Pubdate: Thu, 1 Nov 2001 Source: Western Journal of Medicine (US) Copyright: 2001 WJM Contact: http//www.mapinc.org/media/1612 Website: http//www.ewjm.com/ Author: Eric A Voth, Chair, Institute on Global Drug Policy PO Box 11298 St Petersburg, FL Readers may use this Electronic Letters submission form which may result in online publication and may be considered for print publication http://www.ewjm.com/cgi/eletter-submit/175/5/305 Related: http://www.drugsense.org/dsw/2001/ds01.n226.html#sec5 Cited: Oakland Cannabis Buyers' Cooperative http://www.rxcbc.org/ http://www.druglibrary.org/ocbc Marijuana and Medicine: Assessing the Science Base http://www.nap.edu/readingroom/books/marimed/ Bookmarks: http://www.mapinc.org/mmj.htm (Cannabis - Medicinal) http://www.mapinc.org/ocbc.htm (Oakland Cannabis Court Case) GUIDELINES FOR PRESCRIBING MEDICAL MARIJUANA Competing interests: None declared To the editors, Several states have recently passed either ballot initiatives or laws allowing the use of medical-excuse marijuana when individuals receive a physician's recommendation--in effect, prescribing marijuana for their patients. Those states have allowed a "defense to possession" for marijuana users who obtain a physician's recommendation for the use of crude marijuana. In addition to the ballot initiatives recently passed, the US Supreme Court has recently ruled that medical necessity is not a defense for the sale or cultivation of marijuana. [1] In this move, they further affirmed that marijuana is not a medicine. This new atmosphere of "medicine by popular vote" creates a difficult environment for physicians who seek to treat their patients with compassion. The process of making "recommendations" for marijuana places physicians in the position of suggesting that patients use a schedule I substance (marijuana) for medical uses. The ballot initiatives bypass the Food and Drug Administration's processes that are meant to ensure both efficacy and safety. Physicians who provide such recommendations are, at a minimum, exposing themselves to civil litigation from marijuana smokers who have adverse outcomes. Considering that the patients at highest risk of complications for marijuana use are those for whom it allegedly has benefit, physicians should carefully evaluate the risks involved before recommending marijuana use. The following guidelines define a standard of care and provide some guidance to physicians who may consider recommending marijuana to their patients yet wish to minimize their malpractice risk. These guidelines have been derived from accepted literature [2,3 ] and leading authorities on medicine and drug policy. Physicians should remember that marijuana remains a schedule I drug, that it has not been approved as safe and efficacious by the Food and Drug Administration, and that the use of marijuana by patients holds inherent risk. We do not support recommending the medicinal use of marijuana. MEDICAL EXCUSE MARIJUANA STANDARD OF CARE GUIDELINES Before recommending marijuana to a patient, you as a physician should ask yourself the following: Is there documentation that the patient has had failure of all other conventional medications to treat his or her ailment? Have you counseled the patient (documented by the patient's signed informed consent) regarding the medical risks of the use of marijuana--at a minimum to include infection, pulmonary complications, suppression of immunity, impairment of driving skills, and habituation? Has the patient misused marijuana or other psychoactive and addictive drugs? Do you periodically provide drug testing of the patient who has been prescribed marijuana, and have patients been excluded from being prescribed marijuana who are found to be using other illicit drugs? Who does the drug testing and by what means? Is the use of smoked marijuana part of a study and/or will the monitoring of that use be under the supervision of an investigational review board? Have you carefully reviewed exactly which patients should be allowed to use this drug medicinally and for how long? Do you carefully examine and consistently follow up patients who use smoked marijuana as a medical treatment, including pulmonary function testing, evaluation of immune status, and the presence of any superadded infection? Have you exercised due care in assuring the standardization of the tetrahydrocannabinol potency content of the marijuana to be considered for medicinal use and whether it is free of microbial contaminants? Because marijuana is a federally controlled substance, has a system been established in the state to track all patients and their source of marijuana, as with other controlled substances? Are you complying with such requirements? Will you be required to be licensed by the state or federal government? Have you shown knowledge, training, or certification in addiction medicine? Do you have demonstrable knowledge of the physiologic effects of marijuana, its side effects, and its interaction with other drugs before prescribing it? References US v Oakland Cannabis Buyers' Cooperative, 2001 WL 501567 (US). Voth EA, Schwartz RH. Medicinal applications of delta-9-tetrahydrocannabinol and marijuana. Ann Intern Med 1997;126 791 -798. Joy JE, Watson SJ Jr, Benson JA Jr, Eds. Marijuana and Medicine: Assessing the Science Base. Washington, DC National Academy Press; 1999. Available at www.books.nap.edu/catalog/6376.html - --- MAP posted-by: Richard Lake