The ever increasingly lenient US state legislature on marijuana usage and its contrasting illegal prescription status at the federal level, place physicians in a tight corner. Just recently, the Federation of State Medical Boards (FSMB) in United States has given marijuana dispensation recommendations on what physicians are permissible to do, should there be a need for prescription of the drug, and the conditions to be met before the prescription is made.
Notably, this is the first time that FSMB has ever highlighted the dispensing or use of products derived from the marijuana (Cannabis sativa) plant in a policy recommendation. This is indeed an unprecedented move. The FSMB, itself. includes seventy territorial and state medical licensing boards, which are either medical or osteopathic boards.
According to the 2014 National Survey on Drug Use and Health (NSDUH) report, marijuana is the most commonly used drug in United States with approximately 22.2 million monthly users
According to Dr Deborah S Hasin, a professor of epidemiology at Columbia University, New York, the numbers show that Americans are becoming more permissive of marijuana and fewer people see it as harmful now, even though “Marijuana use does involve some risk of adverse consequences. As an increasing number of Americans use marijuana over time, more will be exposed to these risks”, says Dr Hasin.
The recommendations given for what the board expects the physicians to do while prescribing marijuana includes: documented patient-physician relationship, a thorough evaluation of the patient, Informed and shared decision making among the patient and the doctor, a written treatment plan exploring other options, meeting of the qualifying conditions, continuous ongoing monitoring of the patient, consultation and referral for other treatment if needed, maintenance of accurate and complete medical records, no conflict of interest and no use of the drug by the physician himself while he/she is actively practicing medicine.
Prescription of the drug, which is classified as a Schedule 1 Substance under the Controlled Substances Act of 1970, remains illegal under the United States federal law. However, Department of Justice (DOJ) since 2013 has allowed the use of marijuana for patient care while maintaining its status as an illegal substance. DOJ has advised the state and local governments to effectively regulate and monitor its use in medical care delivery.
Should the federal government consider the measures insufficient and notice someone violating them, it reserves the right to take action against such an individual; even if they are physicians.
The recommendations came in 2015 when the Federation’s Chair, J Danial Gifford, MD, FACP, appointed a panel to develop model policy guidelines regarding the use of marijuana in patient care. These would effectively be guidelines for doctors who need to prescribe this drug.
The panel worked under the title ‘Workgroup on Marijuana and Medical Regulation’. They were also tasked with the responsibility of devising a ‘white paper’ (or position statement) regarding the regulation of licensees who use marijuana themselves.
A systematic review of more than forty peer reviewed articles was conducted to devise these recommendations. A survey of board members to identify issues faced by the state boards related to marijuana and medical regulation was also conducted.
51 out of 70 board members took part in the survey and reported important issues such as recreational use of weed by the physicians, guidance on handling it for medical use and guidelines on recommending the use of weed to patients.
Comments on the language used in the draft of the guidelines were taken from all the stake holders involved including public members, physicians and even the American Society of Addiction Medicine. The process also involved an open testimony at a reference committee at the federation’s annual meeting.
The recommendations given by the board were accepted and adopted by all the medical boards on April 30, 2016.
The responsibility of the appointed panel of devising a position statement on the regulation of marijuana user licensees, however, was ultimately transferred to the FSMB’s board of directors.
A public version of the expected protocol recommendations to be used when prescribing weed or any other marijuana product to patients appeared in The Journal of the American Medical Association on June 16, 2016.
While marijuana is mostly used for recreational purposes, it does have an array of medical uses such as alleviating headache, treating chronic pain and nausea of cancer, relieving muscle spasm of multiple sclerosis, fighting weight loss of chronic illnesses such as HIV, controlling and improving seizures of epilepsy and treating Crohn’s disease. FDA has also approved tetrahydrocannabinol, or THC (Marinol), the active compound found in marijuana, for treating nausea and improving appetite. THC exerts its effect by binding to cannabinoid receptors (CB1 and CB2) in brain, periphery and lymphatic tissue, where it mediates inflammation, pain and other processes. Currently, marijuana enjoys a ‘medical-use only’ status in more than 24 states in the US.
The first major move in marijuana prescription legislation came in 1996 when California voters passed Proposition 215 which allowed the medical use of weed for patients. Proponents of medical marijuana believe it is safe and effective for the treatment of a myriad of medical conditions and their treatment-related side effects such as cancer, HIV, AIDS, Alzheimer’s, Post Traumatic Stress Disorder (PTSD), Crohn’s disease, glaucoma, epilepsy and multiple sclerosis. It can also be used as an alternate to narcotic painkillers. Opponents of medical marijuana, including healthcare professionals, opine that the drug is too dangerous to use, has an addiction potential and has plenty of other, better and safe pharmaceutical alternatives.