unm hospitals and clinics medical cannabis guidance and...

UNM Hospitals and Clinics Medical Cannabis Guidance and FAQs For Providers

Developed by an Ad Hoc Committee of the Organized Medical Staff

Owner: UNMH Medical Staff Affairs Approved by Medical Executive Committee: October 17, 2018

Can I decline a patient’s request for medical cannabis paperwork to be completed even if they have a qualified condition?

Yes.

Which current conditions qualify patients under New Mexico State law for medical cannabis?

Amyotrophic Lateral Sclerosis (ALS), Cancer (please specify type in clinical notes), Crohn’s Disease, Epilepsy/Seizure Disorders, Glaucoma, HCV infection and currently receiving antiviral treatment currently, HIV/AIDS, Huntington’s Disease, Hospice Care, Inclusion Body Myositis, Inflammatory Autoimmune-Mediated Arthritis, Intractable Nausea/Vomiting, Multiple Sclerosis, Damage to the Nervous Tissue of the Spinal Cord, Painful Peripheral Neuropathy, Parkinson’s Disease, Post‐Traumatic Stress Disorder, Severe Chronic Pain, Severe Anorexia/Cachexia, Spasmodic Torticollis (Cervical Dystonia), and Ulcerative Colitis.

What is the current evidence about the health benefits and health risks for Cannabis?

- ASAM handout (Attachment A)

- The Health Effects of Cannabis and Cannabinoids: The Current State of

Evidence and Recommendations for Research, 2017 o visit www.nap.edu/24625 to download the PDF document

There is conclusive or substantial evidence that cannabis is modestly effective for the treatment of chronic pain in adults (cannabis), as an anti-emetics in the treatment of chemotherapy-induced nausea and vomiting (oral cannabinoids), and for improving patient-reported multiple sclerosis spasticity symptoms (oral cannabinoids). There needs to be further research in this latter area as the findings are disputed. There is substantial evidence of a statistical association between smoking cannabis and worsened respiratory symptoms and more frequent chronic bronchitis episodes (long-term cannabis smoking).

http://www.nap.edu/24625




There is a statistically significant association between cannabis use and increased risk of motor vehicle crashes. There is a statistically significant association between maternal cannabis smoking and low birth weight of the offspring. There is a statistically significant association between cannabis use and the development of schizophrenia and other psychoses, with the highest risk among the most frequent users. There is substantial evidence that initiating cannabis use at an early age is a risk factor for the development of problematic cannabis use.

Does smoking cannabis increase patient’s risk for adverse pulmonary effects?

Yes. No level of smoking or vaping of any substance is healthy. There are other

formulations including “edibles,” ointments, and creams that may have less risk

of adverse pulmonary effects.

Is filling out the New Mexico Department of Health Medical Cannabis Program

Medical Certification Form the same as prescribing marijuana?

No, it is considered an endorsement. The New Mexico Department of Health

Medical Cannabis Program Medical Certification Form certifies that your patient

has a qualifying condition for which you believe that the benefits outweigh the

risks of using medical cannabis. Marijuana is still federally illegal and many

health systems, including Federally Qualified Health Centers and Veteran’s

Administration Hospitals, do not allow their clinicians to fill out the form. UNM

Hospitals and clinics does not have such a policy and it is up to each individual

clinician to decide whether they feel comfortable endorsing medical marijuana

for their individual patient.

Does the completed New Mexico Department of Health Medical Cannabis

Program Medical Certification Form go into PowerChart?

No. It is given back to patient and they are responsible for submitting it to the

New Mexico Department of Health state medical cannabis program.




What is the legal risk to the Patient?

This is unknown. Employers are also entitled to have their own policies and

practices about their employees using cannabis. Even if patients have a medical

cannabis card, they can still be terminated from work for a positive urine drug

screen, even if not impaired at work. Furthermore, THC is difficult to test for

acute use given that it can result in a positive drug screen test many days after

consumption.

What is the legal risk to the Provider?

Completing the New Mexico Department of Health Medical Cannabis Program

Medical Certification Form for your patient does not make you a prescriber,

therefore you are not in violation of any Federal or State Statutes. However, it is

impossible to predict any patient malpractice exposure as there is no guiding

precedent at this time.

What is the evidence regarding using cannabis while pregnant or

breastfeeding?

There is insufficient evidence to determine whether using cannabis while pregnant or breastfeeding is safe, and there is some evidence that it is not safe. For example, there is substantial evidence of a statistical association between maternal cannabis smoking and low birth weight of the offspring. Both the American College of Obstetrics and Gynecology and the American Academy of Pediatrics recommend against marijuana use during pregnancy and lactation.

Which clinicians can fill out the New Mexico Department of Health Medical

Cannabis Program Medical Certification Form?

Medical Doctors (not Residents), Doctors of Osteopathy (not Residents), Nurse

Practitioners, and Physician Assistants. Any form completed by a Resident must

be co-signed by a (willing) attending physician.




What is the basic pharmacology of Tetrahydrocannabinol (THC) and Cannabidiol

(CBD)?

There are two known active substances in Cannabis plants: THC and CBD. THC is

the substance that makes people feel “high.” CBD may also be found in hemp

which is a form of cannabis plant that does not have THC. The hemp based CBD,

a non-psychoactive type of Cannabis, can be purchased as a cream, lotion, or

ointments without a medical cannabis card.

Is there a limit to the amount of medical cannabis cards you can fill out

applications for like in the case of Suboxone?

No

Can UNM Physicians and Advance Practice Providers prescribe medical cannabis

to be used in the hospital?

No. UNM Hospital could lose our Hospital DEA license if we allow use of federally

illegal substances in the hospital. Providers would be putting their DEA license at

risk.

Marijuana Legalization:Protecting Public Health and Safety in a Volatile Legal LandscapeThe Position of the American Society of Addiction Medicine

The now-widespread public perception of cannabis use as a harmless pleasure and even a therapeutic practice has prompted a rapidly growing movement for states to legalize its use for recreational or medicinal purposes. As of early 2018, nine states and Washington, DC, have legalized cannabis for adult recreational use. Twenty-nine other states allow “medical” marijuana use. However, cannabis cultivation, distribution, and consumption remain illegal at the federal level, as marijuana is classified as a Schedule I controlled substance under the Controlled Substances Act (CSA), meaning it has been determined to have no legitimate medical use and a high potential for abuse.

The term “cannabis” is used to describe the various products and compounds (e.g., marijuana, cannabinoids) derived from different species of the cannabis plant.1

1Increasing Public Acceptance of MarijuanaA Gallup poll released in October 2017 showed record high support for legalizing marijuana, with 64% of respondents saying its use should be legalized.

Increasing Federal-State TensionDespite growing public support for marijuana legalization, on January 4, 2018, Attorney General Jeff Sessions rescinded Obama-administration guidance (known colloquially as the “Cole memo”) that laid out a policy of federal non-interference with state laws that permitted marijuana cultivation, sales, and use. The decision by the Attorney General changes federal policy from a “hands-off” approach to giving US Attorneys the discretion to use federal resources to prosecute cases against marijuana businesses in states where it is legal for recreational use. A federal appropriations policy still prohibits the Department of Justice from using federal resources to interfere with state medical marijuana programs.

Marijuana’s Effect on HealthThe evolving and complex legal landscape reflects both the shift in public perception of marijuana as well as continued scientific uncertainty about the extent of its harms and its potential therapeutic effects. Eight of the nine states to legalize recreational use have done so through ballot initiatives, reflecting popular opinion rather than measured policy analysis.

A January 2017 comprehensive review by the National Academies of Sciences, Engineering, and Medicine summarizes the recent evidence regarding health effects of using cannabis and cannabis-de-rived products. The report found:

1

2

3

Sanders L. Marijuana Legalization 2018: Which States Might Consider Cannabis Laws This Year? Newsweek. January 2, 2018. Available at: http://www.newsweek.com/marijuana-legal ization-2018-which-states-will-consider-cannabis-laws-year-755282 Accessed January 30, 2018.

National Academies of Sciences, Engineering, and Medicine. 2017. The health effects of cannabis and cannabinoids: Current state of evidence and recommendations for research. Washington, DC: The National Academies Press.

2

3

ATTACHMENT A

Modest improvements in pain symptoms among adults with chronic pain and patient-reported spasticity in adults with multiple sclerosis-related spasticity; inadequate information for the effects of non-pharma-ceutical cannabinoid use on other conditions

Early initiation and greater frequency of cannabis use increases the likelihood of developing problem cannabis use

Cannabis use is likely to increase the risk for developing another substance use disorder

Substantial evidence of an increased risk among frequent cannabis users of developing schizophrenia and other psychoses

Substantial evidence of a link between prenatal cannabis exposure and lower birth weight, but an unclear relationship between smoking cannabis during pregnancy and other pregnancy and childhood outcomes

Increased risk of being involved in a motor vehicle crash if cannabis is used prior to driving

Increased risk of unintentional cannabis overdose injuries among children in states where its use is legal

Impaired cognitive performance in learning, memory, and attention with recent use (within 24 hours of evaluation)

A relationship between cannabis use during adolescence and impairments in subsequent academic achievement and education, employment and income, and social relationships

Evidence that suggests smoking cannabis does not increase the risk for certain cancers (i.e., lung, head, and neck) in adults

What is ASAM’s Position?ASAM has no position on the recent action by the Attorney General, as ASAM’s chief focus is the health and welfare of persons with addiction and the prevention of harm related to substance use. While ASAM does not support the legalization of marijuana and does not want to see the history of “Big Tobacco” repeat itself as “Big Marijuana,” ASAM does support decriminalization of marijuana, which would reduce possession and personal use from criminal offenses to civil infractions penalized by fines and linked to contingencies that promote public health (e.g., mandated referral to clinical assessment and educational activities).

Regardless of marijuana’s legal status, all federal and state authorities should prioritize a public health and safety response to its use to minimize potential harms to vulnerable populations. • Sale of cannabis products to anyone younger than 25 should be prohibited• Marketing and advertising cannabis products to youth should be prohibited• Warning labels should be required on all cannabis products available for retail sale• Cannabis products should be required to be sold in child-proof packaging• Tax revenue collected from sales of cannabis products should be earmarked for public education, prevention activities, and addiction treatment services• Cannabis sales should be limited to state-operated outlets to preserve public access while limiting broad commercialization

ASAM urges all policymakers – at both the state and federal level – to focus their efforts on promoting policies that protect public health and safety; promote access to timely, high-quality addiction treat-ment; and protect the integrity of our pharmaceutical regulatory process, which is grounded in well-de-signed and executed clinical research.

ATTACHMENT A

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