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