Cannabis Can Be Confusing

Common Misconceptions & The Role of Podiatrists and Healthcare Professionals in

Certifying Patients Throughout the USA

Saturday, July 13, 2019 / 10:40–11:20 a.m / PAIN MANAGEMENT TRACK

Leslie McAhren, MFA, MPH, FF DrPH (‘20) Environmental & Occupational Health University of Colorado School of Public Health Anschutz Medical Campus E: Leslie.McAhren@CUAnschutz.edu P: 303.724.1271

What You Will Learn Today

Podiatrists will be supported by evidence-based information as they understand options for patient care and medical cannabis

What are you really doing?

Certifying that a patient has a condition that may be treated by medical cannabis

Post, 2019

11 States Have Fully Illegal Cannabis

• Idaho • Kentucky • Kansas • Mississippi • Nebraska

• North Carolina • South Carolina • South Dakota • Tennessee • Wisconsin • Wyoming

Last updated July 12, 2019

Common Misconceptions About Medical

Cannabis

“All states are going to legalize it” – so – doctors don’t need to learn about medical cannabis

”Podiatrists can’t recommend medical cannabis.” Only MDs and DOs can.

“The use of cannabis is not evidence-based.”

“Cannabis is not as effective at treating pain as opiates or other analgesics.”

More Misconceptions About Medical

Cannabis

“Sustainably grown cannabis is no different than indoor cultivation.”

“Pesticides aren’t a concern.”

“Residual solvents aren’t a problem in the extraction of cannabis.”

EXAMPLE. in Maryland

Maryland Produces A Diversity In Cannabis Program Report

Preliminary Industry Ownership Demographics Industry Totals

35% Racial and Ethnic Diversity Participation 57% Minority Participation Including Females

Preliminary Industry Employee Demographics Industry Totals

58% Racial and Ethnic Diversity Participation 75% Minority Participation Including Females

§§13-3306, 13-3307, 13-3309

EXAMPLE. in Maryland

Maryland defines a certifying physician as Health Occupations Article, §14-101(i), Annotated Code of Maryland.

§14-101(i), Annotated Code of Maryland Connecticut General Statutes Chapter 420f, Section 21a-408

EXAMPLE. in Maryland

Gray Area & State Websites “Any Provider with an active, unrestricted license in good standing with the Maryland State Board, and actively registered to prescribe controlled substances in Maryland, is eligible to register with the Maryland Medical Cannabis Commission, Attending of Hospice Record (AOHR) physician; must register as a “Certifying Provider” Connecticut is similar: chapter 370 and 378 only - not 375 podiatry

§14-101(i), Annotated Code of Maryland Connecticut General Statutes Chapter 420f, Section 21a-408

EXAMPLE. in Maryland

Providers may enroll in an online medical education curriculum developed by TMCIGlobal

Any non-Maryland resident currently in Maryland for the purpose of receiving medical treatment is eligible to register as a patient with the MMCC

§14-101(i), Annotated Code of Maryland

Certifying That A Patient Has A Condition

That May Be Treated By Medical Cannabis

Every state has a “provider certification form”

Example: Vermont 4 page document

https://medicalmarijuana.vermont.gov/sites/vmr/files/documents/Health%20Care%20Professional%20Form%20201801.pdf

Evidence-Based Medicine

From the National Academy of Medicine (2017)

From New Jersey

https://www.nj.gov/health/medicalmarijuana/documents/scholarly_articles.pdf

NAM, 2017

Evidence-Based Medicine

“There is conclusive, substantial evidence that cannabis or cannabinoids are effective for the treatment for chronic pain in adults”

“Cannabis acts both locally and centrally to relive pain and inflammation.”

NAM, 2017

What About Liability? (Schedule 1 Drug)

Conant v. Walters (2002) Case

There have been no criminal or administrative proceedings against doctors to date

Some States Address Liability In State Law

Example: Connecticut

Sec. 21a-408c. Physician or advanced practice registered nurse issuance of written certification. Requirements “Not subject to arrest, prosecution or certain other penalties.”

Handout & Sample Physician Form

Covered All MC States In Handout

take a photo on your phone

Arkansas Physician Form: https://www.healthy.arkansas.gov/images/uploads/pdf/easy_Instructions_for_Phys_cert-FINAL_JG.pdf

Typical Physician Requirements

1. Patient has been diagnosed with a qualifying debilitating medical condition

2. Conclusion of the patient's physician that the patient might benefit from the medical use of cannabis

3. Established medical record for the qualifying patient and am maintaining the qualifying patient's medical record as required

4. May have to provide a certified copy of documentation or EHR printout

Back to Mythbusting

#1 You Can’t Write Prescriptions For

Medical Cannabis

#1 You Can’t Write Prescriptions For

Medical Cannabis

TRUE! MEDICAL CANNABIS CANNOT BE PRESCRIBED. Physicians can only prescribe

Schedule II-V controlled substances to their patients. The federal government classifies cannabis as a Schedule I drug, which means a physician cannot

prescribe it. However, a physician may certify their patient for use of medical cannabis by utilizing state medical cannabis certification forms. The certification is

valid for some period from date of certification.

#2 DPMs Can’t Offer

Medical Cannabis As A Therapeutic Option

#2 DPMs Can’t Offer

Medical Cannabis As A Therapeutic Option

FALSE In NM, CA, NV, & IL, DPMs CAN SIGN THE RECOMMENDATION FOR PATIENTS. The DPM is licensed to prescribe opioids, and many other

medications far more potentially dangerous than cannabis. States where NPs are authoriaed are ripe targets for policy change.

#3 Patients Aren’t Inconvenienced By Not Having A Medical Cannabis Card

#3 Patients Aren’t Inconvenienced By Not Having A Medical Cannabis Card

INABILITY TO OBTAIN MEDICAL CANNABIS DENIES -- OR AT A MINIMUM INCONVENIENCES -- PATIENTS FOR WHOM MEDICAL CANNABIS IS A LEGITIMATE THERAPEUTIC OPTION. Medical cannabis programs are sometimes tax free. This is

an advantage over the recreational marketplace, which seeks to produce tax revenue for community projects. Medical cannabis retails offers higher dosing and more CBD

offerings than recreational options in most states (ex. CO 100mg vs. 500mg in medical)

FALSE

#4 Podiatrists Need To Be Proactive on

The Matter Of Medical Cannabis.

#4 Podiatrists Need To Be Proactive on

The Matter Of Medical Cannabis

LICENSING IS LIMITED AND DPMs NEED TO ADVOCATE FOR INCLUSIVE POLICY . Current policy disadvantageously positions the DPM in the medical market place as an

alternative care provider. DPMs should take CMEs alongside MDs and Dos. Anyone with prescriptive authority to write prescriptions for controlled substances should be allowed to recommend a patient to the program, if the provider has a state Medical License #, a DEA

License # and a state Controlled Substance License #. Such providers could gain reciprocity in other states.

TRUE!

#5 Regulation For DPMs Varies State-

By-State

#5 Regulation For DPMs Varies State-

By-State

APMA AND STATE PODIATRY ASSOCIATIONS CAN OFFER CERTIFIED TRAINING FOR DPMS IN MEDICAL CANNABIS (CME’S). Current training available generally does not offer recognized certification for a DPM (2-4 hours). Encourage DPMs to become active with state legislatures to correct this error. Be prepared to know your state regs and keep the handout

to reference patient-focused policies in other states.

TRUE!

#6 APMA Policy is Clear

APMA's 2017 HOD passed Resolution 11-17

#6 APMA Policy is Clear

“THE AMERICAN PODIATRIC MEDICAL ASSOCIATION (APMA) SUPPORTS EVIDENCE-BASED TREATMENT WITH MEDICAL

MARIJUANA when it provides a therapeutic and palliative benefit…”

APMA's 2017 HOD passed Resolution 11-17

TRUE!

#7 Any View That Comes Across as Anti-Pot

Seems To Be A Source Of Contention

#7 Any View That Comes Across as Anti-Pot

Seems To Be A Source Of Contention

AS A PUBLIC HEALTH PROFESSIONAL I BELIEVE IN EVIDENCE-BASED POLICY AND EVIDENCE-BASED MEDICINE. The benefits have to outweigh the risks. I’m into

harm reduction - not harm promotion. Cannabis has plenty of risks: DUIC, infertility, schizoaffective disorder. There is a 20 year review in the bibliography. As it stands, we are conducting a natural experiment around cannabis and I appreciate skeptical opinions

because these may be the opinions that best protect the public’s health.

FALSE

#8 Cannabis is a Gateway Drug for

Heroin

#8 Cannabis is a Gateway Drug for

Heroin

THE GATEWAY DRUG HYPOTHESIS HAS BEEN DISPROVEN. Yet, Human beings can become addicted to anything. Persons with a family history of substance abuse need to

proceed with extreme caution. Because of the conant v walters (2002) case it is important to have a bona fide relationship with your patients. The National Academy of Medicine

committee found limited evidence that cannabis use increases the rate of initiating other drug use, primarily the use of tobacco. However, the committee found moderate evidence

to suggest that there is a link between cannabis use and the development of substance dependence and/or a substance abuse disorder for substances including alcohol, tobacco,

and other illicit drugs.

FALSE

#9 Impotence Problems Are Caused By

Medical Cannabis

#9 Impotence Problems Are Caused By

Medical Cannabis

CANNABIS USE NEEDS TO BE CONSIDERED AS PART OF FAMILY PLANNING. Chronic exposure can alter male fertility. Sperm motility is

impacted by cannabis use (both medical and recreational).

TRUE!

#10 Cannabis Has No Contraindications

#10 Cannabis Has No Contraindications

CANNABIS HAS NUMEROUS DOCUMENTED AND UNDOCUMENTED CONTRAINDICATIONS. Persons with schizoaffective disorders, for example should not

use cannabis. Furthermore, under age 25 use has proven to be detrimental for the developing brain. Daily use presents its own risk...Colorado researchers are seeing fewer

and fewer once or twice a week users and more daily users. It’s harder to find test subjects. It is important to study cannabis use at the population level.

FALSE

#11 Cannabis And Marijuana Are

Synonymous Terms

#11 Cannabis And Marijuana Are

Synonymous Terms

CANNABIS IS ALWAYS THE CORRECT TERM. OTHER VARIATIONS EXIST, BUT ARE NUANCED. The term marijuana represents an

unwelcome microagression that your patients will likely pick up on and not appreciate. NY State chooses: marihuana (Canadian spelling). Iowa

chooses: chemical name = Office of Medical Cannabidiol (OMC)

FALSE

#12 It’s Fine To Drive Under The

Influence Of Cannabis

#12 It’s Fine To Drive Under The

Influence Of Cannabis

IT’S NOT OKAY TO DRIVE A MOTOR VEHICLE WHEN UNDER THE INFLUENCE OF CANNABIS. There is one Canadian study with

“experienced cannabis users.” In this particular study, chronic cannabis users were better drivers than the general public cohort. Independent of this study, the impact of cannabis tourism on public safety is a concern. Acute, infrequent use may be the most dangerous for driving. There is

another interesting Dutch study on biking under the influence of cannabis.

FALSE

#13 There Are No FDA Approved

Cannabis Medications

#13 There Are No FDA Approved

Cannabis Medications

THERE ARE FDA-APPROVED MEDICATIONS. FDA-approved drugs include Marinol, Syndros, Cesamet, Epidiolex. Sativex, produced by GW

Pharmaceuticals, is part of an FDA-approved clinical trial.

FALSE

#14 Proliferation Of Unregulated OTC CBD

Products Is Equivalent To A Medical Cannabis Program

#14 Proliferation Of Unregulated OTC CBD

Products Is Equivalent To A Medical Cannabis Program

ENFORCEMENT AUTHORITY IN THIS AREA LIES WITH THE FEDERAL DRUG ENFORCEMENT ADMINISTRATION, THE FEDERAL FOOD AND DRUG

ADMINISTRATION, COUNTY ATTORNEYS AND LAW ENFORCEMENT AGENCIES. Iowa & The Office of Medical Cannabidiol (OMC) offers an interesting position paper

on the topic.

FALSE

#15 Cannabis And Spice/K2 Are The

Same Thing

#15 Cannabis And Spice/K2 Are The

Same Thing

SYNTHETIC CANNABIS FIRST APPEARED IN EUROPE IN 2004. THESE COMPOUNDS ARE DIFFERENT FROM THC OR CBD. Spice and K2 are often sold at convenience stores as “herbal incense. Studies show they are toxic and unsafe. Synthetic Cannabinoids were created by experimental cannabis researchers CP 47,497, named after Charles Pfizer of

Pfizer Pharmaceuticals, developed in the 1980s for scientific research. HU-210, named after Hebrew University of Jerusalem where it was first developed in 1988 is 100 to 800 times more potent than natural THC. JWH-018 and others in the JWH series, named after Prof. John W.

Huffman of Clemson University in South Carolina, created in 1995.

FALSE

Patient Conditions (In Arkansas & North Dakota)

Strongly Resemble Trends In Other States

North Dakota has only 753 patients (as of 7/10/2019)

Nevada’s Approach To Defining a

“Provider Of Health Care”

“Provider of health care” defined.

NRS 629.031

Nevada’s Approach To Defining a

“Provider Of Health Care”

“Provider of health care” defined.

NRS 629.031

(a) A physician (b) A physician assistant; (c) A dentist; (d) A licensed nurse; (e) A person who holds a EMT license or (f) A dispensing optician; (g) An optometrist; (h) A speech-language pathologist; (i) An audiologist; (j) A practitioner of respiratory care; (k) A licensed physical therapist; (l) An occupational therapist; (m) A podiatric physician; (n) A licensed psychologist; (o) A licensed marriage and family therapist; (p) A licensed clinical professional counselor; (q) A music therapist; (r) A chiropractor; (s) An athletic trainer;

With Parity Comes Responsibility

“We cannot control this epidemic, but there are certainly ways that each of us can contribute to its demise…With parity as physicians comes responsibility to help eradicate this public health crisis.”

- Kieran T. Mahan, DPM, MS, FACFAS Temple University School of Podiatric Medicine 2016

The Apparent Inability Of A DPM To Offer

Medical Cannabis As A Therapeutic Option

Correct DPM recommending privileges. DPMs are licensed to prescribe opioids, and many other medications.

Match this policy idea with state laws on CMEs/provider education

Pigeonholes increasingly position DPMs with ”alternative care providers” instead of alongside traditional allopathic medical providers

DPMs: Parting Words

1. Demonstrate by training or expertise that he or she is qualified in treating serious medical conditions.

2. DPMs already have prescriptive authority to write prescriptions for controlled substances.

3. DPMs should be allowed to recommend patients to a state medical cannabis program – should they choose to do so.

4. Encourage DPMs to become active in state and national policy debate around licensure!

References

Di Marzo V. Mechhoulam R (2011) Cannabinoids and endocannabinoids in metabolic disorders with focus on diabetes. Handbook of Experimental Pharmacology: 75-104 Hall, W. (2015), Cannabis health effects. Addiction, 110: 19-35. doi:10.1111/add.12703 Hartung B, Schwender H, Roth EH, et al. The effect of cannabis on regular cannabis consumers' ability to ride a bicycle. International journal of legal medicine. 2016;130(3):711. http://www.ncbi.nlm.nih.gov/pubmed/26739323. doi: 10.1007/s00414-015-1307-y. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research, Jan 12, 2017 Rajanahally, S., Raheem, O., Rogers, M., Brisbane, W., Ostrowski, K., Lendvay, T., & Walsh, T. (2019). The relationship between cannabis and male infertility, sexual health, and neoplasm: a systematic review. Andrology, 7(2), 139–147. Rogeberg O, Elvik R. Response to li et al. (2017): Cannabis use and crash risk in drivers. Addiction. 2017;112(7):1316. http://onlinelibrary.wiley.com/doi/10.1111/add.13801/abstract. doi: 10.1111/add.13801. White, CM The Pharmacologic and Clinical Effects of Illicit Synthetic Cannabinoids. J Clin Pharmacol. 2016 Sep 9. PubMed PMID: 27610597 Wood, Ed, Ashley Brooks-Russell & Phillip Drum (2016) Delays in DUI blood testing: Impact on cannabis DUI assessments, Traffic Injury Prevention, 17:2, 105-108, DOI: 10.1080/15389588.2015.1052421

THANK YOU Leslie McAhren, MFA, MPH, DrPH (‘20) Environmental & Occupational Health University of Colorado School of Public Health Anschutz Medical Campus E: Leslie.McAhren@CUAnschutz.edu P: 303.724.1271