The method by which patients may access medical marijuana has been altered by Health Canada. The implications for physicians are unclear at the moment. As a consequence, Council is offering some preliminary advice to assist physicians with this transition.
Under the previous approach, patients would be authorized to grow their own medical marijuana based on a report provided to Health Canada by a physician. Effective April 1st, 2014, medical marijuana may only be possessed by a patient if it is prescribed by a physician and dispensed by a licenced producer. Physicians must complete a medical document, essentially a prescription, which authorizes the patient to obtain medical marijuana calculated as a maximum daily amount. The document is valid for a year. Patients can be dispensed up to a one month supply. Patients cannot legally possess more than a one month supply, based on the daily dose prescribed by the physician, or up to 150 grams. The physician does not need to disclose specific medical information regarding the patient. A sample document is attached.
Medical marijuana has been advocated for a very wide range of conditions. Nevertheless, physicians should remember that strong medical evidence to support any particular use remains lacking. Anecdotal evidence from both patients and physicians has been available for some time. Some assert that marijuana may reduce a patient’s need for other, potentially more dangerous, drugs. In other words, a physician may conclude that it is in the best interest of the patient to consider prescribing medical marijuana. As always, the patient’s best interest should be the primary consideration in any treatment plan. Hence, physicians may find it necessary to educate themselves on the situations where medical marijuana may be considered a potentially useful alternative.
Ideally any prescribing of medical marijuana will be done by the patient’s primary physician. However, it is anticipated that many physicians will find this process initially challenging. For reasons of inexperience or knowledge base, a physician may be hesitant to prescribe such. If a physician believes that it will be in the patient’s best interest to access medical marijuana, the physician may assist the patient in having marijuana prescribed by another New Brunswick physician who is willing to do so. Any such prescribing, by a physician other than the patient’s primary physician, must be done after an appropriate in person assessment and with direct communication to the primary physician. Similarly, if a physician is approached for such a prescription by a patient, such should only be issued after direct communication with the primary physician and after direct assessment of the patient.
The dosing for medical marijuana is complicated. The dose to achieve a particular effect is influenced by the strength of the strain and method of administration, whether by inhalation, ingestion, or other means. There is also anecdotal evidence that different strains of marijuana have varying benefits depending on the clinical condition. The physician need not specify strain or route of administration, but only a maximum daily amount of the dry material which the patient may access. Other issues are to be determined by the patient in concert with the licensed supplier. As a general guideline, patients will usually require between 1g (or less) and 5 grams as a daily dose. If the patient seeks a change in dosage, the physician is entitled to receive information directly from the supplier regarding the specifics of the product that the patient is currently receiving.
Any prescription for medical marijuana should only be on the basis of informed consent. The patient should be adequately warned regarding cautions and risks associated with marijuana. These include safety concerns, such as driving and other activity. The patient should also be warned about obtaining marijuana from another source, from redirecting the patient’s marijuana to another individual, as well as maintaining their supply of marijuana in a secure place. The patient should also be advised about what circumstances would result in a discontinuation of marijuana prescribing by the physician. These issues are best documented in a treatment agreement.
The patient should have complete choice as to the supplier from whom they wish to obtain their prescription. Nevertheless, patients should ideally be limited to a single supplier for the sake of consistency. Any requested changes should be discussed with the physician.
If physicians choose to participate in the production or dispensing of medical marijuana they should be guided by College guidelines on Billing for Uninsured Services, which provides as follows:
When a physician supplies a product or service other than medical care, directly or indirectly, to a patient, and is compensated for same, there is the potential for an ethical conflict.
As noted above, the Code of Ethics precludes “personal gain” as the motive for promoting a product or service.
Thus, it will be presumed that a physician is motivated by personal gain in ordering or dispensing unless this presumption is rebutted by various mitigating factors:
- The product or service is provided at or near cost by the physician.
- The product or service is otherwise unavailable, and continues to be so.
- The product or service is otherwise available, but only at a significantly greater cost or inconvenience to the patient.
- The provision of the product or service requires a particular expertise which is unavailable except through the physician.
In any case, the patient must be made aware of all the alternatives to the provision of the service or product by the physician, such that an informed choice can be made.
Furthermore, in all cases, the physician must be able to demonstrate, if challenged, that any conduct in recommending, ordering, or prescribing a particular product or service was unequivocally in the patient's best interests. [It is acknowledged that “unequivocal” evidence of benefit to this therapy may not always be possible, especially at the start of treatment.]