Getting in the Weeds With Recommending Marijuana for Medical Treatment

Laura M. Cascella, MA, CPHRM

Over the past 25 years, a shift has occurred in both public opinion related to using marijuana for medical purposes ("medical marijuana"¹) and state laws that address this issue. Since 1996, 37 states, the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands have enacted laws that permit marijuana for medicinal purposes.² However, marijuana is still classified as a Schedule 1 drug under the federal Controlled Substances Act — thus, it is illegal.

The conflict between state and federal laws that address marijuana is representative of a larger dichotomy surrounding the drug. A consensus study report from the National Academies of Sciences, Engineering, and Medicine highlights this ambiguity by presenting data showing both therapeutic benefits and harms of marijuana.³

For healthcare providers, these conflicts — as well as potential pressure from patients who seek certification for medical marijuana — present legal, ethical, and liability concerns. Providers who do not want to, or who do not feel comfortable with, certifying patients to use medical marijuana are not required by law to do so. However, for providers who currently are certifying patients, or who plan to do so in the future, the following strategies can help guide a well-defined risk management approach:

• Understand the statutes and regulations governing the use of marijuana for medical purposes in the state(s) in which you practice.
• Research and keep aware of your state's policies and regulations related to:
  • Healthcare provider roles and responsibilities related to certifying patients to use medical marijuana.
  • Limitations on certifying authority (for example, in relation to advanced practice providers and other healthcare professionals).
  • Limitations on medical conditions and symptoms for which marijuana use is approved.
  • Limitations on certifying patients who reside in other states or certifying patients via telehealth technology.
  • Requirements for continuing education or educational certification.
  • Documentation requirements to support an adequate provider–patient relationship and adherence to the standard of care.
• Notify your professional liability carrier of your intentions to certify patients for medical use of marijuana.
• Engage in professional continuing education related to the physiological effects of marijuana, its efficacy in treating certain conditions and symptoms, and potential adverse side effects. Keep current on research advances and changes in laws.
• Develop a policy that details the requirements patients must meet for providers to engage in the certification process for medical marijuana (e.g., the patients must be established with the practice, they must have a physical exam within a specified timeframe, they must sign a behavior or pain management contract, etc.).
• Engage in a thorough informed consent process with patients who seek certification for medical marijuana. Determine whether state law mandates the inclusion of specific information as part of the informed consent process for medical marijuana certification. In addition to state-mandated information, consider disclosing the following information as part of informed consent:
  • The federal government's classification of marijuana as a Schedule 1 narcotic, and the state's position on using marijuana for medical purposes.
  • State-specific requirements patients must follow to register with an agency or commission following certification for medical marijuana.
  • The lack of U.S. Food and Drug Administration (FDA) oversight related to marijuana products and potential variances in ingredients, potency, and quality.
  • What is known about the efficacy of marijuana treatment in relation to the patient's condition or symptoms as well as what remains unknown or unclear.
  • Contraindications for marijuana use, such as certain medical and mental health conditions, a history of addiction, and pregnancy or trying to become pregnant.
  • The potential benefits (e.g., pain relief) and risks (e.g., addiction) of using marijuana as a medical treatment.
  • The potential side effects of marijuana — such as respiratory issues, dizziness, anxiety, and loss of judgment — and possible adverse drug interactions.
  • The ways in which marijuana can impair coordination and cognition, and activities that patients should not engage in while using marijuana (e.g., driving, operating machinery, or participating in activities that require high alertness and the ability to respond quickly).
  • Alternative options and therapies to treat the patient's medical condition or symptoms.
• Develop a thorough treatment plan for each patient seeking certification for medical marijuana. Include the rationale for selecting marijuana as a treatment option as well as goals and objectives for treatment.
• Establish a schedule for routine follow-up and review of the patient's treatment plan and progress.
• Provide detailed documentation of the patient's medical and family history, physical evaluations, diagnostic decision-making, test results, referrals, conventional medications or therapies that have not worked for the patient, the informed consent process, and all verbal and written patient education, communication, and follow-up.
• Avoid activities that could present unwanted legal or disciplinary actions, such as recommending medical marijuana for patients who are outside of the normal scope or population of your practice, dispensing marijuana products, or assisting patients in physically obtaining or administering marijuana.

Although many questions about using marijuana for medical treatment abound, one certainty is that its role in medical care and the laws that govern it will continue to evolve. Staying aware of these changes and developing proactive strategies to address patients' interest in, and requests for, medical marijuana certification can help healthcare providers maintain a sound risk management approach.

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¹ In the context of this article, the term "medical marijuana" refers to marijuana used to treat medical conditions. It does not imply a purified, medical grade, or FDA-approved substance. The U.S. Department of Health and Human Services' National Institute on Drug Abuse states that "The term medical marijuana refers to using the whole, unprocessed marijuana plant or its basic extracts to treat symptoms of illness and other conditions." (Source: U.S. Department of Health and Human Services, National Institute on Drug Abuse. [2019]. Marijuana as medicine. Drug Facts. Retrieved from https://nida.nih.gov/sites/default/files/marijuanamedicinedrugfacts_july2019_.pdf)

² National Conference of State Legislature. (2022, June 14). State medical cannabis laws. Retrieved from www.ncsl.org/research/health/state-medical-marijuana-laws.aspx

³ National Academies of Sciences, Engineering, and Medicine. (2017). The health effects of cannabis and cannabinoids: The current state of evidence and recommendations for research. Washington, DC: The National Academies Press. doi: 10.17226/24625.

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