JAMA edition provides summary of FSMB policy recommendations about marijuana in patient care

The Journal of the American Medical Association (JAMA) has published in its online edition a summary of new policy adopted by the Federation of State Medical Boards (FSMB) that provides recommendations about marijuana in patient care and a cautionary note advising actively licensed physicians to abstain from using marijuana while practicing medicine.

The online "Viewpoint" summary, published June 16, was written by FSMB President and CEO Humayun J. Chaudhry, DO, MACP; FSMB Chair Arthur S. Hengerer, MD; and FSMB Chair-Elect Gregory B. Snyder, MD.

Heightened public interest in marijuana and marijuana-infused products for medicinal and recreational purposes led the nation's state medical and osteopathic boards to issue the recommendations during the FSMB's 2016 House of Delegates meeting in April.

This is the first time that the dispensing or use of marijuana in patient care have been highlighted in a policy recommendation of the FSMB, whose members include 70 state and territorial medical licensing boards of the United States. In addition to summarizing the FSMB's ten recommendations, the authors examine the dilemma of physicians practicing today, who they say are "caught between increasingly permissive local statutes and prohibitive federal regulations" regarding the use of marijuana.

Although there is little evidence for the efficacy of marijuana in treating certain medical conditions, marijuana has been variously suggested for alleviating some or all symptoms of a range of debilitating medical conditions - from certain types of cancer to glaucoma.

The "prescribing" of marijuana, however, remains illegal under federal law, where it is classified as a Schedule I substance under the Controlled Substances Act of 1970. Therefore, under federal law, marijuana cannot be knowingly or intentionally distributed, dispensed, or possessed, and an individual who aids and abets another in violating federal law or engages in a conspiracy to purchase, cultivate, or possess marijuana may be punished to the same extent as the individual who commits the crime.

With the increasing number of jurisdictions permitting the use of marijuana in patient care, the U.S. Department of Justice updated its marijuana enforcement policy in 2013, advising states and local governments that authorize marijuana-related conduct to implement strong and effective regulatory and enforcement systems to address any threat those laws could pose to public safety, public health, and other interests.

About the FSMB Policy Recommendations
The FSMB convened a workgroup in 2015 with representatives from more than a dozen state and territorial regulatory boards to develop policy recommendations to help guide physicians practicing in this environment. The recommendations were developed after a systematic review of medical literature and feedback from state medical board members and staff, including physicians and public members, as well as interested stakeholders such as the American Society of Addiction Medicine. The recommendations were unanimously adopted by state medical boards on April 30, 2016.

The FSMB's recommendations stress that physicians recommending marijuana in medical care should carefully document the establishment of an appropriate patient-physician relationship, adhere to rigorous patient-evaluation and informed decision-making standards, and document a written treatment plan for all patients using medical marijuana.

While physicians have the discretion of determining the health conditions that warrant treatment with marijuana, the appropriateness and safety of their recommendations should be evaluated in accordance with current standards of practice and in compliance with state laws and regulations.

Physicians should regularly assess the patient's response to the use of marijuana and overall health and level of function, and they should check their state's prescription-drug monitoring program. They should also register with the appropriate oversight agency (such as a marijuana registry, as exists in Colorado and Minnesota), providing the registry with information each time a recommendation, attestation, authorization, or reauthorization for marijuana is issued.

Physicians should be aware that patients who have a known or suspected history of substance use disorder or a co-occurring mental health disorder may require specialized assessment and treatment, and for all patients, they should keep accurate and complete medical records. They should also take steps to ensure they are free from conflicts of interest -- a physician who recommends marijuana should not have a professional office located at a dispensary or cultivation center, for example.

The FSMB recommendations suggest that state medical and osteopathic boards should advise their licensees to abstain from the use of marijuana for medical or recreational purposes while actively engaged in the practice of medicine. Practicing medicine under the influence of marijuana may constitute unprofessional conduct or incompetence.