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Cannabis for Medical Purposes

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Approved by Council: May 2002
Reviewed and Updated: November 2005; April 2006; March 2015; December 2016; January 2019

 

Policies of the College of Physicians and Surgeons of Ontario (the “College”) set out expectations for the professional conduct of physicians practising in Ontario. Together with the Practice Guide and relevant legislation and case law, they will be used by the College and its Committees when considering physician practice or conduct.

Within policies, the terms ‘must’ and ‘advised’ are used to articulate the College’s expectations. When ‘advised’ is used, it indicates that physicians can use reasonable discretion when applying this expectation to practice.

 

Definitions

Cannabis (marijuana): Throughout this policy, the terms “cannabis” and “cannabis for medical purposes” should be understood to mean not only dried cannabis, but also any other form of cannabis that is legally permitted for medical use.1

Medical document: The Cannabis Regulations2 require that patients obtain a “medical document” completed by an authorized healthcare practitioner in order to access a legal supply of cannabis 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, and the daily quantity of cannabis to be used by the patient, among other information.3

Prescription: It is the College’s position that the medical document is equivalent to a prescription. Throughout this policy, the term “prescription” should be understood to include the completion of a medical document in accordance with the Cannabis Regulations.

 

Policy

  1. When prescribing cannabis for medical purposes, physicians must comply with:
    1. the requirements for prescribing cannabis that are set out in this policy,
    2. the general expectations for prescribing that are set out in the College’s Prescribing Drugs policy,
    3. any other relevant College policies,4 and
    4. relevant legislation.5

Before Prescribing

As with any treatment, physicians are not obligated to prescribe cannabis if they do not believe it is clinically appropriate for the patient.6

  1. Physicians must always practise within the limits of their knowledge, skills, and judgment, and not provide care that is beyond the scope of their clinical competence.7, 8

Assessing the appropriateness of cannabis for the patient

  1. Physicians must carefully consider whether cannabis is the most appropriate treatment for the patient.9
  2. In making this determination, physicians must:
    1. consider the risks associated with the use of cannabis;10 and
    2. weigh the available evidence in support of cannabis against other available treatment options, including the oral and buccal11 pharmaceutical form of cannabinoids.
  3. Physicians must comply with the applicable standard of practice when assessing the risk of cannabis to their patients, and take such steps as are clinically indicated in the specific circumstances of each case to mitigate those risks.12

Prescribing to patients under the age of 25

  1. As evidence strongly suggests that the risks of cannabis are greater for youth and young adults, physicians must not prescribe cannabis to patients under the age of 25 unless all other conventional therapeutic options have been attempted and have failed to alleviate the patient’s symptoms.13
  2. Even after all other conventional therapeutic options have been exhausted, physicians must still be satisfied that the anticipated benefit of cannabis outweighs its risk of harm.

Obtaining consent

  1. Physicians must always obtain valid and informed consent in accordance with their legal obligations14 and the College’s Consent to Medical Treatment
    1. In keeping with this obligation, physicians must advise patients about the material risks15 and benefits of cannabis, including its effects and interactions, material side effects, contraindications, precautions, and any other information pertinent to its use.
    2. Physicians must also caution all patients who engage in activities that require mental alertness that they may become impaired while using cannabis.16

When Prescribing

  1. Absent established clinical guidelines, physicians must proceed cautiously when determining what dosage to prescribe:
    1. Physicians are advised to initiate prescribing with a low quantity of cannabis17 and using strains and/or formulations that are low in the psychoactive compound tetrahydrocannabinol (THC)18.
  2. Physicians must specify on every prescription the quantity of cannabis to be dispensed to the patient as well as the percentage of THC it must contain.
  3. Physicians must monitor patients for any emerging risks or complications.
  4. Physicians must discontinue prescribing where cannabis fails to meet the physician’s therapeutic goals or the risks outweigh the benefits.
  5. 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 College’s Prescribing Drugs policy.
  6. Physicians are further advised to require patients to sign a written treatment agreement.19
    1. This agreement must contain, at minimum, a statement from the patient that they: will not seek cannabis from another physician or any other source, will only use cannabis as prescribed,  will store their cannabis in a safe and secure manner, and will not sell or give away their cannabis.
    2. It is advised that the treatment agreement contain a statement that if the agreement is breached, the physician may decide not to continue prescribing cannabis to the patient.

 Charging Fees

  1. Physicians must not charge patients or licensed producers of cannabis for completing a 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 cannabis, or confirming the validity of a prescription in accordance with the Cannabis Regulations.20
 

Endnotes

1. The College has no formal position or guidance with respect to the consumption of cannabis for recreational purposes.

2. Cannabis Regulations, SOR/2018-144.

3. Section 273 of the Cannabis Regulations.

4. Including, but not limited to, the Dispensing Drugs, Complementary/Alternative Medicine, and Telemedicine policies.

5. The Government of Canada’s Cannabis Regulations establish the legal framework that enables patients to obtain authorization to possess cannabis for medical purposes. The recreational consumption of cannabis, which is not addressed in this policy, is governed by separate legislation.

6. Physicians may sometimes have difficulty addressing patient disagreement with a decision not to prescribe cannabis. 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.

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 Public Health Emergencies policy for more detail.

9. While conclusive evidence regarding the safety and effectiveness of cannabis 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 are reminded that resources may become outdated as further research is undertaken in this field.

10. Evidence shows that risks may include, among others: a risk of addiction; the onset or exacerbation of mental illness, including schizophrenia; and – when smoked – symptoms of chronic bronchitis. For a more complete overview of the adverse health effects associated with the consumption of cannabis, please see: Volkow, N.D, et al. (2014).  Adverse Health Effects of Marijuana Use. The New England Journal of Medicine. 370(23): 2219-2227.

11. Buccal pharmaceutical cannabinoids include oromucosal sprays.

12. The published literature with respect to cannabis 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; and an assessment of risk factors for psychotic disorders, mood disorders, and other mental health issues that may be affected by the use of cannabis.

13. Current evidence strongly suggests that children, adolescents, and young adults who consume cannabis are at a greater risk than older adults for cannabis-associated harms, including suicidal ideation, illicit drug use, cannabis use disorder, and long-term cognitive impairment. 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.

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

15. 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.

16. The consumption of cannabis has been correlated with an increased risk of traffic accidents based on epidemiological studies. For more information on the impact of cannabis 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.

17. While there are currently no established clinical guidelines setting out appropriate dosages for cannabis in any formulation, 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.

18. Tetrahydrocannabinol (THC) is the primary psychoactive compound found in cannabis. At high levels, THC has been correlated with cannabis-related harm and is more likely to produce undesirable psychoactive effects in patients.

19. 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.

20. The College considers the medical document authorizing patient access to cannabis to be equivalent to a prescription. Prescriptions, together with activities related to prescriptions, are insured services. 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.