COMMENTARY

What's the Standard of Care for Managing Medical Marijuana?

Carolyn Buppert, MSN, JD

Disclosures

April 22, 2019

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A Patient on Medical Marijuana

A primary care provider in a state where medical marijuana is legal asked the following question:

In my state, an individual can get a recommendation for medical marijuana from a qualified practitioner who has a visit with that person for that reason only. Alternatively, the individual's primary care provider or specialist can recommend it. I have recommended medical marijuana for several of my patients who had conditions qualifying them for medical marijuana. My concern is about my patients who have been qualified for a medical marijuana card by someone else, and I may or may not agree that the patient should have it. I'd like to know what my responsibilities are for evaluating and managing these patients. Is there a standard of care for managing patients on medical marijuana?
Response from Carolyn Buppert, MSN, JD
Healthcare attorney

A hypothetical case could go like this: A man has a medical marijuana card recommended by a provider whose practice is limited to recommending medical marijuana. The man sees his psychiatric provider and primary care provider on a regular basis. The man is using marijuana daily in large amounts. He has a history of suicidal ideation. He takes his own life. His family sues the psychiatric provider and primary care provider, claiming that they should have warned the patient that marijuana use has been connected with suicidal ideation and behaviors.

Standards of care may come from malpractice cases, governmental or association guidelines, or experts. I looked for cases involving clinicians' care of patients on medical marijuana and did not find any malpractice lawsuits based on how a practitioner dealt with medical marijuana. So, the hypothetical case above is still hypothetical.

I have not heard of cases before boards of nursing in which a nurse practitioner was disciplined for the way he or she cared for a patient on medical marijuana. However, the National Council of State Boards of Nursing (NCSBN) recently came out with guidance for nurses: The NCSBN National Nursing Guidelines for Medical Marijuana. The Federation of State Medical Boards came out with guidelines for recommending marijuana. Both of these documents may be considered outlines for the "standard of care." In summary, the NCSBN guidelines say that it is a reasonable expectation that nurses will recognize and attend to:

  • Side effects of marijuana use;

  • Potential for exacerbation of existing health problems;

  • Potential for potentiating or mitigating the effect of other medications;

  • Moderate increase in risk for automobile collision; and

  • Symptoms of withdrawal.

Here are the practice pointers from the NCSBN that apply to your situation:

  • Marijuana may exacerbate tachycardia, appetite, sleepiness, dizziness, low blood pressure, dry mouth/eyes, decreased urination, hallucinations, paranoia, anxiety, poor balance and posture in patients with dyskinetic disorders, and impaired attention, memory, and psychomotor performance. It may worsen mental faculties in conditions that cause cognitive deficits.

  • Cognitive impairment by cannabis may be dose- and age-dependent.

  • High blood concentrations of cannabinoids, usually from overconsumption of edibles, can cause prolonged and often debilitating psychoses or hyperemesis syndrome.

  • Side effects may include fatigue, suicidal ideation, nausea, asthenia, and vertigo.

  • People with asthma, bronchitis, or emphysema should be cautioned not to smoke cannabis.

  • Withdrawal from heavy and prolonged use of cannabis has varying symptomatology, including insomnia, loss of appetite, physical symptoms, and restlessness (initially), followed by irritability and anger, and then vivid and unpleasant dreams after a week.

  • Individuals with risk for suicide, schizophrenia, bipolar disorder, or other psychotic conditions should be cautioned that cannabis may exacerbate existing psychoses.

To reduce the risk for lawsuits, both psychiatric and primary care providers should warn patients using marijuana of the risk for exacerbation of suicidal thoughts.

I find nothing in the laws or literature which obligates a practitioner to confirm that some other practitioner's recommendation is appropriate. I find nothing in the literature which requires a practitioner to alter a course of treatment if a patient is on medical marijuana. However, more research is needed about the effects of cannabis, and clinicians should plan their continuing education for this in the coming years to include talks and articles about marijuana therapy.

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