Medical marijuana: Considerations for Canadian doctors
Originally published May 2014 / Revised August 2016
Following the phased-in introduction of the Marihuana for Medical Purposes Regulations (MMPR) in 2013 and 2014, medical regulatory authorities (Colleges) put in place policies on medical marijuana. The federal marijuana regulations were recently updated with the introduction of the Access to Cannabis for Medical Purposes Regulations (ACMPR) on August 24, 2016, which repeal the MMPR.1 The College policies reflect the concerns that have been expressed by some in the medical community. Among those concerns are the absence of scientific evidence on the benefits of medical cannabis and the challenging role being given to physicians and other healthcare providers when a patient requests access to medical marijuana.
Under the ACMPR patients can access fresh or dried marijuana or cannabis oil.2 Despite patients’ ability to access various forms of cannabis, the ACMPR continue to require that healthcare practitioners indicate in the medical document the daily quantity of dried marihuana, expressed in grams, that they authorize for the patient. The licensed producer who sells or provides fresh marihuana or cannabis oil will be the one to determine the quantity of fresh marihuana or cannabis oil that is equivalent to the quantity of dried marihuana recommended by the physician.
The aim of the ACMPR is to treat marijuana like other psychoactive drugs used for medical purposes. Under the regulations, the patient must consult with an authorized healthcare practitioner (i.e., a physician or an authorized nurse practitioner) and obtain a signed "medical document." The patient can then get the cannabis by submitting the medical document directly to a licensed commercial producer or by registering with Health Canada to produce a limited amount of marijuana for their own medical purposes, or designate someone else to produce it for them. Alternatively, arrangements can be made for the producer to transfer the drug to the healthcare practitioner who signed the medical document and the patient can obtain it from the healthcare practitioner. The regulations impose limits on the total quantity of cannabis that can be transferred at one time and within a 30-day period. Physicians should be aware however, that many Colleges prohibit or strongly discourage their members from dispensing, providing, or accepting delivery of marijuana for medical purposes (e.g. British Columbia, Alberta, Newfoundland and Labrador, Saskatchewan, Prince Edward Island, Québec, Manitoba, and Yukon). Physicians are advised to consult with their College before agreeing to accept the transfer of marijuana from a licensed producer.
Where patients register to produce cannabis for their own medical purposes or to have it produced for them by a designated person, Health Canada will determine the maximum number of marijuana plants the patient is allowed to have for each production period. To make that determination, Health Canada will use a formula based on the daily quantity of dried marijuana indicated in the medical document and the average yield of a plant under certain growing conditions, such as indoor or outdoor growing.
Medical regulatory authority policies
In addition to being familiar with the ACMPR, doctors should know and abide by the applicable College guidelines and policies, and by the rules in their jurisdiction on billing for medical documents for marijuana.
The guidelines and policies issued to date by most Colleges consistently state that more information is required on the medical risks and therapeutic benefits of marijuana. Most Colleges suggest that physicians should only sign the medical document when they have the necessary clinical knowledge to engage in a meaningful consent discussion with patients.
The College of Physicians and Surgeons of British Columbia's Professional Standards and Guidelines on Marijuana for Medical Purposes (July 2015) state that physicians completing a medical document should write in the medical record that conventional therapies were attempted but were unsuccessful. The College also requires physicians to assess a patient's risk of addiction using a validated addiction risk tool and to retain a copy of that assessment in the medical record. Doctors must also “review the patient’s PharmaNet information prior to issuing an authorization for marijuana for medical purposes and in any reassessment of patients receiving marijuana for medical purposes.”
The College of Physicians and Surgeons of Alberta's (CPSA) Standard of Practice on Marihuana for Medical Purposes (April 2014) states that doctors who choose to complete a medical document must register with the College. Once the patient has stabilized, they must be evaluated in person at least every three months.
The Yukon Medical Council adopted the CPSA’s Standard of Practice on Marijuana for Medical Purposes in September 2015.
Physicians practising in the Northwest Territories or Nunavut should watch for new information or policies that may be provided by their medical regulatory bodies, or contact them directly to enquire about specific practices that must be followed when issuing a medical document under the ACMPR.
The College of Physicians and Surgeons of Saskatchewan revised its Regulatory Bylaws (August 2015) to require physicians to obtain a signed, written treatment agreement from patients setting out the patients' obligations, including using the marijuana as directed and not giving or selling it to anyone else. Physicians must also keep a separate record containing the names, quantity of marijuana authorized and duration of authorization, medical condition, and licensed producer (if known) for all relevant patients.
The College of Physicians and Surgeons of Manitoba's Standards of Practice of Medicine (Bylaw 11) (updated July 2016) indicates that physicians must remain at arm’s length from licensed producers and be the treating physician for the condition for which marijuana is authorized. Physicians must keep a separate log of all authorizations and make the log available for inspection by the College.
The College of Physicians and Surgeons of Ontario's Policy Statement on Marijuana for Medical Purposes (March 2015) states that “physicians must weigh the available evidence in support of dried marijuana against other available treatment options,” and must not sign medical documents for marijuana for patients under the age of 25 unless all other conventional treatment has been attempted and failed to alleviate the patient’s symptoms. Doctors must also “advise patients about the material risks and benefits of dried marijuana.” The College recommends that physicians who suggest the use of dried marijuana first require patients to sign a written treatment agreement.
Québec has a unique approach. The Collège des médecins du Québec states in its Guidelines concerning the use of dried cannabis for medical purposes (May 2015) that based on a provision in the province's Code of ethics of physicians, physicians in Québec should not provide patients with a medical document to access medical marijuana except as part of a recognized research project and only for specified conditions. A provincial research project on dried cannabis was announced in May 2015, and patients wishing to obtain medical marijuana may now register to participate in the study.
In New Brunswick, the College's Guidelines on Medical Marijuana (April 2014) require physicians who provide a medical document to warn the patient about obtaining marijuana from an unauthorized source and about redirecting the drug to another individual. The patient must also be advised to maintain the marijuana in a secure place and about the circumstances under which the marijuana could be discontinued. The College recommends that these issues be documented in a treatment agreement with the patient.
The College of Physicians and Surgeons of Nova Scotia's Policy Regarding the Authorization of Marijuana for Medical Purposes (June 2014) indicates "physicians may only authorize the use of marijuana for medical purposes when in direct, in-person contact with their patients." The College also prohibits physicians from billing patients directly for services related to the authorization of marijuana for medical purposes.
The College of Physicians and Surgeons of Prince Edward Island's revised Policy on Prescribing of Medical Marijuana (September 2014) states that any doctors contemplating providing a patient with a medical document must first make themselves aware of the CMPA and CMA's positions on this matter. The College also states that physicians cannot provide the medical document via telehealth. Further, physicians must obtain written patient consent to notify the College of patients’ names and other specified relevant details (a template form is provided by the College), and must tell patients that this information will be provided to the College, which will report any irregularities to the physician signing the medical document and the legal authorities.
The College of Physicians and Surgeons of Newfoundland and Labrador (CPSNL) issued an advisory and interim guideline (March 2014) outlining eight conditions that must be met before a physician considers completing the medical document. Similar to the College in British Columbia, the CPSNL requires physicians to assess the patient for risk of addiction using a standardized addiction risk tool. Doctors are also expected to establish an individualized written protocol for periodic reassessment of those patients receiving marijuana and can only issue the medical document if they are the primary treating physician.
Additional information about the ACMPR and answers to frequently asked questions can also be found on Health Canada's website.
Guidance for family physicians
In September 2014, the College of Family Physicians of Canada (CFPC) published Preliminary Guidance on authorizing dried cannabis for chronic pain or anxiety. Among the CFPC's recommendations it is noted that authorizations should only be considered for patients with neuropathic pain that has failed to respond to standard treatments and not as a therapy for anxiety or insomnia. Physicians should assess and monitor all patients on cannabis therapy for potential misuse or abuse. The CFPC also notes that the authorizing physician, if not the patient's most responsible health provider, should communicate regularly with the patient’s family physician. Further, it is recommended physicians should specify the percentage of tetrahydrocannabinol (THC) on the medical document. The CFPC also states physicians should follow the regulations of their provincial medical regulators (Colleges).
Physicians are reminded of the importance of having the necessary clinical knowledge to engage in meaningful discussions with patients about medical marijuana. They should also document all consent discussions in patients' medical records.
Physicians should not feel obligated to complete the medical document for medical marijuana when they are unfamiliar with its use or management, or when they feel it is medically inappropriate for a patient. Physicians who choose to complete a medical document should rely on sound medical judgment and comply with their College's relevant guideline or policy. Members may also call the CMPA for advice.
Under the ACMPR, licensed producers are required to provide a College, upon request, with any factual information that has been obtained about a healthcare practitioner. The Narcotic Control Regulations have also been amended to require the Minister of Health to report physicians to their College if the Minister has reasonable grounds to believe a physician contravened a College rule of conduct, the Narcotic Control Regulations or the ACMPR, or was found guilty of a designated drug offence or of contravening either the Narcotic Control Regulations or ACMPR.
While individuals can now register with Health Canada to produce marijuana for their own medical purposes, or to designate someone else to produce it for them, the regulations state that only licensed producers are authorized to sell or provide medical marijuana. Supplying a patient with marijuana is different from a physician agreeing to assist in transferring it to the patient, as discussed above. Suppliers or producers of medical marijuana must be licensed and must meet strict quality control, safety, and security requirements. Some Colleges specifically prohibit physicians from applying to become licensed producers, such as the Colleges in Alberta, Yukon, Manitoba, Saskatchewan, Québec, and Newfoundland and Labrador. Physicians in other jurisdictions thinking about applying to be a licensed producer should consider, among other things, the risk that it might be perceived to be a conflict of interest for a doctor to both complete medical documents for patients to access medical marijuana and also to be a licensed producer or supplier.
Under the ACMPR, licensed producers are now allowed to sell cannabis for medical purposes in three basic forms: fresh or dried marijuana, or cannabis oil. There is no change to the role of healthcare professionals in authorizing medical marijuana, nor is there any change to the medical document. Under the exemption, licensed producers are required to develop a conversion method between dried marijuana and cannabis oil and fresh marijuana, and to post that information on their website.
Finally, when considering whether or not to provide patients with access to medical marijuana, physicians must be aware of the regulations governing the drug and of their College’s policies or guidelines. They must also determine if their clinical knowledge of the drug is sufficient and if it is appropriate for the specific patient.
- On February 24, 2016, the Federal Court invalidated the MMPR, but suspended the declaration of invalidity for six months (until August 24, 2016) to allow the federal government to enact a new or parallel medical marijuana regime (Allard v Canada, 2016 FC 236). The ACMPR was the government’s response to the Federal Court decision.
- The term "marijuana" is defined in the Regulations as including marijuana plants and dried or fresh marijuana, and the term “cannabis” is defined as including marijuana as well as cannabis preparations and derivatives such as oil.