Colorado Medical Board Policy: Policy Regarding Recommendations for Marijuana as a Therapeutic option.
Date Issued: November 19, 2015
Purpose: To provide guidelines for Colorado Physicians who recommend Marijuana for medical use.
The Colorado Medical Board is creating a policy that will greatly impact access to Medical Marijuana. If passed the impact of this could be substantial and detrimental to Medical Marijuana Patients, Medical Marijuana Dispensaries, Infused Product Manufacturers who focus on creating Medical Marijuana products and the Doctors who evaluate patients for Medical Marijuana. I have been evaluating patients for Medical Marijuana for the past year and a half and it has been an amazing experience. Every day I meet with patients who suffer pain, nausea or have developed cancer among the other reasons patients can have Medical Marijuana recommended to them. Patients come to me for evaluation for a Medical Marijuana License. I will tell you that on a daily basis I meet people who inspire me. They come to me to tell me what Medical Marijuana does for them. Patients come to me often as a last resort. They have tried medications prescribed to them by their physician and have found the side effects of the medications make them feel like a “zombie”.
Here are the points of the policy that seem unique to Doctors evaluating patients for Medical Marijuana.
1) Risk Assessment
a) Patient and family history of substance abuse
b) Abuse history including physical, emotional or sexual
c) Health conditions that could aggravate adverse reactions
2) Review PDMP
3) Imaging studies or lab testing
a) Physicians should order imaging studies or laboratory testing as necessary to render a diagnosis. Urine Drug Screens should be considered to ensure compliance with treatment recommendations. Pregnancy testing should be considered for all women of child–bearing age.
4) For patients who in the opinion of the physician require an increased marijuana plant count, the medical record must reflect the rationale for the increased plant count. This rationale should include documentation of a stepwise progression of efficacy.
6) Collaborate with other Healthcare Providers
7) Patient Education, Monitoring and follow up
Here are my thoughts on each of these points.
By the Constitutional Amendment 20 the patients that can get recommendations for Medical Marijuana all have chronic or debilitating medical conditions. These conditions are going to stay the same or worsen over time for the patient.
1) Risk assessment:
a) Some patients come to me addicted to a Narcotic that were prescribed for them by a pain specialist or by serial ED visits. The vast majority of these patients do not want to continue Narcotics and use Medical Marijuana to help relieve the pain as they wean themselves from Narcotics or Benzodiazepines. I have met patients that have been able to rid themselves of nine medications replaced with Medical Marijuana. With nearly ten years of Emergency Department experience I believe that Narcotics and Benzodiazepines have a safer alternative and that is Medical Marijuana. I will always recommend Medical Marijuana over prescribing Narcotics and Benzodiazepines.
b) Sexual Abuse History? Physical and emotional abuse history?
i) I do not understand what this will add. In six years working in Denver General Emergency Department as an attending physician I asked patients sexual abuse questions rarely if ever. I am no stranger to the bad things people do and say to each other. I am unclear as to how this would help me one way or the other deciding whether Medical Marijuana might help their unrelated chronic debilitating medical problem. The overriding assumption made by the Board of Health and those who wrote this policy is that the patients I am seeing are not patients, but drug addicts and are doing something illicit.
2) Review PDMP
a) Online program designed to monitor for people visiting multiple doctors for purpose of obtaining Narcotics illegally. I have used this at Denver General and find it to be rarely useful, sometimes harmful and would not find occasion to use it for people coming to me for Medical Marijuana evaluations. Again, the overriding assumption from the Medical Board is that the people who come to see me are not to be trusted and likely addicted to Narcotics.
3) Imaging or Lab studies:
a) Remember we are dealing with chronic conditions here and I am not associated with a hospital. Shooting a quick X-ray for a chronic problem because of a State Policy, in my mind, would be a violation of the Hippocratic Oath. While swearing in as a physician I swore that I would “First Do No Harm.” Taking an X-ray on a patient with a chronic debilitating disease because the Board of Health told me I had to is harmful because it is un-necessary to the patient and exposes the patient to radiation
b) Lab work: There is not a Lab I can order that would help me evaluate a patient for Medical Marijuana. Ordering a Urine Pregnancy Test for female patients of childbearing age is ridiculous. If we went to a fully paternalistic state we would have to order Urine Pregnancy Tests on every woman before she purchased alcohol or went to a recreational dispensary. It would make no more sense to do this, but at least it would be consistent. Drug screens, except for in the unconscious patient, are not medically helpful. I believe patients are honest with me about their use and addiction to Narcotics. I love it when a patient can cleanse themselves of Narcotics.
c) Cost to the patient is another issue with this. This is not covered by insurance. A typical X-ray at a hospital will be billed at 3-500$ and with X-ray read will come to 1-1,200$. My typical Doctor visit cost 70$. A Urine Pregnancy Test through a hospital can cost 120$ and beyond.
4) Plant Counts:
a) People are trying to find ways to use Medical Marijuana that are better than smoking. I agree with this effort. It is my belief that many of the therapeutic benefits of the cannabinoids found in Medical Marijuana are lost in the burning of the flower. I encourage edibles and juicing whole plants and growing smaller plants in effort to manipulate the CBD content.
a) The Board of Health states that we must diagnose or independently confirm diagnosis and that I must provide a legitimate medical purpose appropriate for marijuana therapy. In looking at Amendment 20 to the Colorado Constitution it is written “A chronic or debilitating disease or medical condition, or treatment for such conditions, which produces, for a specific patient, one or more of the following, and for which, in the professional opinion of the patient's physician, such condition or conditions reasonably may be alleviated by the medical use of marijuana: cachexia; severe pain; severe nausea; seizures, including those that are characteristic of epilepsy; or persistent muscle spasms, including those that are characteristic of multiple sclerosis.” Many of the patients I see have chronic back pain or hand pain and have never been to see a doctor. Many of these patients have developed arthritis. After seeing thousands of patients in the Emergency Department it is clear to me that many people come into the ED for back pain and leave with the diagnosis of back pain. It was considered bad medicine to X-ray, CT or MRI every patient with back pain. I am comfortable recommending the patient establish a relationship with their PMD or under rare circumstances asking the patient to go to the Emergency Department or even rarer calling 911 if I thought the patient was having a heart attack or stroke.
6) Collaborate with other health care providers. I do this at the patient’s request and never without their consent.
7) Patient Education, Monitoring and Follow Up:
a) Patient Education is the most important part of the process. I evaluate the patient’s experience with Medical Marijuana. Many patients come stating they haven’t tried Marijuana since high school ranging in age from 60-93 years old. They come to me in pain or with cancer or nausea because of the chemo after they have tried the drugs the doctors have prescribed. I take the time to answer every question and I give every patient a hand written lesson explaining how to safely begin using Medical Marijuana and give them alternatives. My phone is on all the time if they have questions or concerns. Patients frequently stop by or send me emails when they find something that works for them or doesn’t work for them. The renewal process ensures an annual visit for those who choose to continue using Medical Marijuana.
We should remember that Medical Marijuana has existed for 15 years in Colorado helping hundreds of thousands of patients. Only since the legalization of Recreational Marijuana and the Millions of dollars of tax revenue it has created has Medical Marijuana come under such scrutiny. There seems to be a effort from the Board of Health to restrict Medical Marijuana. What or who is motivating the Board of Health to restrict and change something that has been working so well for so long. Since graduating from Medical School I have never felt more like a Doctor than I do now. I am a teacher. I educate. I am learning. Medical Marijuana should be preserved and protected.
Peter Pryor MD MPH