The Legalization of Marijuana: “Be Prepared”

On October 17, 2018, the Cannabis Act (Bill C-45) will become law in Canada. The act will legalize the recreational use of cannabis nationwide by individuals 18 years of age and older and allow for the personal possession of 30 grams of dried marijuana. The provinces will then determine the specific rules surrounding use and access in their individual jurisdictions. This law will undoubtedly change the nature of our practices—both medical and surgical.
I have tried to anticipate this event by highlighting a CME article published in the March/April 2018 issue of JCMS (volume 22, issue 2) by Drs Gurbir Dhadwal and Mark Kirchhof, titled “The Risks and Benefits of Cannabis in the Dermatology Clinic,” and featuring the article in a companion JCMS podcast (available on iTunes, Google Music [podcasts], TuneIn, and Stitcher—enter JCMS as well as the SAGE website and the CDA webpage).
In the article and podcast, we discussed the known cutaneous risks of cannabis use and the risk/benefit ratio in the same manner that we would review any therapy that we currently prescribe. The discussion emphasizes the risks as there are virtually no known proven dermatologic benefits and a plethora of potential risks affecting every organ system, including the skin.
It is estimated that over 250,000 Canadians have been prescribed marijuana for medical purposes. Currently, this use is regulated by the Access to Cannabis for Medical Purposes Regulation (August 2016). This regulation defines who health care practitioners are for the purposes of marijuana prescribing and the conditions under which these practitioners may prescribe marijuana. The prescription, or Medical Document as it is referred to in the act, must indicate the daily quantity of dried marijuana, expressed in grams, that the practitioner authorizes for the person and the period for which it is to be used. The prescription must not exceed the calculated needs in “dried marijuana equivalency units” of the patient for 30 days of use or exceed 150 grams using this same equivalent.
In the regulation, licensed producers are required to label their products with the “dried marijuana equivalency factor” so that the dose may be accurately dispensed to the patient. Physicians may be asked to dispense the marijuana to the patient for the licensed producer. Licensed producers are also required to report a serious adverse event (similar definition as those used in clinical trials) to the minister with a case report within 15 days of the occurrence, and all adverse events are to be submitted by written report annually to the minister.
In addition to administering the Access to Cannabis for Medical Purposes Regulation, each province and each provincial College of Physicians applies their own jurisdictional regulations. The Canadian Medical Protective Association, in its publication, “Medical Marijuana: Considerations for Canadian Doctors” (revised August 2016), urges us to become familiar with the ACT and to consult our respective college regulations before prescribing marijuana. The article reviews the provincial college regulations active at the time of publication (2016). This review emphasizes the recurring theme, present in all of the provincial regulations, that prescribing physicians must be certain that they have the relevant knowledge of cannabis as a therapy, that they document clearly their therapeutic decision process, and that the patient not only consents to the use of marijuana but has been made fully aware of the potential side effects, including the potential for addiction.
In this age of evidence-based medicine, a review of the literature does not provide us with dosing schedules or therapeutic insights for the use of marijuana in the management of any disease of the skin. Undoubtedly, the Internet/social media “evidence-based” medicine will continue to be an abundant source of information for our patients. Legalization will be considered synonymous with safe and like, tea tree and coconut oil, there will be many therapeutic uses proposed. Unfortunately, marijuana will not be free.
The legalization of the recreational use of marijuana will remove the need for physician prescription of this drug. However, physician authorization and prescription will continue to be required for access to reimbursement for medical use. I anticipate that requests (likely demands) for the prescription of marijuana from our patients will increase given that they will be certain of its positive effect. In fact, given the bonanza that private commercial producers and governments expect, I believe that licensed producers will be encouraging physician consultation and prescription. This will be an attempt by all, including patients, to justify the medical use of marijuana and to insist on reimbursement of the costs by private and/or public insurance and shift the medical liability to physicians. Although we have been able to prescribe marijuana for a number of years, I expect that requests for medical prescriptions will become common as access becomes defined by price alone.
I anticipate that each of us has been including the use of “street drugs” in our medical drug history, but now that marijuana is legal, the questioning will be more about lifestyle, and undoubtedly, we will need to probe deeper than we have before. This will be particularly important as we assess our patients’ level of competence at the time of “informed consent” for our medical and surgical procedures.
There is no turning back, and as individual physicians in the forefront of patient care, we must anticipate all of these eventualities. I will quote the Scout motto—“be prepared.”
READ, WRITE, REVIEW, CITE.
Kirk Barber, MD, FRCPC FCDA
Editor-in-Chief, JCMS