ARTICLE IN BRIEF
Neurologists who conduct research on medicinal marijuana and neuroethicists respond to the guidelines by the Federation of State Medical Boards on how to approach patients who request prescriptions for medical marijuana.
Doctors who prescribe or recommend marijuana to patients for medicinal purposes should follow the same procedures they use when prescribing any medication: fully evaluate the patient; go over the drug's potential benefits and risks; document the decision in the medical record; and schedule follow-up appointments to monitor the effect of marijuana on the patient's health and overall functioning.
Doctors also need to consider patients' mental health and substance abuse history in deciding if medical marijuana is an option, according to a new policy recommendation by the Federation of State Medical Boards (FSMB), whose members includes 70 state and territorial licensing boards around the United States. [See “Guidelines for Prescribing Marijuana.”]
As more states approve the use of marijuana in various forms for medicinal and recreational purposes, doctors are increasingly being asked about marijuana by their patients. Neurologists in particular face such questions because of some research and anecdotal reports suggesting marijuana could be helpful in the treatment of intractable epilepsy, multiple sclerosis and other neurologic conditions.
Because marijuana remains banned by the federal government, except in a few special medical circumstances, doctors face both ethical and legal consideration in deciding whether to prescribe or recommend something that is legal in their state but not at the national level.
“The guidelines should in no way be construed as encouraging or endorsing physicians to recommend marijuana as part of patient care,” noted the document, released in April by the FSMB. But it also recognized the reality that “over the past two decades, the attitudes and laws in the United States have become more tolerant towards marijuana, with the proportion of adults using the substance doubling between 2001 and 2013.”
Humayun Chaudhry, DO, chief executive officer of FSMB, said that “as this issue gained traction across the country, it became clear there was a lack of information to guide regulators.” He said state medical boards requested that the FSMB develop a guidance document.
In a follow-up viewpoint piece in the August 9 edition of the Journal of the American Medical Association, Dr. Chaudhry wrote that even if the model guidelines are not adopted point by point by every state licensing board, he hopes they are seen as a “reasonable effort to offer best practices for clinicians to follow when considering marijuana in patent care.”
Approximately 25 states and the District of Columbia allow for medical marijuana, though the regulations on under what conditions and in what form it can be prescribed differ from state to state and some programs are still in the early stages of implementation. Keeping up with the changes can be very hard for physicians.
“This is a fluid area of law and medicine that is in transition,” Dr. Chaudhry told Neurology Today. “We will continue to monitor it closely.”
NEW GUIDELINES WELCOME
Judy Illes, PhD, Canada research chair in neuroethics and professor of neurology at the University of British Columbia, said the new guidelines should prove helpful to both medical licensing boards and physicians.
“It is sage guidance that provides a framework for physicians to operate in this new culture and world of medical marijuana,” Dr. Illes told Neurology Today. She said she appreciated that the recommendations draw on “the strengths of well-established best practices” for arriving at informed treatment decisions instead of casting medical marijuana as a totally fringe therapy that doesn't merit consideration. As part of good medical practice, clinicians need to be as informed as they can be on the latest scientific evidence, whether it's about marijuana or a new drug on the market, she said.
“I was delighted to see [the FSMB guideline] has added considerations for individuals with a mental health or substance abuse history,” she said. “Clinical medicine needs to give special consideration to all vulnerable people.”
While offering a lot of practical advice, the guidelines may not settle the conflict many doctors feel, perhaps both professionally and personally, about medical marijuana, including the fact that clinical research on the drug's efficacy is still limited, and federal law does not support medicinal or recreational use. Marijuana is classified as a Schedule I drug under the Controlled Substances Act, and the federal Drug Enforcement Agency said recently that it has no plans to loosen the designation.
“For physicians practicing in a state where medical marijuana is allowed...there is ambiguity and uncertainty about what they should do,” said James L. Bernat, MD, FAAN, professor of neurology and medicine and Louis and Ruth Frank chair of neuroscience at Dartmouth College Geisel School of Medicine.
He said he would not be comfortable at this point in prescribing medical marijuana, even if New Hampshire law permitted it, because “research showing safety and efficacy is very limited.” Also unknown is how marijuana may affect other medications a patient is taking.
Dr. Bernat's patients often come to appointments requesting a drug they saw advertised on TV, but the doctor is not required to prescribe it if the drug is not appropriate for the patient or has a short track record of safety and efficacy.
“It's up to the doctor's discretion,” he said.
MARIJUANA CLASSIFIED NOT JUSTIFIED
Orrin Devinsky, MD, FAAN, director of the Epilepsy Center at New York University Langone Medical Center and a registered prescriber of marijuana in New York State, said the new guidelines make sense because they encourage doctors to apply the same professional standards they use for every medical encounter. He prescribes marijuana, in oil or capsule form, to some of his epilepsy patients and has been involved in clinical trials of cannabidiol, a marijuana extract, for adults and children with a rare form of epilepsy not treatable by standard medicines.
Dr. Devinsky agreed that there is a need for more medical research, and specifically clinical trials, to determine the safety and efficacy of specific medical marijuana formulations, but he said the classification of marijuana as a Schedule I drug “flies in the face of scientific evidence and isn't based on a fair and balanced reading of the scientific literature.”
The Obama administration, while not easing the classification of the drug, moved earlier this month to institute new rules that will allow more research institutes to grow marijuana for study purposes, rather than allowing only a research center at the University of Mississippi to do so. Wider availability of various types of marijuana could encourage more medical research.
David Gloss, MD, a neurologist in private practice in Charleston, WV, said he understands the dilemma doctors face when it comes to marijuana. [Dr. Gloss was the coauthor of an editorial in the August 2015 issue of Neurology: Clinical Practice about the AAN guideline on medical marijuana, published in 2014.]
“I have patients come to me and say, ‘Can I get a prescription for medical marijuana so I can go to another state and get it?’” Dr. Gloss said. He doesn't pull out his prescribing pad, but tries to use the moment to educate patients about what the evidence is and isn't for marijuana for their given condition.
“I don't get into a political discussion,” he said, noting that most patients are appreciative of having their medical questions answered in a non-judgmental way.
Dr. Gloss said that while the question of whether to legalize marijuana may be a pressing social issue, more patients he sees are far more worried about having health insurance and paying for their prescription drugs. “People just want help,” he said.
GUIDELINES ON PRESCRIBING MARIJUANA
The FSMB recommendations set forth some basic ground rules for doctors who choose to prescribe or make a referral for medical marijuana:
- The doctor should adhere to current stands of practice and comply with state laws, rules and regulations, which may specify conditions for which a patient may quality.
- The doctor's office should not be located at a marijuana dispensary or cultivation center. The doctor should not receive financial compensation from or hold a financial interest in marijuana-related businesses or be affiliated with them in any way.
- The physician should not use marijuana either medicinally or recreationally while actively engaged in the practice of medicine.
The recommendations also focus on specifics of the office visit:
- There should be an established doctor-patient relationship before the doctor considers the use of medical marijuana.
- The doctor should do a physical exam and gather health history, including documentation of previous therapies used by the patient and information on any personal or family history of substance abuse, mental illness or psychotic disorders. The diagnosis should justify the consideration of medical marijuana.
- The doctor should review other treatment options. The known benefits and risks of marijuana should be presented, along with the warning that, unlike with FDA-approved drugs, there is variability and lack of standardization in marijuana preparation.
- If the medical marijuana is chosen, a specific treatment plan for a limited period of time should be agreed on, with details documented in the medical record. The doctor should instruct the patient not to drive or operate heavy machinery while using marijuana.
- The patient should be seen for follow-up visits to monitor for efficacy and side effects of medical marijuana.
- Patients with a history of mental health problems, substance abuse or addiction should be referred for further evaluation as needed.