Caregiver Roles in the Use of Marijuana

1. Caregiver Roles in the Use of Marijuana Division of Licensing and Regulatory Services July 2011

2. Conundrum According to the U.S. Attorney, “Nor does this guidance preclude investigation or prosecution, even when there is clear and unambiguous compliance with existing state law….”

3. Federal Position The federal government continues to be concerned about the growers and dispensers, not the patients. In July, the Justice Departmentsaid that marijuana dispensaries and licensed growers in states with medical marijuana laws could face prosecution for violating federal drug and money-laundering laws.

4. Legally Prescribed Meds • Marinol – It comes in the form of a pill and is being studied by researchers for suitability via other delivery methods, such as an inhaler or patch. The active ingredient is synthetic THC, which has been found to relieve the nausea and vomiting associated with chemotherapy for cancer patients and to assist with loss of appetite with AIDS patients. • Side effects – For some patients, it causes confusion; decreased coordination; dizziness; drowsiness; elevated or relaxed mood; headache; nausea; stomach pain; trouble concentrating; vomiting; weakness.

5. Drugs Under Study Sativex- An oral spray approved outside the U.S. and derived from the cannabis plant (THC and cannabinoids) and not a synthetic. For use in treating symptoms of MS. Trials underway for treating cancer pain. Side Effects - Dizziness and tiredness. Some people may also feel depressed or confused, may feel over-excited or lose touch with reality, may have difficulties with memory or trouble concentrating and may feel sleepy or giddy.

6. Cancer Glaucoma Positive Status for HIV Hepatitis C ALS Chron’s Agitation of Alzheimers Nail-Patella Syndrome A chronic or debilitating disease/medical condition or its treatment that produces intractable pain. Cachexia or wasting syndrome Severe nausea Seizures characteristic of Epilepsy Severe and persistent spasms characteristic of MS Any other medical condition or its treatment approved by the Commissioner of DHHS What is Marijuana Authorized For?

7. What the literature says: • Cancer – According to the National Cancer Institute, there has been much interest in the use of marijuana to treat chemotherapy-induced nausea and vomiting in cancer patients. However, there are no definitive research results. Advocates cite its effectiveness for chemotherapy induced nausea and vomiting. • Glaucoma – Advocates cite evidence that hemp products can lower intraocular pressure (IOP) in people with glaucoma. The Glaucoma Research Foundation, however, indicates a high dose of marijuana is necessary to produce a clinically relevant effect on IOP in the short term and requires constant inhalation, as much as every three hours.

8. The literature…… • Positive Status for HIV – Some patients use marijuana to stimulate appetite and reduce nausea. Some may use it for the accompanying peripheral neuropathy. • Hepatitis C - Published in the October 2006 European Journal of Gastroenterology and Hepatology, a Northern California study involving 71 participants demonstrated that moderate marijuana use may relieve interferon’s side effects, helping people with Hepatitis C stick with the full treatment regimen.

9. The literature…… • ALS – The Department of Rehabilitation Medicine at the University of Washington conducted a 2004 survey. This study was the first, anonymous survey of persons with ALS regarding the use of cannabis. There were 131 respondents, 13 of whom reported using cannabis in the last 12 months. Although the small number of people with ALS that reported using cannabis limits the interpretation of the survey findings, the results indicate that cannabis may be moderately effective at reducing symptoms of appetite loss, depression, pain, spasticity, and drooling.

10. The literature…… • Crohn’s- anecdotal evidence that cannabis relieves some of the symptoms of inflammatory bowel disease • Agitation of Alzheimers – Marinol has been used for this, but not everyone has good results with marinol.

11. The literature…… • Nail Patella Syndrome - Marijuana may help relieve the associated pain. • Intractable Pain – The number one reason why physicians recommend marijuana. Anecdotally, patients reduce the use of narcotic pain medicines.

13. American Medical Association Adopted a resolution in November 2009, calling for the government to review its classification of marijuana, in order to ease the way for more research into the use of medical marijuana. While the AMA, the largest physician's organization in the U.S., explicitly states it does not endorse any current state-based medical marijuana programs or the legalization of marijuana, the move is a significant shift that continues a trend toward support for easing restrictions against the drug.

14. Routes of Administration • Progress has been made in recent years to reduce the disadvantages of certain routes of cannabis administration, notably the slow onset of action with oral use and harm associated with the inhalation of combustion products when smoking cannabis. • "Inhalation of carcinogenic combustion products associated with smoking is generally regarded as the major health hazard in connection with the medical use of cannabis products.”

16. Consumers in NF’s Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease pain from a back injury. She would not consider living in a nursing home that did not permit her to use the oil. (from the NY Times)

17. Things Caregivers Need to Know • Children and incapacitated adults have the same opportunity to participate in the program, with the permission of their guardians, or the assistance of a caregiver. • Licensing staff are not responsible for monitoring the administration of marijuana in nursing homes or inpatient hospice, the only approved settings where staff of facilities may assist patients. There are separate program staff.

18. No Assisted Housing

19. Prohibitions A person whose conduct is authorized under the MMMP Act may not be denied any right or privilege or be subjected to any penalty or disciplinary action, including but not limited to a civil penalty or disciplinary action by a business or occupational or professional licensing board or bureau, for lawfully engaging in conduct involving the medical use of marijuana authorized.

20. Protections • A school, employer or landlord may not refuse to enroll or employ or lease to or otherwise penalize a person solely for that person's status as a registered patient or a registered primary caregiver unless failing to do so would put the school, employer or landlord in violation of federal law or cause it to lose a federal contract or funding. • This does not prohibit a restriction on the administration or cultivation of marijuana on premises when that administration or cultivation would be inconsistent with the general use of the premises.

21. Permissions • A landlord may prohibit the smoking of marijuana for medical purposes on the premises of the landlord if the landlord prohibits all smoking on the premises and posts notice to that effect on the premises. • Bangor Daily News story on campus students – reminding students it is a smoke free campus.

22. DHHS Position • MMMP rules provide guidelines for NF and inpatient hospice to ensure the security and non-diversion of marijuana. • DHHS works closely with Maine DEA, the federal government and other law enforcement officers to validate participation in the program, when necessary.

23. Patients, Caregivers and Dispensaries • On September 28, 2011, registration for patients became voluntary. Patients may voluntarily register and receive a registry identification card, or may choose to simply carry their written physician certification form. • Lawful acts include possession of no more than 2.5 ounces of prepared marijuana and no more than 6 mature flowering marijuana plants.

24. Unlawful Acts • Undertake any task under the influence of marijuana when doing so would constitute negligence or professional malpractice or would otherwise violate any professional standard • Possess marijuana or otherwise engage in the medical use of marijuana: (1) In a school bus; (2) On the grounds of any preschool or primary or secondary school; or (3) In any correctional facility;

25. More Unlawful Acts • Smoke marijuana: (1) On any form of public transportation; or (2) In any public place; • Operate, navigate or be in actual physical control of any motor vehicle, aircraft, motorboat, snowmobile or all-terrain vehicle while under the influence of marijuana; or • Use marijuana if that person does not have a debilitating medical condition.

26. Confidentiality • Information about patients, caregivers and physicians is confidential. • DHHS may verify to law enforcement personnel whether an identification card is valid. • All existing medical information in DHHS records will be expunged in 6 months.

27. Experience to Date • Most patients who apply are very sick and/or suffering individuals. Pain is the number one condition. • Most have tried other forms of treatment and/or medication for their conditions without success. • Many favor marijuana over scheduled drugs because of fewer side effects.

28. More Experience • More physicians than were anticipated are certifying patients and DHHS has given them authority to recommend marijuana for less than 12 months. • An ounce of prepared marijuana is enough for 70 joints. A patient may have 2.5 ounces every 15 days. • The THC content in medical grade marijuana is increasing 10% each year. • Maine is seeing an increasing in treatment for marijuana addiction.

29. Facility Participation • Inpatient hospice providers and nursing facilities may voluntarily participate in the MMMP to assist registered patients. It is not required. • MMMP documentation is not included in the medical record, chart or medication administration record that is required under facility licensing and/or certification laws. • A registered patient’s MMMP record must be maintained at the facility as a separate record and shall include but is not limited to the inventory record, documentation of marijuana administration and the relief provided.

30. Process • Patients designate the nursing facility as a primary caregiver. • The physician certification of the patient’s qualifying medical condition is required. • The nursing facility or inpatient hospice must register with DLRS and registry identification cards will be issued to staff who will help the resident.

31. More Process • Sources of marijuana must be registered as caregivers or dispensaries, unless it is a family member, where no registration is required. • Facilities are not required to help in marijuana administration.

32. More and More Process • If the facility has a criminal background record for an individual staff member within the last 12 months, send it along to DLRS. If not, DLRS will request a background check. There is no charge. • Staff are prohibited from assisting patients if there are drug offenses within the last 10 years of more than a misdemeanor.

33. More and More • No staff member should remove his or her card from the facility unless transporting marijuana from a dispensary or caregiver. • Marijuana from a dispensary will be labeled with a trip ticket indicating the amount. • A facility may not cultivate marijuana for a registered patient.

34. More and More • Dispensary may deliver. • A facility may not make marijuana into products to be ingested. Edibles may be purchased from a dispensary or caregiver. • Edibles from a dispensary or a registered caregiver will be labeled as food products with ingredients and the amount of marijuana in the dose. Family members are not required to do this.

35. More and More • Registered patients may not keep marijuana in their room or on their person as it is a danger to other residents. The facility must store the marijuana in accordance with the provisions for storing controlled substances. Special storage consideration is required for food that contains this controlled substance.

36. More and More • When marijuana is removed from inventory, it must be signed out by two licensed staff persons who have MMMP registry identification cards. In the event there is only one licensed staff on duty, a CNA-M may be substituted once rules are changed. • Unless the dispensary or the cultivating caregiver has provided the marijuana in unit doses, the facility will need scales and other necessary tools to monitor its marijuana inventory.

37. More and More • Prepared marijuana must be kept under double lock and inventoried daily by two staff persons who have MMMP registry identification cards, one of whom must be a licensed professional. • A medication technician or a nurse may administer marijuana as long as he or she has a registry identification card. • The registered patient’s cultivating caregiver may not administer marijuana medication in the facility.

38. More and More • The fact that a patient is participating in the medical use of marijuana program is highly confidential and each facility serving MMMP patients must develop “need to know” protocols. • The registered patient will let the facility know what dosage gives relief. The lowest dosage possible that gives the registered patient relief is optimal.

39. More and More • Patients who smoke marijuana are subject to the same facility policies as patients who smoke tobacco. The facility may encourage registered patients that the use of alternative forms of marijuana administration may be preferable. • Follow established protocols for monitoring patient response to any treatment or medication and observe the registered patient’s response to the administration of marijuana.

40. More and More • A resident may not be discharged solely because the patient registers in the Maine Medical Use of Marijuana Program. • Unused, unadulterated marijuana in the possession of the registered patient, registered primary caregiver, a hospice provider or a nursing facility named as a primary caregiver, or a registered dispensary that is no longer needed for the registered patient’s medical use may be disposed of by: Donating it to a registered patient; or Donating it to a registered primary caregiver; or Donating it to a registered dispensary. Unused marijuana may also be disposed of by transporting the unused portion to a state or local law enforcement office. Presentation of a valid registry identification card and a Maine driver’s license or other state-issued photo identification may be required.

41. Resources www.maine.gov/dhhs/dlrs Growing medical grade marijuana is an art to be perfected in Maine.

42. Thank you! Be open minded Be patient centered