Duties and responsibilities

Expectations of physicians in practice

Medical cannabis: Considerations for Canadian doctors

Originally published May 2014 / Revised April 2019
W14-005-E

The legal regime governing medical cannabis, including the role of healthcare practitioners, remains substantively unchanged following the legalization of recreational cannabis. The Cannabis Regulations1 have replaced and incorporated provisions from the previous Access to Cannabis for Medical Purposes Regulations. These changes affected patient access to cannabis, the range of cannabis-related products permitted for medical purposes, and possession limits that differ from limits applicable to recreational use, among other things.

Nearly all medical regulatory authorities (Colleges) in Canada have in place policies on medical cannabis. The College policies reflect the concerns expressed by some in the medical community, including 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 cannabis.

Regulations

Under the Cannabis Regulations, patients can access dried cannabis or equivalent amounts in non-dried form. Despite patients’ ability to access various forms of cannabis, the Regulations continue to require that healthcare practitioners indicate in the required medical document the daily quantity of dried cannabis, expressed in grams, that they authorize for the patient. The licensee who sells or provides cannabis in a form other than dried will determine the quantity that is equivalent to the quantity of dried cannabis recommended by the physician.2

The aim of the Cannabis Regulations is to treat cannabis 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."3 The patient can then obtain cannabis by:

  • submitting the medical document directly to a licensed commercial producer;
  • registering with Health Canada to produce a limited amount of cannabis for their own medical purposes;
  • designating someone else to produce it for them; or
  • purchasing it from authorized provincial or territorial retail outlets or online sales platforms (subject to provincial/territorial age limits).

Alternative arrangements can be made for a licensed producer or seller to transfer the drug to the healthcare practitioner who signed the medical document. The patient can then obtain it from the healthcare practitioner. The regulations impose limits on the total quantity of cannabis that can be transferred at one time. Physicians should be aware, however, that many Colleges prohibit or strongly discourage dispensing, providing, or accepting delivery of cannabis for medical purposes (e.g. British Columbia, Alberta, Newfoundland and Labrador, Saskatchewan, Prince Edward Island, Québec, Manitoba, and Yukon). Physicians should consult with their College before agreeing to accept the transfer of cannabis from a licensed producer or seller.

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 cannabis 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 cannabis 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 Cannabis Regulations, physicians should know and abide by applicable College guidelines and policies, and by the rules in their jurisdiction on billing for medical documents for cannabis.

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 cannabis. 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 Practice Standard on Cannabis for Medical Purposes (April 2019) [PDF] states that physicians completing a medical document should write in the medical record that conventional therapies were attempted but 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 cannabis for medical purposes and in any reassessment of patients receiving cannabis for medical purposes.”

The College of Physicians and Surgeons of Alberta's (CPSA) Standard of Practice on Cannabis for Medical Purposes (April 2014) states that doctors who choose to complete a medical document must register with the College and provide the College a copy of the patient’s medical document within one week of completing it. Once stabilized, the patient must be evaluated in person at least every three months.

The Yukon Medical Council’s Standard of Practice on Marijuana for Medical Purposes (September 2018) [PDF] also requires that doctors who choose to complete a medical document register with the College. Physicians are only required to provide the College a copy of the patient’s medical document upon request. Patients must also be followed every three months, once stabilized.

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 Cannabis Regulations.

The College of Physicians and Surgeons of Saskatchewan’s Regulatory Bylaws [PDF], revised February 2019, require physicians to obtain a signed, written treatment agreement from patients setting out the patients' obligations, including using cannabis as directed and not giving or selling it to anyone else. Physicians must also keep a separate record, available for inspection by the College, of the names, quantity of cannabis authorized, 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 (January 2019) [PDF] indicates that physicians must be the treating physician for the condition for which cannabis is being 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 on Cannabis for Medical Purposes (January 2019) states that “physicians must weigh the available evidence in support of cannabis against other available treatment options.” It also states that physicians must not sign medical documents for cannabis for patients under the age of 25 unless all other conventional treatment has been attempted and failed to alleviate the patient’s symptoms. Physicians must also “advise patients about the material risks and benefits of cannabis.” The College recommends that physicians who are considering signing a medical document to authorize the use of cannabis first require patients to sign a written treatment agreement.

While the Collège des médecins du Québec previously allowed physicians to provide patients with a medical document to access medical cannabis only if it was part of a recognized research project, it has since removed this requirement. Physicians may now provide patients with a medical document to access medical cannabis as long as the conditions in the CMQ guidance document (September 2018) [PDF] are met. Among these conditions, physicians must exhaust other possible treatments before authorizing cannabis and must document the treatments that were attempted but failed. Physicians must also keep a registry of all patients for whom they have provided a medical document for cannabis.

In New Brunswick, the College's Guidelines on Medical Marijuana (September 2017) require that physicians assess patients in person and that the initial prescription be for the lowest dose possible and for no longer than three months. Physicians must conduct regular follow-up for as long as the patient continues the treatment.

The College of Physicians and Surgeons of Nova Scotia's Professional Standards Regarding the Authorization of Marijuana for Medical Purposes (December 2017) [PDF] indicates "physicians must only authorize the use of marijuana for medical purposes when in direct, in-person contact with their patients" and in the context of a doctor-patient relationship. Physicians must also provide ongoing monitoring of the patient’s response to medical cannabis.

The College of Physicians and Surgeons of Prince Edward Island's Policy on Prescribing of Medical Marijuana (November 2016) [PDF] states that physicians contemplating providing a patient with a medical document must first make themselves aware of the CMPA’s and CMA's positions (CMA Statement authorizing marijuana for medical purposes [PDF]) 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, Physician-Patient Contract for Marijuana Prescribing  [PDF] 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 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 and to retain a copy of that assessment in the medical record. Doctors are also expected to establish an individualized written protocol for periodic reassessment of those patients receiving cannabis and can only issue the medical document if they are the primary treating physician.

The Health Canada website has more information for healthcare practitioners about the medical use of cannabis.

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 is 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. Dried cannabis is also not appropriate for patients under the age of 25. The CFPC also notes that the authorizing physician, if not the patient's most responsible healthcare provider, should communicate regularly with the patient’s family physician. Further, it is recommended that physicians specify the percentage of tetrahydrocannabinol (THC) on the medical document. The CFPC also states physicians should follow the regulations and guidelines of their provincial College.

The CFPC’s website provides a list of cannabis resources for family physicians, including a guideline on prescribing medical cannabinoids in primary care (February 2018) [PDF].

Other considerations

The Cannabis Regulations state that licensed sellers are required to provide a College, upon request, with any factual information obtained about a healthcare practitioner. The Regulations also 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 Cannabis Regulations (or former medical marijuana regulations), or was convicted of a designated offence under the Cannabis Act or a controlled substance offence in relation to cannabis.

While individuals can register with Health Canada to produce cannabis for their own medical purposes, or to designate someone else to produce it for them, the Regulations state that only licensed sellers are authorized to sell medical cannabis. Supplying a patient with cannabis is different from a physician agreeing to assist in transferring it to the patient, as discussed above. Suppliers or producers of medical cannabis must be licensed and must meet strict quality control, safety, and security requirements.

Some Colleges, including in Alberta, Yukon, Manitoba, Saskatchewan, and Newfoundland and Labrador, specifically prohibit physicians from applying to become licensed producers or from having an economic interest in a licensed producer. Although there is no prohibition in Québec on physicians being a licensed producer, physicians are required to inform the patient of any financial interest they have in a licensed cannabis producer. Physicians in other jurisdictions considering applying to become a licensed producer or seller should consider, among other things, the risk that it might be perceived to be a conflict of interest to both complete medical documents for patients to access medical cannabis and to be a licensed producer or seller, or to have a financially interest in one. Physicians are encouraged to seek legal advice on this issue and, if necessary, contact the College to confirm their position.

Physicians are reminded of the importance of having the necessary clinical knowledge to engage in meaningful discussions with patients about medical cannabis. They should also document all consent discussions in patients' medical records. Physicians should not feel obligated to complete the medical document for medical cannabis 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 contact the CMPA for advice.

Additional reading


 

  1. Cannabis Regulations, SOR/2018-144, ss 264-353.
  2. The Cannabis Act contains a chart (Schedule 3) to assist licensees in this conversion process by providing equivalencies between various cannabis products and 1 gram of dried cannabis.
  3. A sample is available from Health Canada at: https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/information-medical-practitioners.html.

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.