Practical Guidelines for Medical Cannabis

Service: Risk Management
Subject: Care
Setting: Medications
Type: Risk Notes

Overview of Issue

Medical cannabis has been authorized for sale in Canada for more than a decade. Medical cannabis refers to the use of marihuana, including constituents of cannabis, Tetrahydrocannabinol (THC) and other cannabinoids, as medical therapy to treat illnesses or alleviate symptoms. In August 2016, Health Canada announced the Access to Cannabis for Medical Purposes Regulations (ACMPR). These regulations replace the Marihuana for Medical Purposes Regulations (MMPR) and allow for reasonable access to cannabis for medical purposes for Canadians who have a medical document from their authorized healthcare practitioner.

Key Points

  • Marihuana (the common name given to cannabis) is the most widely used illicit drug in Canada.
  • Pain is the most common reason for using medical cannabis.
  • An individual who requires cannabis for medical purposes must first get a medical document that contains similar information to a prescription from an authorized healthcare practitioner.

Things to Consider

The Issue

Regulating access to marihuana for medical purposes is complicated by many factors, including:

  • Its status as a controlled substance;
  • Some healthcare practitioners may not feel comfortable nor knowledgeable with prescribing it;
  • Some healthcare practitioners may discourage patients from using it (e.g. due to the potential for exacerbating various mental illnesses);
  • Some healthcare practitioners may be reluctant to ‘re-order or re-assess’ medical cannabis;
  • Some healthcare organizations may not approve the use of medical cannabis, instead offering an alternative cannabinoid or another clinical intervention indicated for the patient’s condition;
  • Depending on how the marihuana is consumed (i.e. smoking or vaping), there may be second hand smoke concerns;
  • Concerns about diversion for non-therapeutic use;
  • Social beliefs and values;
  • Limited research available regarding its clinical efficacy;
  • More information is required on the medical risks.

Legal Status

  • The Government of Canada’s Access to Cannabis for Medical Purposes Regulations (ACMPR) replaced the Marihuana for Medical Purposes Regulations (MMPR) in August 2016. These regulations establish the framework for commercial production by licensed producers responsible for the production and distribution of quality-controlled fresh or dried marihuana, cannabis oil or starting materials (i.e. marihuana seeds and plants) in secure and sanitary conditions, amongst other things.
  • Individuals with a medical need who have a medical document from their authorized healthcare practitioner may access cannabis in three ways. They can:
    • Continue to access quality-controlled cannabis by registering with licensed producers;
    • Register with Health Canada to produce a limited amount for their own medical purposes;
    • Designate someone else to produce it for them.
  • Registered individuals and designated individuals have the ability to alter the dried marihuana they harvest into other products such as oils, subject to certain restrictions. No matter how individuals obtain cannabis, their possession limit is the lesser of a 30-day supply or 150 grams of dried marihuana or the equivalent amount in another form.
  • It remains illegal for a company or an individual to advertise cannabis to the general public.

Other Considerations

  • Oral and buccal (including oromucosal sprays) pharmaceutical forms of cannabinoids (chemicals found in the cannabis plant) are alternate treatment options to dried marihuana. Some individuals use marihuana in foods, teas or with a vaporiser.
    • Marihuana can produce cognitive and memory impairment, changes in mood, altered perception and decreased impulse control. Patients should be cautioned to be supervised when administration is initiated.
    • Patients using marihuana should be warned not to drive or perform hazardous tasks, such as operating heavy machinery (depending on the dose, impairment can last for over 24 hours after last use because of the long half-life).
    • Marihuana use in adolescence poses a risk of harm to the developing brain and could have implications for academic social and occupational functioning extending into later life.
    • Drug tests for screening for marihuana can be positive for weeks after last use. Impairment may be exacerbated with co-consumption of other central nervous system depressants (benzodiazepines, barbiturates, opioids, antihistamines, muscle relaxants or ethanol).
    • Tolerance, psychological and physical dependence can occur with prolonged use of marihuana.

Guidance for Healthcare Practitioners

  • The role of healthcare practitioners is unchanged by the introduction of ACMPR. As with the previous regulations, an individual who requires cannabis for medical purposes must first get a medical document from an authorized healthcare practitioner. The medical document must contain similar information to a prescription, including:
    • the authorized healthcare practitioner’s licence information;
    • the patient’s name and date of birth;
    • a period of use of up to one (1) year; and
    • a daily quantity of dried marihuana expressed in grams.
  • It continues to be up to each healthcare organization to permit the sale, provision or administration of cannabis to its patients.
  • Healthcare organization employees and healthcare practitioners, including physicians and nurse practitioners, may possess fresh or dried marihuana or cannabis oil if possession is for the practice of their profession or for the purposes and in connection with their employment. (ACMPR, 2016)
  • A licensed producer may sell or provide fresh or dried marihuana or cannabis oil to a healthcare organization employee if the possession of the substance is for the purposes of and in connection with employment. In this instance, a written order, in accordance with specifications prescribed in the ACMPR regulations, must be provided by the healthcare organization pharmacist practicing in the healthcare organization or a healthcare practitioner authorized to place orders for that substance on behalf of the healthcare organization. (ACMPR, 2016)
  • Develop/update policies on medical cannabis use in the healthcare organization.
  • Authorized healthcare practitioners should practice discretion in authorizing the patient’s self administration of medical cannabis ensuring this is done in accordance with organizational policy.
  • To provide clarity for professional staff and employees, consider developing a Consent and Waiver form for use in the admission process to address applicable circumstances for the healthcare practitioners when they authorize the self-use of medical cannabis and for when they do not authorize its use during the patient’s admission.
  • When an admitted patient is using medical cannabis:
    • Consider empowering the patient to use his/ her own prescription/supply (preferably ingested rather than smoked);
    • Determine where the patient is authorized to use the medical cannabis (e.g. restrict to the designated smoking area or off property if there is no smoking area) and reinforce with the patient to be discreet when using medical cannabis;
    • Consider the use of vaporizers that do not produce second-hand smoke;
    • Alert Security (as a courtesy notification and with the patient’s consent) that the patient is authorized to use medical cannabis;
    • Familiarize the patient with the pertinent organizational procedures on the use of medical cannabis and obtain the patient’s agreement to follow these procedures;
    • Document the above discussion in the patient’s health record;
    • Assess the patient’s pain management as per organizational protocol and document in the patient’s health record;
    • Devise methods for the patient to keep the medical cannabis in a secure place (e.g. locked bedside table drawer; locked cupboard);
    • Minimize the handling or storage of the patient’s supply by professional and administrative staff and implement a standard procedure for such.

References