Cannabis Can Be Confusing - apma.org 2019 v7 salt... · Cannabis Can Be Confusing Common...
Transcript of Cannabis Can Be Confusing - apma.org 2019 v7 salt... · Cannabis Can Be Confusing Common...
Cannabis Can Be Confusing
Common Misconceptions & The Role of Podiatrists and Healthcare Professionals in
Certifying Patients Throughout the USA
Saturday, July 13, 2019 / 10:40–11:20 a.m / PAIN MANAGEMENT TRACK
Leslie McAhren, MFA, MPH, FF DrPH (‘20) Environmental & Occupational Health University of Colorado School of Public Health Anschutz Medical Campus E: [email protected] P: 303.724.1271
What You Will Learn Today
Podiatrists will be supported by evidence-based information as they understand options for patient care and medical cannabis
What are you really doing?
Certifying that a patient has a condition that may be treated by medical cannabis
Post, 2019
11 States Have Fully Illegal Cannabis
• Idaho • Kentucky • Kansas • Mississippi • Nebraska
• North Carolina • South Carolina • South Dakota • Tennessee • Wisconsin • Wyoming
Last updated July 12, 2019
Common Misconceptions About Medical
Cannabis
“All states are going to legalize it” – so – doctors don’t need to learn about medical cannabis
”Podiatrists can’t recommend medical cannabis.” Only MDs and DOs can.
“The use of cannabis is not evidence-based.”
“Cannabis is not as effective at treating pain as opiates or other analgesics.”
More Misconceptions About Medical
Cannabis
“Sustainably grown cannabis is no different than indoor cultivation.”
“Pesticides aren’t a concern.”
“Residual solvents aren’t a problem in the extraction of cannabis.”
EXAMPLE. in Maryland
Maryland Produces A Diversity In Cannabis Program Report
Preliminary Industry Ownership Demographics Industry Totals
35% Racial and Ethnic Diversity Participation 57% Minority Participation Including Females
Preliminary Industry Employee Demographics Industry Totals
58% Racial and Ethnic Diversity Participation 75% Minority Participation Including Females
§§13-3306, 13-3307, 13-3309
EXAMPLE. in Maryland
Maryland defines a certifying physician as Health Occupations Article, §14-101(i), Annotated Code of Maryland.
§14-101(i), Annotated Code of Maryland Connecticut General Statutes Chapter 420f, Section 21a-408
EXAMPLE. in Maryland
Gray Area & State Websites “Any Provider with an active, unrestricted license in good standing with the Maryland State Board, and actively registered to prescribe controlled substances in Maryland, is eligible to register with the Maryland Medical Cannabis Commission, Attending of Hospice Record (AOHR) physician; must register as a “Certifying Provider” Connecticut is similar: chapter 370 and 378 only - not 375 podiatry
§14-101(i), Annotated Code of Maryland Connecticut General Statutes Chapter 420f, Section 21a-408
EXAMPLE. in Maryland
Providers may enroll in an online medical education curriculum developed by TMCIGlobal
Any non-Maryland resident currently in Maryland for the purpose of receiving medical treatment is eligible to register as a patient with the MMCC
§14-101(i), Annotated Code of Maryland
Certifying That A Patient Has A Condition
That May Be Treated By Medical Cannabis
Every state has a “provider certification form”
Example: Vermont 4 page document
https://medicalmarijuana.vermont.gov/sites/vmr/files/documents/Health%20Care%20Professional%20Form%20201801.pdf
Evidence-Based Medicine
From the National Academy of Medicine (2017)
From New Jersey
https://www.nj.gov/health/medicalmarijuana/documents/scholarly_articles.pdf
NAM, 2017
Evidence-Based Medicine
“There is conclusive, substantial evidence that cannabis or cannabinoids are effective for the treatment for chronic pain in adults”
“Cannabis acts both locally and centrally to relive pain and inflammation.”
NAM, 2017
What About Liability? (Schedule 1 Drug)
Conant v. Walters (2002) Case
There have been no criminal or administrative proceedings against doctors to date
Some States Address Liability In State Law
Example: Connecticut
Sec. 21a-408c. Physician or advanced practice registered nurse issuance of written certification. Requirements “Not subject to arrest, prosecution or certain other penalties.”
Handout & Sample Physician Form
Covered All MC States In Handout
take a photo on your phone
Arkansas Physician Form: https://www.healthy.arkansas.gov/images/uploads/pdf/easy_Instructions_for_Phys_cert-FINAL_JG.pdf
Typical Physician Requirements
1. Patient has been diagnosed with a qualifying debilitating medical condition
2. Conclusion of the patient's physician that the patient might benefit from the medical use of cannabis
3. Established medical record for the qualifying patient and am maintaining the qualifying patient's medical record as required
4. May have to provide a certified copy of documentation or EHR printout
#1 You Can’t Write Prescriptions For
Medical Cannabis
TRUE! MEDICAL CANNABIS CANNOT BE PRESCRIBED. Physicians can only prescribe
Schedule II-V controlled substances to their patients. The federal government classifies cannabis as a Schedule I drug, which means a physician cannot
prescribe it. However, a physician may certify their patient for use of medical cannabis by utilizing state medical cannabis certification forms. The certification is
valid for some period from date of certification.
#2 DPMs Can’t Offer
Medical Cannabis As A Therapeutic Option
FALSE In NM, CA, NV, & IL, DPMs CAN SIGN THE RECOMMENDATION FOR PATIENTS. The DPM is licensed to prescribe opioids, and many other
medications far more potentially dangerous than cannabis. States where NPs are authoriaed are ripe targets for policy change.
#3 Patients Aren’t Inconvenienced By Not Having A Medical Cannabis Card
INABILITY TO OBTAIN MEDICAL CANNABIS DENIES -- OR AT A MINIMUM INCONVENIENCES -- PATIENTS FOR WHOM MEDICAL CANNABIS IS A LEGITIMATE THERAPEUTIC OPTION. Medical cannabis programs are sometimes tax free. This is
an advantage over the recreational marketplace, which seeks to produce tax revenue for community projects. Medical cannabis retails offers higher dosing and more CBD
offerings than recreational options in most states (ex. CO 100mg vs. 500mg in medical)
FALSE
#4 Podiatrists Need To Be Proactive on
The Matter Of Medical Cannabis
LICENSING IS LIMITED AND DPMs NEED TO ADVOCATE FOR INCLUSIVE POLICY . Current policy disadvantageously positions the DPM in the medical market place as an
alternative care provider. DPMs should take CMEs alongside MDs and Dos. Anyone with prescriptive authority to write prescriptions for controlled substances should be allowed to recommend a patient to the program, if the provider has a state Medical License #, a DEA
License # and a state Controlled Substance License #. Such providers could gain reciprocity in other states.
TRUE!
#5 Regulation For DPMs Varies State-
By-State
APMA AND STATE PODIATRY ASSOCIATIONS CAN OFFER CERTIFIED TRAINING FOR DPMS IN MEDICAL CANNABIS (CME’S). Current training available generally does not offer recognized certification for a DPM (2-4 hours). Encourage DPMs to become active with state legislatures to correct this error. Be prepared to know your state regs and keep the handout
to reference patient-focused policies in other states.
TRUE!
#6 APMA Policy is Clear
“THE AMERICAN PODIATRIC MEDICAL ASSOCIATION (APMA) SUPPORTS EVIDENCE-BASED TREATMENT WITH MEDICAL
MARIJUANA when it provides a therapeutic and palliative benefit…”
APMA's 2017 HOD passed Resolution 11-17
TRUE!
#7 Any View That Comes Across as Anti-Pot
Seems To Be A Source Of Contention
AS A PUBLIC HEALTH PROFESSIONAL I BELIEVE IN EVIDENCE-BASED POLICY AND EVIDENCE-BASED MEDICINE. The benefits have to outweigh the risks. I’m into
harm reduction - not harm promotion. Cannabis has plenty of risks: DUIC, infertility, schizoaffective disorder. There is a 20 year review in the bibliography. As it stands, we are conducting a natural experiment around cannabis and I appreciate skeptical opinions
because these may be the opinions that best protect the public’s health.
FALSE
#8 Cannabis is a Gateway Drug for
Heroin
THE GATEWAY DRUG HYPOTHESIS HAS BEEN DISPROVEN. Yet, Human beings can become addicted to anything. Persons with a family history of substance abuse need to
proceed with extreme caution. Because of the conant v walters (2002) case it is important to have a bona fide relationship with your patients. The National Academy of Medicine
committee found limited evidence that cannabis use increases the rate of initiating other drug use, primarily the use of tobacco. However, the committee found moderate evidence
to suggest that there is a link between cannabis use and the development of substance dependence and/or a substance abuse disorder for substances including alcohol, tobacco,
and other illicit drugs.
FALSE
#9 Impotence Problems Are Caused By
Medical Cannabis
CANNABIS USE NEEDS TO BE CONSIDERED AS PART OF FAMILY PLANNING. Chronic exposure can alter male fertility. Sperm motility is
impacted by cannabis use (both medical and recreational).
TRUE!
#10 Cannabis Has No Contraindications
CANNABIS HAS NUMEROUS DOCUMENTED AND UNDOCUMENTED CONTRAINDICATIONS. Persons with schizoaffective disorders, for example should not
use cannabis. Furthermore, under age 25 use has proven to be detrimental for the developing brain. Daily use presents its own risk...Colorado researchers are seeing fewer
and fewer once or twice a week users and more daily users. It’s harder to find test subjects. It is important to study cannabis use at the population level.
FALSE
#11 Cannabis And Marijuana Are
Synonymous Terms
CANNABIS IS ALWAYS THE CORRECT TERM. OTHER VARIATIONS EXIST, BUT ARE NUANCED. The term marijuana represents an
unwelcome microagression that your patients will likely pick up on and not appreciate. NY State chooses: marihuana (Canadian spelling). Iowa
chooses: chemical name = Office of Medical Cannabidiol (OMC)
FALSE
#12 It’s Fine To Drive Under The
Influence Of Cannabis
IT’S NOT OKAY TO DRIVE A MOTOR VEHICLE WHEN UNDER THE INFLUENCE OF CANNABIS. There is one Canadian study with
“experienced cannabis users.” In this particular study, chronic cannabis users were better drivers than the general public cohort. Independent of this study, the impact of cannabis tourism on public safety is a concern. Acute, infrequent use may be the most dangerous for driving. There is
another interesting Dutch study on biking under the influence of cannabis.
FALSE
#13 There Are No FDA Approved
Cannabis Medications
THERE ARE FDA-APPROVED MEDICATIONS. FDA-approved drugs include Marinol, Syndros, Cesamet, Epidiolex. Sativex, produced by GW
Pharmaceuticals, is part of an FDA-approved clinical trial.
FALSE
#14 Proliferation Of Unregulated OTC CBD
Products Is Equivalent To A Medical Cannabis Program
ENFORCEMENT AUTHORITY IN THIS AREA LIES WITH THE FEDERAL DRUG ENFORCEMENT ADMINISTRATION, THE FEDERAL FOOD AND DRUG
ADMINISTRATION, COUNTY ATTORNEYS AND LAW ENFORCEMENT AGENCIES. Iowa & The Office of Medical Cannabidiol (OMC) offers an interesting position paper
on the topic.
FALSE
#15 Cannabis And Spice/K2 Are The
Same Thing
SYNTHETIC CANNABIS FIRST APPEARED IN EUROPE IN 2004. THESE COMPOUNDS ARE DIFFERENT FROM THC OR CBD. Spice and K2 are often sold at convenience stores as “herbal incense. Studies show they are toxic and unsafe. Synthetic Cannabinoids were created by experimental cannabis researchers CP 47,497, named after Charles Pfizer of
Pfizer Pharmaceuticals, developed in the 1980s for scientific research. HU-210, named after Hebrew University of Jerusalem where it was first developed in 1988 is 100 to 800 times more potent than natural THC. JWH-018 and others in the JWH series, named after Prof. John W.
Huffman of Clemson University in South Carolina, created in 1995.
FALSE
Patient Conditions (In Arkansas & North Dakota)
Strongly Resemble Trends In Other States
North Dakota has only 753 patients (as of 7/10/2019)
Nevada’s Approach To Defining a
“Provider Of Health Care”
“Provider of health care” defined.
NRS 629.031
Nevada’s Approach To Defining a
“Provider Of Health Care”
“Provider of health care” defined.
NRS 629.031
(a) A physician (b) A physician assistant; (c) A dentist; (d) A licensed nurse; (e) A person who holds a EMT license or (f) A dispensing optician; (g) An optometrist; (h) A speech-language pathologist; (i) An audiologist; (j) A practitioner of respiratory care; (k) A licensed physical therapist; (l) An occupational therapist; (m) A podiatric physician; (n) A licensed psychologist; (o) A licensed marriage and family therapist; (p) A licensed clinical professional counselor; (q) A music therapist; (r) A chiropractor; (s) An athletic trainer;
With Parity Comes Responsibility
“We cannot control this epidemic, but there are certainly ways that each of us can contribute to its demise…With parity as physicians comes responsibility to help eradicate this public health crisis.”
- Kieran T. Mahan, DPM, MS, FACFAS Temple University School of Podiatric Medicine 2016
The Apparent Inability Of A DPM To Offer
Medical Cannabis As A Therapeutic Option
Correct DPM recommending privileges. DPMs are licensed to prescribe opioids, and many other medications.
Match this policy idea with state laws on CMEs/provider education
Pigeonholes increasingly position DPMs with ”alternative care providers” instead of alongside traditional allopathic medical providers
DPMs: Parting Words
1. Demonstrate by training or expertise that he or she is qualified in treating serious medical conditions.
2. DPMs already have prescriptive authority to write prescriptions for controlled substances.
3. DPMs should be allowed to recommend patients to a state medical cannabis program – should they choose to do so.
4. Encourage DPMs to become active in state and national policy debate around licensure!
References
Di Marzo V. Mechhoulam R (2011) Cannabinoids and endocannabinoids in metabolic disorders with focus on diabetes. Handbook of Experimental Pharmacology: 75-104 Hall, W. (2015), Cannabis health effects. Addiction, 110: 19-35. doi:10.1111/add.12703 Hartung B, Schwender H, Roth EH, et al. The effect of cannabis on regular cannabis consumers' ability to ride a bicycle. International journal of legal medicine. 2016;130(3):711. http://www.ncbi.nlm.nih.gov/pubmed/26739323. doi: 10.1007/s00414-015-1307-y. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research, Jan 12, 2017 Rajanahally, S., Raheem, O., Rogers, M., Brisbane, W., Ostrowski, K., Lendvay, T., & Walsh, T. (2019). The relationship between cannabis and male infertility, sexual health, and neoplasm: a systematic review. Andrology, 7(2), 139–147. Rogeberg O, Elvik R. Response to li et al. (2017): Cannabis use and crash risk in drivers. Addiction. 2017;112(7):1316. http://onlinelibrary.wiley.com/doi/10.1111/add.13801/abstract. doi: 10.1111/add.13801. White, CM The Pharmacologic and Clinical Effects of Illicit Synthetic Cannabinoids. J Clin Pharmacol. 2016 Sep 9. PubMed PMID: 27610597 Wood, Ed, Ashley Brooks-Russell & Phillip Drum (2016) Delays in DUI blood testing: Impact on cannabis DUI assessments, Traffic Injury Prevention, 17:2, 105-108, DOI: 10.1080/15389588.2015.1052421
THANK YOU Leslie McAhren, MFA, MPH, DrPH (‘20) Environmental & Occupational Health University of Colorado School of Public Health Anschutz Medical Campus E: [email protected] P: 303.724.1271