Finding balance for patients: Hospitals and marijuana
Monday, December 14, 2015
Stories abound about how marijuana has helped relieve symptoms in those who are seriously ill, and thousands of basic science studies provide the foundation for these claims. So it is not surprising that 23 states and the District of Columbia have passed legislation permitting cannabis use for some medical purposes.
There are those who have taken advantage of the new medical marijuana laws, but this does not diminish its genuine therapeutic value. The regulations in some states narrowly limit cannabis use, while other state legislatures, such as California, are adding regulations to strengthen oversight.
Dr. David Bearman, a Goleta, California, physician says it's unfortunate that some states deny patients of an effective medicine that the DEA's Chief Administrative Law Judge said was one of "the safest therapeutic agents known to man" back in 1988. Irrespective of our personal beliefs, the use of marijuana as a nonpsychoactive pain reliever, anti-inflammatory, anti-epileptic and for the treatment of PTSD and other ailments still violates federal law.
A 1925 Supreme Court decision confirms it is only the states that have the constitutional authority to regulate the practice of medicine within their boundaries. However, the federal government has a great deal of power over the healthcare delivery system as a payor, distributor of federal grants and related regulatory powers.
This means that most hospitals, clinics, hospice and other providers in states where medical marijuana is legal still don't permit the use of this alternative treatment in their facilities. This raises the question of whether the risks of cannabinoid medicine in healthcare facilities have been fully explored.
Some justify their policy of prohibiting medical marijuana use because of questionable reports that long-term use of marijuana can lead to addiction and loss of IQ. But, as Dr. Sanja Gupta's CNN documentary demonstrates (see video below), this has not deterred many parents of children who suffer from intractable treatment-resistant epileptic seizures.
Nor has it stopped many with debilitating pain who want to avoid the use of addictive and constipating narcotics, such as those derived from opium. Cannabis has also provided some relief for others with severe forms of autism who use medical marijuana to control self-harm and violent behaviors because conventional strategies have failed.
Clinicians are expected to reconcile all of a patient's medications, including alternative therapies and "herbal" supplements, to ensure that care is safe and effective. Patients want to tell providers about their use of oils to control pain that help quicken their recovery or other uses. But when hospitals and physicians fear federal action and convey that concern to patients, the patients get afraid of telling the truth or determine their providers don't really want to know.
The result? The patients use medical marijuana when their providers aren't looking. Not recognizing and documenting all of a patient's medications in medical record is unsafe. Providers need to be aware of their patient's use of alternative and complementary medicine.
Effective hospital and healthcare leaders have begun to explore the possible legal or financial risks and create policies for their organizations that balance their compliance to regulations with the legitimate needs of their patients.
While there has been some movement with regard to legislation, research and making sense of conflicting regulations and policy, the time has come to focus a bit more on patient needs and recognize that not every therapy or medication currently being used in hospitals has received FDA approval for the intended use. Some of these off-label uses also don't have sufficient research to support their desired use. But there may be enough anecdotal evidence to apply the modality when the care team suspects it will benefit specific patients.
Where is progress being made?
- Minnesota has passed legislation allowing hospitals to administer pill and liquid forms as an amendment to their original bill legalizing medical marijuana within the state. Patients need to be on the cannabis registry, and hospitals can restrict use and storage.
- Mt. Sinai Hospital is collaborating with a medical marijuana provider on research.
- North Shore-LIJ Health System is partnering with growers on their application for a state license.
- Health systems in Illinois are educating their providers about the law.
- Veterans Affairs has relaxed its stance in states permitting use, as long as their providers follow state law closely. However, as federal employees, providers may not prescribe medical marijuana.
- Boston Children's and Nationwide Children's Hospitals have both outlined their policy of not permitting medical marijuana in their facilities due to regulatory limitations and/or maturity of research.
Hospitals, clinics, hospices and other facilities should begin the process of understanding the range of risks and establishing policy that incorporates the legitimate needs of their patients. Actions that can be taken now include the following:
- Have proactive discussions with key physicians, staff, governing members and community supports.
- Assess the risk of an early discharge or refusal to treat patients when they are upfront and honest about their desire to continue using their alternative therapies, especially in relation to EMTALA and liability.
- Review liability insurance policies (malpractice, directors and officers, general liability, etc.).
- Review agreements related to federal funding, including grants, demonstration projects, etc.
- Assess the risk of patients sneaking to use their medical marijuana products without the knowledge of their physician or other staff; including drug food/interactions, unanticipated symptoms, insecure storage, etc.
- Assess your patient populations to identify those needing more accommodating policies.
- Recognize existing off-label uses of medication, especially for pediatric patients.
- Consider assignment of oversight of cannabinoid use to the Institutional Review Board and following investigative drug protocols.
- Communicate your organization's policy and procedures to your community and train staff.
- Present patient and family stories and discuss gaps in legislation with lawmakers.
- Invite organizations such as the American Academy of Cannabinoid Medicine to provide category I CME on cannabis, cannabinoids and the endocannabinoid system.
Cannabinoid medicine will increasingly find its way into patient treatment plans. Certainly more research is needed for increased confidence and more widespread use, but some patients just don't have the time to wait. Effective healthcare leaders will find those paths that limit the risks and balance the needs of their patients with the regulatory environment.
In addition, effective leaders in the federal departments that oversee aspects of the healthcare delivery system will work with legislators and provide guidance to ensure the legitimate needs of patients are being addressed in regulations and policy. To not do so, violates their own interest in improving patient satisfaction, quality, safety and outcomes for all patients.
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