Is it time to consider a medical marijuana policy?

Abstract

As more and more states approve the use of medical marijuana, hospitals will surely be admitting patients who rely on cannabis for medicinal purposes. Upon admission, institutions will be faced with the decision to allow patients to continue their cannabis as an inpatient or disallow its use for fear of legal repercussions. Therefore, careful planning and the development of policies to guide clinicians are needed as use of medical cannabis becomes more widespread. “There is an ever-increasing amount of research linking cannabis to positive treatment outcomes,” Benjamin Caplan, MD, founder of CED Clinic in Massachusetts, told Pharmacy Today. “The efficacy of cannabis, particularly when it is used as a component of a treatment plan for chronic pain, and its potential to be a replacement for opioids, makes it especially appealing to use in select patients,” he said. “Unfortunately, there are very few hospitals in the United States that formally embrace cannabis as a helpful option for their patients.” Caplan explained that as long as cannabis remains a Schedule 1 substance per the Controlled Substance Act, many hospitals fear they may violate federal rules that prohibit them from having these types of substances on the premises. “Hospitals and their clinicians face conflict, either to condone the use of cannabis for their patients’ well-being, yet violate and risk losing their federal contracts, or to withhold the medicine from patients and uphold their formal obligations, suffering potential risk and ethical liability to their patients,” Caplan said. To address the issue of medical cannabis in the hospital setting, the Minnesota Hospital Association (MHA) has released three sample policies that may be useful to facilities and clinicians. The sample templates, available online, focus on the following three scenarios: 1) not allowing use of medical cannabis in the hospital; 2) allowing its use and administration by patients; or 3) allowing its use and administration by nurses. MHA noted that committees such as the pharmacy and therapeutics committee, physician committees, legal committees, and/or executive committees should all work together to determine appropriate processes for patients using medical cannabis. Decisions may be based on patient characteristics and needs, as well as staff and legal considerations. There is no single standard for all Minnesota hospitals, with some prohibiting its use and others allowing it only in select situations. They key is that policies are put in place to guide clinicians before they encounter these patients. Caplan stressed that misconceptions and misinformation about cannabis have permeated both the popular and medical cultures for decades. He described the mountain of scientific literature and data that exist today in support of its abundant medicinal qualities, of which many clinicians seem to be unaware. He also commented on some of the safety considerations associated with cannabis use, such as select drug–drug interactions and effects on metabolism and the heart. “Plant cannabinoids are degraded by the cytochrome P450 hepatic enzymes, and as with other medications that are processed hepatically, the presence of enzyme regulators, whether inhibitors or activators, affects the duration and strength of plant cannabinoids,” Caplan said. “Generally speaking, patients taking medications or foods that inhibit cytochrome P450 may have prolonged or stronger effects from the same cannabis consumed without enzymatic inhibition, whereas enzyme activators will have the opposite results.” In addition to drug–drug interactions that may be affected by hepatic degradation, Caplan noted that chronotropic effects and cannabis’s activation of cardiomyocytes deserve consideration. “While the majority of cannabis patients are not at elevated risk related to its stimulating effects on normal cardiac function, patients with sensitive, damaged, or at-risk physiology would likely benefit from a cautious approach to self-medicating or guidance from a supportive expert.” Hospital pharmacists should be aware of and familiar with policies that address the use of medical cannabis in the inpatient setting. If use is allowed, pharmacists can play an essential role in parsing therapeutics, discussing appropriate use with their patients and other care team members, and evaluating patients for potential drug–drug interactions and adverse effects.