Marijuana for Medical Purposes


Policy Number:#1-15
Policy Category: Drug/Prescribing
Under Review: No
Approved by Council: May 2002
Reviewed and Updated: November 2005; April 2006; March 2015
College Contact: Physician Advisory Service

Downloadable Version(s): Marijuana for Medical Purposes


Introduction

The Government of Canada’s Marihuana for Medical Purposes Regulations (MMPR)1 establish the legal framework that enables patients to obtain authorization to possess dried marijuana for medical purposes.

Under these regulations, physicians have primary responsibility for the decision to authorize patient use of dried marijuana for medical purposes.2 Physicians enable patients to access a legal supply of dried marijuana by completing a medical document that functions like a conventional prescription.

While conclusive evidence regarding the safety and effectiveness of dried marijuana as a medical treatment is limited, many patients, physicians, and researchers have voiced support for the cautious and compassionate use of dried marijuana, particularly where other therapeutic options have been exhausted and failed to alleviate the patient’s symptoms. Furthermore, court rulings have required reasonable access to a legal source of dried marijuana for medical purposes when authorized by a physician.3

In keeping with the College’s mandate to serve and protect the public,4 this policy sets out expectations for physicians relating to the prescribing of dried marijuana for medical purposes.

These expectations are grounded in the principles of medical professionalism set out in the Practice Guide, and take into account the best available evidence regarding the medical use of dried marijuana.

Principles

The key values of professionalism – compassion, service, altruism and trustworthiness – form the basis for the expectations set out in this policy. Physicians embody these values and uphold the reputation of the profession by:

  1. Acting in the best interests of their patients;
  2. Demonstrating professional competence, which includes maintaining the medical knowledge and clinical skills necessary to prescribe appropriately;
  3. Collaborating effectively and respectfully with patients, physicians and other health-care providers;
  4. Avoiding or appropriately managing conflicts of interest;5 and
  5. Participating in the self-regulation of the medical profession by complying with the expectations set out in this policy.

Purpose & Scope

This policy sets out the College’s expectations of all physicians who prescribe dried marijuana for medical purposes.

As the MMPR permit physicians to prescribe marijuana in a dried form only, this policy does not address alternative forms of marijuana, such as cannabis oils or edible products.

Terminology

Marijuana: Throughout this policy, the terms “marijuana” and “dried marijuana” should be understood to mean only harvested marijuana that has been subjected to a drying process.

Medical document: The MMPR require that patients obtain a medical document completed by an authorized health-care practitioner in order to access a legal supply of dried marijuana for medical purposes. The medical document contains information that would normally be found on a prescription, including the patient’s name, the physician’s name and CPSO number, the daily quantity of dried marijuana to be used by the patient, and the period of use, among other information.6 Completed medical documents must be submitted directly to a federally licensed producer of dried marijuana in order for dried marijuana to be dispensed to the patient.

Prescription: Throughout this policy, the term “prescription” should be understood to include the completion of a medical document in accordance with the MMPR.

Policy

It is the College’s position that the medical document required under the MMPR is equivalent to a prescription.

Physicians who prescribe dried marijuana must comply with the expectations set out in this policy, as well as the expectations and guidelines for prescribing that are set out in the College’s Prescribing Drugs policy. Physicians must also ensure compliance with the MMPR and any other relevant College policies, including, but not limited to, the Dispensing Drugs, Complementary/Alternative Medicine, and Telemedicine policies.

1. Before Prescribing

Physicians must always practise within the limits of their knowledge, skills and judgment7, and never provide care that is beyond the scope of their clinical competence.8 As with any treatment, physicians are not obligated to prescribe dried marijuana if they do not believe it is clinically appropriate for their patient.9

Assessing the appropriateness of dried marijuana for the patient
Before a physician may prescribe dried marijuana, he/she must carefully consider whether it is the most appropriate treatment for their patient.10

As part of this process, physicians must weigh the available evidence in support of dried marijuana against other available treatment options, including the oral and buccal11 pharmaceutical form of cannabinoids.

Physicians must also consider the risks associated with the use of dried marijuana, which may include, among others, a risk of addiction, symptoms of chronic bronchitis, and the onset or exacerbation of mental illness, including schizophrenia.12

Physicians are expected to comply with the applicable standard of practice when assessing the risk of dried marijuana to their patients and take such steps as are clinically indicated in the specific circumstances of each case to mitigate those risks. The published literature with respect to dried marijuana provides some general guidance as to some of the recommended components in such a risk assessment. These include, among others, an assessment of each patient for their risk of addiction and substance diversion,13 and an assessment of risk factors for psychotic disorders, mood disorders, and other mental health issues that may be affected by the use of dried marijuana.

Prescribing to patients under the age of 25
Current evidence strongly suggests that children, adolescents, and young adults who consume dried marijuana are at a greater risk than older adults for marijuana-associated harms, including suicidal ideation, illicit drug use, cannabis use disorder, and long-term cognitive impairment.14 Given the potentially severe nature of these risks, physicians must not prescribe dried marijuana to patients under the age of 2515 unless all other conventional therapeutic options have been attempted and have failed to alleviate the patient’s symptoms.

Even after all other conventional therapeutic options have been exhausted, physicians must still be satisfied that the anticipated benefit of dried marijuana outweighs its risk of harm.

Obtaining consent
In order to authorize any therapeutic intervention, physicians must always obtain valid and informed consent in accordance with their legal obligations16 and the College's Consent to Medical Treatment policy.

In keeping with these obligations, physicians who prescribe dried marijuana must advise patients about the material risks17   and benefits of dried marijuana, including its effects and interactions, material side effects, contraindications, precautions, and any other information pertinent to its use. As part of this discussion, physicians must caution all patients who engage in activities that require mental alertness that they may become impaired while using dried marijuana.18

Furthermore, the College recommends that physicians explain to the patient the extent and quality of the evidence that informs their understanding of the appropriateness of dried marijuana for their clinical condition.

2. When Prescribing

Determining a safe and effective dose
Unlike conventional pharmaceutical products, dried marijuana is available in a variety of strains that vary significantly in their potency and chemical composition. Furthermore, research suggests that there are significant differences among patient sensitivities to the psychoactive and therapeutic effects of dried marijuana. For these reasons, determining a safe and effective dose for each patient may be challenging.

Absent established clinical guidelines, physicians must proceed cautiously: the College recommends that physicians initiate treatment with a low quantity of dried marijuana19 and prescribe only strains that are low in the psychoactive compound tetrahydrocannabinol (THC).20 Where the initial prescription proves ineffective, physicians may incrementally increase the quantity prescribed and/or substitute strains higher in THC until a dose is reached that achieves symptom management while causing minimal euphoria or cognitive impairment.

In order to ensure that the above expectations are met, physicians must specify on every prescription the quantity of dried marijuana to be dispensed to the patient as well as the percentage of THC it must contain.

Managing the risk of abuse, misuse and diversion
Dried marijuana, like many other conventionally prescribed drugs, carries with it a risk of abuse, misuse and diversion. As the risks posed by dried marijuana are not fundamentally different from those posed by other controlled drugs, physicians are advised to follow the guidelines for managing the risk of abuse, misuse and diversion of narcotics and controlled substances set out in the Prescribing Drugs policy.

As with any drug, physicians who prescribe dried marijuana must monitor patients for any emerging risks or complications. Prescribing must be discontinued where dried marijuana fails to meet the physician’s therapeutic goals or the risks outweigh the benefits.

The College also recommends that physicians who prescribe dried marijuana first require patients to sign a written treatment agreement.21 This agreement must contain, at minimum, a statement from the patient that they: will not seek dried marijuana from another physician or any other source; will only use dried marijuana as prescribed; will store their dried marijuana in a safe and secure manner; and will not sell or give away their dried marijuana. It is recommended that the treatment agreement contain a statement that if the agreement is breached, the physician may decide not to continue prescribing dried marijuana to the patient.

3. Charging Fees

The College considers the medical document authorizing patient access to dried marijuana to be equivalent to a prescription. Prescriptions, together with activities related to prescriptions, are insured services. Accordingly, physicians must not charge patients or licensed producers of dried marijuana for completing the medical document, or for any activities associated with completing the medical document, including, but not limited to: assessing the patient; reviewing his/her chart; educating or informing the patient about the risks or benefits of dried marijuana; or confirming the validity of a prescription in accordance with the MMPR.

Physicians who are unsure about what services they may charge for are advised to refer to the College’s Block Fees and Uninsured Services policy and the OHIP Schedule of Benefits for further guidance.

Endnotes

1. Marihuana for Medical Purposes Regulations, SOR/2013-119.

2. The MMPR authorize both physicians and nurse practitioners to prescribe dried marijuana for medical purposes; however, to date the College of Nurses of Ontario has not permitted their members to prescribe.

3. R. v. Mernagh, 2011 ONSC 2121.

4. Section 3(2) of the Health Professions Procedural Code, Schedule 2 of the Regulated Health Professions Act, 1991, S.O. 1001, c.18 (hereinafter HPPC).

5. For more information on conflicts of interest, please see Part IV of the General, O. Reg., 114/94, enacted under the Medicine Act, 1991, S.O. 1991, c. 30  (hereinafter Medicine Act, General Regulation).

6.  Section 129 of the Marihuana for Medical Purposes Regulations.

7. Sections 2(1)(c), 2(5), O. Reg. 865/93, Registration, enacted under the Medicine Act, 1991, S.O. 1991, c.30; Changing Scope of Practice policy; The Practice Guide.

8. This expectation applies to all non-emergent situations. In emergency situations, physicians may be permitted to act outside their scope of expertise in some circumstances. See the Physicians and Health Emergencies policy for more detail.

9. Physicians may sometimes have difficulty addressing patient disagreement with a decision not to prescribe dried marijuana. Recommendations for communicating with patients about this decision can be found in Kahan, Meldon, et al. (2014). Prescribing Smoked Cannabis for Chronic Noncancer Pain: Preliminary Recommendations. Canadian Family Physician, 60, 1083-1090.

10. While conclusive evidence regarding the safety and effectiveness of dried marijuana is currently limited, there are a number of resources physicians can consult for more information. These include, among others: Health Canada’s Information for Health Professionals webpage; the College of Family Physicians of Canada’s Authorizing Dried Cannabis for Chronic Pain or Anxiety: Preliminary Guidance; and Kahan, Meldon, et al. (2014). Prescribing Smoked Cannabis for Chronic Noncancer Pain: Preliminary Recommendations. Canadian Family Physician, 60: 1083-1090. Physicians must be mindful that resources may become outdated as further research is undertaken in this field.

11. Buccal pharmaceutical cannabinoids include oromucosal sprays.

12. For a more complete overview of the adverse health effects associated with the consumption of dried marijuana, please see: Volkow, N.D, et al. (2014).  Adverse Health Effects of Marijuana Use. The New England Journal of Medicine. 370(23): 2219-2227.

13. Physicians who wish to find further guidance with respect to preventing prescription drug abuse and assessing patients for their risk of addiction should refer to the National Opioid Use Guideline Group, Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain and the Specific Issues in Prescribing: Narcotics and Controlled Substances section of the College’s Prescribing Drugs policy.

14. For more information, please see Volkow, N.D, et al. (2014). Adverse Health Effects of Marijuana Use. The New England Journal of Medicine. 370(23): 2219-2227, Health Canada’s Information for Health Professionals webpage, the Centre for Addiction and Mental Health’s Cannabis Policy Framework, and the College of Family Physicians of Canada’s Authorizing Dried Cannabis for Chronic Pain or Anxiety: Preliminary Guidance.

15. Current evidence suggests that children, adolescents, and young adults are at a higher risk of experiencing the harmful effects of marijuana. This may be because their brains are still undergoing a process of neural development, during which they are more vulnerable to the harmful effects of certain chemical compounds found in marijuana. Until the effects of marijuana on the developing brain are better understood, all patients within the period of neural development – which continues from the prenatal period until the mid 20’s – must be considered higher risk for marijuana-related harm.

16. Health Care Consent Act, 1996, S.O. 1996, c. 2, Sched. A.

17. The material risks that must be disclosed are risks that are common and significant, even though not necessarily grave, and those that are rare, but particularly significant. In determining which risks are material, physicians must consider the specific circumstances of the patient and use their clinical judgment to determine the material risks.

18. An important consideration is the impact that the consumption of dried marijuana may have on an individual’s ability to safely operate a motor vehicle. The consumption of marijuana has been correlated with an increased risk of traffic accidents based on epidemiological studies. For more information on the impact of dried marijuana on driving, please see: Neavyn, M, Blohm, E, & Babu, K. (2014). Medical Marijuana and Driving: A Review. American College of Medical Toxicology. DOl l0.1007/s13181-014-0393-4.

19. While there are currently no established clinical guidelines setting out appropriate dosages for dried marijuana, more information on dosing can be found on Health Canada’s Information for Health Professionals webpage and the College of Family Physicians of Canada’s Authorizing Dried Cannabis for Chronic Pain or Anxiety: Preliminary Guidance document.

20. Tetrahydrocannabinol (THC) is the primary psychoactive compound found in dried marijuana. It is responsible for the “high” that users experience when consuming dried marijuana, but may also be responsible for some of marijuana’s beneficial therapeutic effects. At high levels, THC has been correlated with marijuana-related harm and is more likely to produce undesirable psychoactive effects in patients. While some commercially available strains of dried marijuana contain THC concentrations as high as 30%, the College of Family Physicians of Canada’s Authorizing Dried Cannabis for Chronic Pain or Anxiety: Preliminary Guidance document suggests that current evidence does not support prescribing dried marijuana with a THC concentration greater than 9%.

21. Treatment agreements are formal and explicit agreements between physicians and patients that delineate key aspects regarding adherence to the treatment. A sample treatment agreement can be found in the College of Family Physicians of Canada’s Authorizing Dried Cannabis for Chronic Pain or Anxiety: Preliminary Guidance document.

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