How Does Prescribing Medical Marijuana Work? A Tutorial for Nurse Practitioners

I have never really looked into prescribing medical marijuana because it is not legal in the state where I live, not to mention its not an area I plan to include in my practice. So, when news sources discuss legal changes to the medical marijuana scene, I always assume that writing a prescription for pot looks something like “smoke one joint q6 hours PRN anxiety”. Not surprisingly, I discovered today that my uneducated assumptions were wrong.

In researching for my last post about states that allow nurse practitioners to prescribe marijuana for medical use, I got some insight into the world of curative cannabis and made some interesting discoveries. For example, medical providers don’t technically prescribe marijuana, rather they “recommend” it to patients as a way of legal approval.

Regardless of your thoughts on the medical marijuana movement, it’s a good idea to stay up to date with the latest changes in medical practice. So, here is a quick tutorial on prescribing marijuana for medical use, its legal background and implications.

Medical Marijuana Laws- A Brief Overview

Medical marijuana use is currently only legal on a state-by-state basis. California began the movement to legalize pot for medical purposes in 1996 and since then a number of states have followed suit. As of May 2014, 22 states had legalized the use of medical marijuana.

State laws vary when it comes to cannabis. Frequently cited restrictions within state laws include who can prescribe marijuana and to whom, how the substance is distributed, how much marijuana patients can possess, and even if patients are allowed to grow their own weed and if so how much. Generally, states do not legalize the buying and selling of medical marijuana, at least not for profit. Laws also typically protect caregivers, such as family members caring for a sick loved one, from prosecution for possession.

At the federal level, marijuana use, for any reason, is technically illegal. However, don’t expect to spend the night in the slammer if you are using the substance prudently for medical purposes. In 2009, U.S. Attorney General Eric Holder stated “It will not be a priority to use federal resources to prosecute patients with serious illnesses or their caregivers who are complying with state laws on medical marijuana”.

Recommending vs. Prescribing- Pot is Not Your Typical Medication

Since marijuana is technically illegal at the federal level, pharmacies are not allowed to carry cannabis, for medical purposes or otherwise. Marijuana is deemed a Schedule 1 substance along the lines of ecstasy and LSD. Categorization as a Schedule I substance means that, in the eyes of the federal government, it has no acceptable medical use. As a result of its illicit status, medical marijuana is currently distributed through dispensaries, or cultivated by patients themselves, rather than handed out at pharmacies.

Given that pharmacies cannot carry cannabis rather than prescribing marijuana, healthcare providers “recommend” it through a state regulated legal process. State laws vary on the exact requirements for “recommending” medical marijuana. For example, in New Mexico the process depends on the patient’s diagnosis. Individuals applying for the state’s Medical Cannabis Program for treatment of chronic pain must provide objective proof of chronic pain, for example X-rays and MRIs and receive two recommendations, one from a primary care physician and one from a specialist. In California, any medical provider can write a recommendation for THC. Some legislators believe California’s laws are too loose and are pushing a bill that would require primary care providers to be involved in “recommending” the controversial therapy.

Will Medical Marijuana Ever Reach the Mass Market?

Currently, a few drug manufacturers are working to put pot into pill form although efforts are made difficult by marijuana’s Schedule I status and federal legal implications. Most recently, the FDA approved a new cannabis-based medication manufactured by drug maker GW Pharmaceuticals to treat childhood-onset epilepsy. The drug is still undergoing the full FDA approval process but preliminary approval was made possible by skirting federal laws using a so called “orphan drug designation”. The “orphan drug designation” is granted by the FDA in cases where a medication is intended to treat rare disorders.

As an increasing number of states adopt medical marijuana laws and federal laws begin to follow suit it is likely more pharmaceutical companies will capitalize on the growing market.

Most Common Implications for Recommending Medical Marijuana

A number of medical conditions are commonly cited by state laws as weed-worthy diagnoses. These conditions include, but are not limited to, cancer, glaucoma, AIDS/HIV, hepatitis C, ALS, Crohn’s disease, Alzheimer’s disease, cachexia, chronic pain, severe nausea, seizures, muscle spasms, multiple sclerosis, anorexia, PTSD, and migraines.

Legal Implications of Recommending Medical Marijuana

As with prescribing any medication, recommending medical marijuana to patients carries legal implications for medical providers. First and foremost, marijuana use, for any reason, breaches federal law. Despite the federal government’s informal declaration to turn a blind eye to the substance, it is still in violation of the law. Recommending cannibas to patients could be seen as aiding and abetting the acquisition of marijuana in court.

Although prescribing medical marijuana in the face of federal laws opposing the practice seems risky, very few providers have actually been prosecuted for doing so. Those that have were most often not acting within a true provider-patient relationship.

Another legal challenge for providers is the lack of research and standardization when it come to medical marijuana use. For example, how much weed constitutes a reasonable amount for a 55 year-old woman seeking pain relief who has never smoked pot? What about a 22 year-old suffering from PTSD who has a history of casual use in the past?

Healthcare providers who decide to prescribe medical marijuana are best off treating THC like other commonly prescribed medications. That means doing so with informed consent. Risks and benefits as well as talking through necessary precautions with patients is a must to prevent legal trouble.

Medical marijuana is a relatively new issue in medicine and a complex one at that. It carries legal, moral, ethical, and scientific implications. As individuals, states, and the federal government work through marijuana’s integration into clinical practice, its role in medicine and the laws regulating its use will continue to evolve.

Will you consider prescribing medical marijuana?

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