Medical Marijuana and Ethical Dilemmas for CDP’s

1. Medical Marijuana and Ethical Dilemmas for CDP’s Paul Weatherly MA, CDP

2. Examine problems for the chemical dependency counseling field related to medical marijuana, standards of care and ethics. Focus of Training

3. Goals • To develop a better understanding of marijuana and its use as a medication • To identify various dilemmas for CDP(T)’s working with clients and patients who are using marijuana for medicinal purposes. • To improve understanding of the pharmacology supporting marijuana for medicinal purposes. • To begin the discussion for agencies and providers regarding policy and procedures regarding clients, patients and counselors using marijuana as a medication.

4. Topics for Today’s Discussion • Medical Marijuana Law • CDP Law • Uniform Disciplinary Act • American’s With Disabilities Act • Uniform Substance Control Act • NAADAC Code of Ethics • Overview of Medical Marijuana Pharmacology

5. Topics Not Included in Today’s Discussion • Decriminalization of Marijuana • Legalization of Marijuana • Impact of Marijuana Use on Adolescents and Adults • Treatment Methodology for Marijuana Addiction

6. Medical Marijuana Law Intent: • There is medical evidence that some patients with terminal or debilitating medical conditions may, under their health care professional's care, benefit from the medical use of cannabis. • Humanitarian compassion necessitates that the decision to use cannabis by patients with terminal or debilitating medical conditions is a personal, individual decision, based upon their health care professional's professional medical judgment and discretion.

7. Medical Marijuana Law Question: Is medical marijuana legal? Answer: Marijuana possession is illegal in Washington. The medical marijuana law provides protection from arrest or other criminal sanctions for qualified patients and designated caregivers who are complying with the law. People who qualify have a valid reason to possess a 60-day supply of marijuana. However, medical marijuana is not legal under federal law. There is no protection for people who are arrested or charged under federal law. http://www.doh.wa.gov/hsqa/medical-marijuana/FAQmore.htm

8. Medical Marijuana Law Question: Can a Patient be prescribed marijuana for medical use? Answer: No! Doctors may not "prescribe" marijuana for medical use under federal law, though they can "recommend" its use under the First Amendment.

9. Medical Marijuana Law Question: How is a patient allowed to use marijuana as a medication if it is not prescribed? Answer: A Health care professional licensed in WA may not be prosecuted for advising a qualifying patient about the risks and benefits of medical use of marijuana or that the qualifying patient may benefit from the medical use of marijuana.

10. Medical Marijuana Law Question: What kinds of health care professionals are eligible to advise patients about medical uses of marijuana? Answer: • licensed physician • licensed physician assistant • licensed osteopathic physician • licensed osteopathic physicians' assistant • licensed naturopath • licensed advanced registered nurse practitioner

11. Medical Marijuana Law Question: What conditions must the health care professional meet prior to recommending the use of marijuana as a medication? Answer: A health care professional may only provide a patient with valid documentation if he or she has a newly initiated or existing documented relationship with the patient related to the diagnosis and ongoing treatment or monitoring of the patient's terminal or debilitating medical condition after: • a physical examination of the patient as appropriate, based on the patient's condition and age • documented the terminal or debilitating medical condition of the patient in the patient's medical record and that the patient may benefit from treatment of this condition or its symptoms with medical use of cannabis • informed the patient of other options for treating the terminal or debilitating medical condition • documented other measures have been attempted to treat the terminal or debilitating medical condition that do not involve the medical use of cannabis

12. Medical Marijuana Law Question: What does valid documentation mean (green card)? Answer: Recommendations must be written on tamper-resistant paper. They must include an original signature by the healthcare provider, a date, and a statement that says in the healthcare provider's professional opinion the patient may benefit from the medical use of marijuana. The use of a copy of the patient's medical records in lieu of a recommendation is prohibited.

13. Medical Marijuana Law Question: What does terminal or debilitating medical condition mean? Answer: • Cancer, human immunodeficiency virus (HIV), multiple sclerosis, epilepsy or other seizure disorder, or spasticity disorders • Intractable pain, limited for the purpose of this chapter to mean pain unrelieved by standard medical treatments and medications; • Glaucoma, either acute or chronic, limited for the purpose of this chapter to mean increased intraocular pressure unrelieved by standard treatments and medications • Crohn's disease with debilitating symptoms unrelieved by standard treatments or medications • Hepatitis C with debilitating nausea or intractable pain unrelieved by standard treatments or medications • Diseases, including anorexia, which result in nausea, vomiting, wasting, appetite loss, cramping, seizures, muscle spasms, or spasticity, when these symptoms are unrelieved by standard treatments or medications

14. Medical Marijuana Law Question: What are most researched medical conditions that are illustrate the most credible uses of marijuana as a medication? Answer: • Wasting syndrome associated with antiretroviral drugs and chemo/radiation therapy • Gastrointestinal disorders and diseases

15. Medical Marijuana Law Question: How does an individual get a medical condition recognized for treatment with medical marijuana? Answer: Anyone may petition the commission to add a condition to the list. By law, the commission will consult with the Board of Osteopathic Medicine and Surgery. For more information about this process, you may contact the commission at: Medical Quality Assurance CommissionP.O. Box 47866Olympia, WA 98504-7866 http://www.doh.wa.gov/hsqa/medical-marijuana/FAQmore.htm#3

16. Medical Marijuana Law Question: Can a person be arrested or prosecuted for possession of medical marijuana? Answer: No, a patient in compliance with medical marijuana law may not be arrested or prosecuted.

17. Medical Marijuana Law Question: What is non-compliance with this law? Answer: The investigating peace officer does not possess evidence that: • The designated provider has converted cannabis produced or obtained for the qualifying patient for his or her own personal use or benefit • The qualifying patient has converted cannabis produced or obtained for his or her own medical use to the qualifying patient's personal, nonmedical use or benefit • The designated provider has served as a designated provider to more than one qualifying patient within a fifteen-day period

18. Medical Marijuana Law Question: How much medical marijuana may a patient or provider possess? Answer: A qualifying patient or designated provider may have a 60-day supply of medical marijuana. A 60-day supply is defined as 24 ounces and 15 plants.

19. Medical Marijuana Law Question: What is the average daily dose based on the definition of the 60 day supply? Answer: 11.2 grams

20. Medical Marijuana Law Question: What is considered a therapeutic dose? Answer: The law and literature on the use of medical marijuana does not define a therapeutic dose. • A urinalysis test or blood test can not be used to determine if a patient is using as recommended or abusing marijuana. • The patient self doses based on achieving the desired result to relieve symptoms.

21. Medical Marijuana Law Question: Does the law recommend a particular route of administration? Answer: No, the patient can use marijuana in anyway he or she feels is the best to obtain the desired result. • Smoking or Inhaling • Oral Consumption • Transdermal Delivery

22. Side Effects of Medical Marijuana • Euphoria • Paranoia • Fatigue • Loss of Motivation • Memory Loss • Weight gain or loss

23. Side Effects of Medical Marijuana Question: Do patients complain about the side effects of medical marijuana or cannabinoid derivative prescription drugs? Answer: Yes!!!!! The number one complaint was euphoria.

24. Cannabinoid Derivative Prescription Drugs Dronabinol (Marinol)- synthetic form of delta-9-THC was approved by the FDA in 1985 Nabilone (Cesamet): This drug is a synthetic, substituted cannabinoid approved by the FDA in 2006 Delta-9-THC/Cannabidiol (Sativex):Sativex was approved in Canada for treatment of neuropathic pain in patients with MS and as an adjunct for pain in cancer patients. It is currently undergoing clinical trials in the U.S. for cancer pain. Rimonabant (Acomplia): FDA approval was denied and approval by the European Commission was withdrawn due to the emergence of side effects, including depression and suicidality.

25. Federal Controlled Substances Act Question: What is a Schedule I drug? Answer: • The drug or other substance has a high potential for abuse. • The drug or other substance has no currently accepted medical use in treatment in the United States. • There is a lack of accepted safety for use of the drug or other substance under medical supervision. http://www.deadiversion.usdoj.gov/21cfr/21usc/812.htm

26. Federal Controlled Substances Act Question: Why is marijuana a schedule I drug? Answer: Under the CSA, marijuana is classified as a Schedule I drug, which means that the federal government views marijuana as highly addictive and having no medical value.

27. Federal Controlled Substances Act Question: What is a schedule II drug? Answer: • The drug or other substance has a high potential for abuse. • The drug or other substance has a currently accepted medical use in treatment in the United States or a currently accepted medical use with severe restrictions. • Abuse of the drug or other substances may lead to severe psychological or physical dependence. http://www.deadiversion.usdoj.gov/21cfr/21usc/812.htm

28. Federal Controlled Substances Act Question: If marijuana is being considered a medication, will it be moved to Schedule II? Answer: The AMA, NORMAL, and various state attorney generals have petitioned the congress to do this but to date congress has denied the petitions.

29. The Nature of Dilemma Dilemma occurs when laws and ethical guidelines are in conflict. The following laws create conflict for healthcare providers not protected by medical marijuana law: • Uniform Disciplinary Act • Americans With Disabilities Act • Chemical Dependency Professional Law

30. Americans With Disabilities Act Question: Are Alcoholics and Drug Addicts qualified individuals with a disability? Answer: No, A qualified individual with a disability shall not include any employee or applicant who is currently engaging in the illegal use of drugs, when the covered entity (employer, school, treatment program, etc.) acts on the basis of such use. http://www.ada.gov/pubs/adastatute08mark.htm#12114a

31. Americans With Disabilities Act Question: Are Alcoholics and Drug Addicts qualified individuals with a disability? Answer: Yes, history of illegal drug use does not prevent an alcoholic or drug addict from being a qualified individual with a disability who • has successfully completed a supervised drug rehabilitation program and is no longer engaging in the illegal use of drugs, or has otherwise been rehabilitated successfully and is no longer engaging in such use • is participating in a supervised rehabilitation program and is no longer engaging in such use • is erroneously regarded as engaging in such use, but is not engaging in such use It would not be a violation for a covered entity to adopt or administer reasonable policies or procedures, including but not limited to drug testing, designed to ensure that an individual described in paragraph (1) or (2) is no longer engaging in the illegal use of drugs. http://www.ada.gov/pubs/adastatute08mark.htm#12114a

32. Uniform Disciplinary Act Question: Are there laws that govern the conduct, scope of practice and consumption of alcohol and drugs by CDP(T)’S. Answer: Yes! There are stipulations regarding these areas in RCW 18.130.180.

33. Uniform Disciplinary Act Three stipulations in RCW 18.130.180 have the potential to create conflicts for CDP’s. (7) Violation of any state or federal statute or administrative rule regulating the profession in question, including any statute or rule defining or establishing standards of patient care or professional conduct or practice (12) Practice beyond the scope of practice as defined by law or rule (23) Current misuse of:(a) Alcohol;(b) Controlled substances; or(c) Legend drugs http://apps.leg.wa.gov/RCW/default.aspx?cite=18.130.180

34. Chemical Dependency Professional Law Question: What are the legally defined competencies of a CDP? Answer: (6) "Core competencies of chemical dependency counseling" means competency in the nationally recognized knowledge, skills, and attitudes of professional practice, including assessment and diagnosis of chemical dependency, chemical dependency treatment planning and referral, patient and family education in the disease of chemical dependency, individual and group counseling with alcoholic and drug addicted individuals, relapse prevention counseling, and case management, all oriented to assist alcoholic and drug addicted patients to achieve and maintain abstinence from mood-altering substances and develop independent support systems. http://apps.leg.wa.gov/RCW/default.aspx?cite=18.205.020

35. NAADAC Code of Ethics Question: Does the code of ethics for the chemical dependency field offer guidance regarding patients who use marijuana for medical conditions? Answer: Yes! Five of the nine principles in the code offer implicit insight regarding medical marijuana but offer no solutions.

36. NAADAC Code of Ethics Principle 4: Trustworthiness I understand that effectiveness in my profession is largely based on the ability to be worthy of trust, and I shall work to the best of my ability to act consistently within the bounds of a known moral universe, to faithfully fulfill the terms of both personal and professional commitments, to safeguard fiduciary relationships consistently, and to speak the truth as it is known to me. • I shall never misrepresent my credentials or experience. • I shall make no unsubstantiated claims for the efficacy of the services I provide and make no statements about the nature and course of addictive disorders that have not been verified by scientific inquiry. • I shall constantly strive for a better understanding of addictive disorders and refuse to accept supposition and prejudice as if it were the truth.

37. NAADAC Code of Ethics Principle 5: Compliance with Law I understand that laws and regulations exist for the good ordering of society and for the restraint of harm and evil, and I am aware of those laws and regulations that are relevant both personally and professionally and follow them, while reserving the right to commit civil disobedience. • I understand that the determination that a law or regulation is unjust is not a matter of preference or opinion but a matter of rational investigation, deliberation, and dispute. • I willingly accept that there may be a penalty for justified civil disobedience, and I must weigh the personal harm of that penalty against the good done by civil protest.

38. NAADAC Code of Ethics Principle 6: Rights and Duties I understand that personal and professional commitments and relationships create a network of rights and corresponding duties. I shall work to the best of my ability to safeguard the natural and consensual rights of each individual and fulfill those duties required of me. • I understand that justice extends beyond individual relationships to the community and society; therefore, I shall participate in activities that promote the health of my community and profession. • I shall, to the best of my ability, actively engage in the legislative processes, educational institutions, and the general public to change public policy and legislation to make possible opportunities and choice of service for all human beings of any ethnic or social background whose lives are impaired by alcoholism and drug abuse.

39. NAADAC Code of Ethics Principle 8: Preventing Harm I understand that every decision and action has ethical implication leading either to benefit or harm, and I shall carefully consider whether any of my decisions or actions has the potential to produce harm of a physical, psychological, financial, legal, or spiritual nature before implementing them. • I shall terminate a counseling or consulting relationship when it is reasonably clear that the client is not benefiting from the relationship. • I understand an obligation to protect individuals, institutions, and the profession from harm that might be done by others. Consequently, I am aware that the conduct of another individual is an actual or likely source of harm to clients, colleagues, institutions, or the profession, and that I have an ethical obligation to report such conduct to competent authorities.

40. NAADAC Code of Ethics Principle 9: Duty of Care I shall operate under the principle of Duty of Care and shall maintain a working/therapeutic environment in which clients, colleagues, and employees can be safe from the threat of physical, emotional or intellectual harm. • I respect the right of others to hold opinions, beliefs, and values different from my own. • I shall strive for understanding and the establishment of common ground rather than for the ascendancy of one opinion over another. • I shall maintain competence in the area of my practice through continuing education, constantly improving my knowledge and skills in those approaches most effective with my specific clients. • I shall scrupulously avoid practicing in any area outside of my competence. http://www.ndbace.org/forms/NAADACCodeofEthics-2004.pdf

41. Looking for Solutions The Problem: • Marijuana is a schedule I drug. • The job of a CDP is to assist the patient in finding ways to maintain abstinence and create a clean and sober support system. • CDP’s are not identified as protected as health care providers in the medical marijuana law. • The UDA requires CDP’s to follow all state and federal laws related to the profession.

42. Looking for Solutions The foundation to the implementing a solution to the dilemmas presented lies in: • Developing agency policy and procedure that clearly identifies the criteria for accepting a medical marijuana patient for addiction treatment or for referring a medical marijuana patient to another addiction treatment agency.

43. Looking for Solutions Policy and Procedure for Referral: • Create criteria to determine a medical marijuana patient’s eligibility for assessment and evaluation of a substance use disorder. • Create procedures for documenting assessment outcomes that include marijuana abuse and dependence for medical marijuana patient. • Create procedure for documenting diagnostic impressions used to determine assessment outcomes. • Document Urinalysis or Blood test results.

44. Looking for Solutions Policy and Procedure for admission to Treatment • Develop policy defining the agency’s philosophy regarding medical marijuana • Develop policy defining the role of a CDP treating medical marijuana patients. • Create criteria to determine a medical marijuana patient’s eligibility for assessment and evaluation of a substance use disorder. • Create procedure for documenting diagnostic impressions used to determine assessment outcomes. • Create procedures to determine patient’s use periods prior to care, during care and post-care.

45. Looking for Solutions Policy and Procedure for admission to Treatment (cont) • Create procedures to determine patient’s use periods prior to care, during care and post-care. • Develop treatment planning guidelines that clearly demonstrate the ongoing benefits of maintaining the therapeutic relationship. • Create policies that define levels of acceptable THC metabolites present in a UA and how to address spikes in the THC creatinine ratio

46. Looking for Solutions Policy and Procedure for admission to Treatment (cont) • Develop policies that define purpose and frequency of urinalysis • Develop policies to define relapse on medical marijuana and procedures for documenting the relapse. • Develop policies that define expectations for participation in treatment and mandatory reporting responsibilities if a medical marijuana patient violates the conditions that qualify them as a medical marijuana patient.

47. Looking for Solutions Problem: Retaining a CDP using medical marijuana Counselor in Recovery is recommended medical marijuana for a medical condition. • Develop agency philosophy defining “being in recovery”. • Develop agency definition of impaired professional including acceptable times for use pre and post work hours, UA tolerance levels and creatinine ratios. • Develop policy defining duties in agency and stipulations on serving different patient populations.

48. Looking for Solutions Problem: Zero tolerance for CDP using medical marijuana and Counselor in Recovery is recommended medical marijuana for a medical condition. • Develop policy and procedure for documenting termination and reporting use to DOH. • Develop policy and procedure for documenting leave of absence and completion of WHPS program.

49. Looking for Solutions Problem: CDP not in recovery who would not meet diagnostic criteria for substance abuse or dependence is recommended to use medical marijuana for a medical condition. Question: Should agencies have different standards for CDP’s who are in recovery from standards for CDP’s who do not meet criteria warranting the need to be in recovery?

50. Looking for Solutions Problem: Medical marijuana patient leaves treatment and gets in an accident Question: Is the agency liable knowing a patient potentially is leaving treatment under the influence. Hint: Use of medical marijuana is not an affirmative defense for driving under the influence.