommendation should be evaluated in accordance with current standards of practice and in compliance with state laws, rules and regulations which specify qualifying conditions for which a patient may qualify for marijuana.

Ongoing Monitoring and Adapting the Treatment Plan: Where available, the physician recommending marijuana should register with the appropriate oversight agency and provide the registry with information each time a recommendation, attestation, authorization, or reauthorization is issued [see Appendix 1]. Where available, the physician recommending marijuana should check the state Prescription Drug Monitoring Program (PDMP) each time a recommendation, attestation, authorization, or reauthorization is issued.

The physician should regularly assess the patient’s response to the use of marijuana and overall health and level of function. This assessment should include the efficacy of the treatment to the patient, the goals of the treatment, and the progress of those goals.

Consultation and Referral: A patient who has a history of substance use disorder or a cooccurring mental health disorder may require specialized assessment and treatment. The physician should seek a consultation with, or refer the patient to, a pain management, psychiatric, addiction or mental health specialist, as needed.

Medical Records: The physician should keep accurate and complete medical records. Information that should appear in the medical record includes, but is not necessarily limited to the following:

  • The patient’s medical history, including a review of prior medical records as appropriate;
  • Results of the physical examination, patient evaluation, diagnostic, therapeutic, and laboratory results;
  • Other treatments and prescribed medications;
  • Authorization, attestation or recommendation for marijuana, to include date, expiration, and any additional information required by state statute;
  • 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, including instructions on safekeeping and instructions on not sharing.

Physician Conflicts of Interest: A physician who recommends marijuana should not have a professional office located at a dispensary or cultivation center or receive financial compensation from or hold a financial interest in a dispensary or cultivation center. Nor should the physician be a director, officer, member, incorporator, agent, employee, or retailer of a dispensary or cultivation center.

 Additional PCMA Medical Marijuana Standards

  1. Physicians providing patient recommendations for medical marijuana must be registered with the  Florida Department of Health.
  2. Physicians providing patient recommendations for medical marijuana should maintain continuing medical education in the field of  Medical Marijuana. This task force recommends a minimum of 4hrs of credit dedicated to the field of Medical Marijuana.
  3. Physicians providing patient recommendations for medical marijuana must operate out of a dedicated medical office space.
  4. Physicians providing patient recommendations for medical marijuana must conduct comprehensive evaluations including a patient history and physical by physician
  5. Physicians providing patient recommendations for medical marijuana should provide  patient education including
    –lists of dispensaries with addresses, emails, phone number
    –education about hemp vs cannabis, cannabinoids and terpenes, potential side effects, routes of administration, entourage effect, etc
    –product recommendations
    –dosing guidance
  6. Physicians providing patient recommendations for medical marijuana should provide patients assistance with opioid and benzodiazepine weaning.
  7. This task force recommends that physicians remove THC from “standard” drug screening tests (see “Drug Testing and Medical Marijuana”)
  8. Physicians providing patient recommendations for medical marijuana should maintain electronic medical records.
  9. Physicians providing patient recommendations for medical marijuana should maintain open communication with other providers (with patient consent).
  10. Physicians providing patient recommendations for medical marijuana should provide reasonable follow up evaluations to ensure therapeutic efficacy: recommend a follow-up visit or call within 8 weeks of initial evaluation.
  11. Physicians providing patient recommendations for medical marijuana should provide care to patients at reasonable prices.
  12. Physicians providing patient recommendations for medical marijuana should not  withholding high CBD/low THC orders in lieu of selling patients hemp based products.
  13. Physicians providing patient recommendations for medical marijuana must maintain updated knowledge of local dispensaries and product offerings
  14. Physicians providing patient recommendations for medical marijuana should consider restriction of high-THC orders in patients who display a high risk of abuse and/or diversion.
  15. Physicians providing patient recommendations for medical marijuana must utilize informed consent and treatment agreements.
  16. Physicians providing patient recommendations for medical marijuana must assess and document any adverse effects related to medical marijuana use.
  17. Physicians providing patient recommendations for medical marijuana must utilize appropriate referrals and consultations.

Drug Testing and Medical Marijuana

The PCMA Medical Marijuana task force recommends that physicians remove THC from “standard” screening urine drug tests.

Physicians that continue to include THC on “standard” screening urine drug tests, should acknowledge that patients using broad spectrum hemp products and/or medical cannabis may test positive for THC. If a patient tests positive for THC on their screening drug test, they should be asked about their use medical marijuana and hemp products.

As long as the patient is obtaining medical cannabis medication through a proper legal channel, they should not be discriminated against, discharged from the practice or have appropriate medical care withheld.

If the patient is using a broad spectrum hemp product, they should be given a grace period to cease the product, or change the product to a THC free hemp product, or seek the care of a registered medical marijuana physician.