Medicinal cannabis: Concern with College standard. College replies

The College appreciates the opportunity to respond to a letter regarding its professional standard, Marijuana for Medical Purposes. According to the Health Professions Act (HPA), the role of the College is to establish, monitor, and enforce standards of practice to reduce incompetent, impaired, or unethical practice. The regulation of medical marijuana is an obligation that medical regulatory authorities across Canada have been reluctant to take on. The revisions to the Medical Marijuana Access Regulations essentially removed Health Canada from any oversight of the use of this substance.

When the College’s Ethics Committee drafted the standard regarding medical use of marijuana, it reviewed the considerable experience of the state medical boards that have been regulating this aspect of practice for a while. Published and personal reports emphasized the importance of documenting a professional interaction with the patient, which includes taking a history, conducting an examination, considering a differential or provisional diagnosis, formulating a treatment plan, and following the patient. It may seem unnecessary to remind physicians to act professionally in this regard, but multiple instances of documents being signed with no or minimal patient interactions had been identified. The College did not want to have the entire profession disgraced because of a few individuals exchanging their signature for a fee—and not much else.

Turning to the specifics in the letter, the College standard is not a clinical practice guideline so it does not address how marijuana is used for medical purposes. The paucity of scientific evidence is acknowledged by the authors of the letter, and is noted on the Health Canada website as well as the College standard. The College doesn’t evaluate studies, scientific or otherwise, in the context of ethical and professional standards. This is the purview and responsibility of subject matter experts who draft clinical practice guidelines.

With respect to the cautions in the standard, the College is reminding physicians that as a natural substance, marijuana use is not without potential harmful effects. Given the high rate of recreational use and the lack of legal access to marijuana, the lines between true medical use and convenience for recreational use are blurry. Even in jurisdictions that authorize medical use and lawful recreational use, recreational users may still seek out medical authorization because it is cheaper.

The College is encouraged that the federal government is moving to legalize recreational use of marijuana. This will no doubt alleviate pressure on the existing medical access pathways. The foundation of the College’s standard—that medical marijuana is a treatment decision based on a professional interaction with the patient, weighing the unique risks and benefits for each patient, and in the context of a longitudinal relationship—is to ensure good medical practice.

Readers may wish to review the Federation of State Medical Boards’ Model Guidelines for the Recommendation of Marijuana in Patient Care, adopted as policy in April 2016. Like the College standard, the guideline addresses similar important topics: the physician-patient relationship, patient evaluation, informed and shared decision making, treatment agreements, qualifying conditions, ongoing monitoring and adapting treatment plans, consultation and referral, medical records, and physician conflict of interest.

The College hopes that continued research and the development of pharmaceutical cannabis-derived products provided through traditional prescription/pharmacist dispensing will soon be reality. When recreational use of marijuana is legalized, taxed appropriately to increase revenues for the publically funded health care system, and sold responsibly through provincial agencies that have a solid track record of not selling alcohol to children, physicians will be able to perform their customary role where substance use is concerned: counseling patients to moderate their consumption.
—Gerrard A. Vaughan, MD
President, College of Physicians and Surgeons of British Columbia
—Heidi M. Oetter, MD
Registrar and CEO, College of Physicians and Surgeons of British Columbia