The Massachusetts Medical Society appreciates the opportunity to comment to the Department of Public Health prior to the formal regulatory hearing process on the issues associated with implementing the Commonwealth's new law on the use of marijuana.
The MMS's House of Delegates, after the passage of last year's referendum question, amended its policies on the use of marijuana for clinical purposes. The society remains opposed to the recreational use of marijuana but has adopted policies which should help the Department in its efforts to create a regulatory framework that supports responsible implementation of the new law.
The MMS policies address several issues. The first is that the Massachusetts Board of Registration in Medicine should be the agency to establish what is a bona fide physician patient relationship in any context, including that of certifying a patient for marijuana use. We suggest that the DPH defer to the Board on this issue in its regulations and that further elements of our policy will help the Board in defining the relationship in this context. Clearly the Board should include in the nature of a legitimate relationship that a physician who is certifying that a patient may benefit from marijuana use will encourage patients to engage in follow up assessments and provide them the opportunity for an assessment of the patient's experience and a reassessment of a patient's treatment plan which includes marijuana use.
An additional area which must be addressed in the Board's evaluation of a appropriate relationship is the element of parental consent for those under 18 in making an informed choice of treatment options.
Here is the actual text of the relevant section of our policy:
That the MMS work with the MA Board of Registration in Medicine (BORIM) to define the nature of the relevant physician-patient relationship required under "An Act for the Humanitarian Medical Use of Marijuana" including an appropriate reassessment interval and required parent or guardian permission for individuals less than 18 years old.
The Department must clarify the referendum questions use of the term licensed physician to include only MD's and DO's fully licensed by the Massachusetts Board of Registration in Medicine.
Here is the actual text of the relevant section of our policy:
That the MMS advocate for the development of appropriate standards for marijuana certifications by physicians, including that physicians must have an active license from the Massachusetts Board of Registration in Medicine, a Massachusetts Department of Public Health Controlled Substances registration, and a federal Drug Enforcement Agency registration.
The MMS is concerned that language in the referendum question is overly broad in its authorizations for certifying a debilitating medical condition to include: "other conditions as determined in writing by a qualifying patient's physician."
The MMS supports the use of specific criteria in certifications which are consistent with the following policy:
That the MMS advocate that written certifications for marijuana registration cards are based on:
The patient's diagnosis; and
b) The physician's assessment that the patient's symptoms of spasticity, neuropathic pain or other symptoms determined by the Department of Public Health are not optimally controlled with conventional medical therapy;
Our policy requires us to ask you to reference the following standards as part of the professional standards consistent with a bona fide physician patient relationship:
That the MMS advocate to the BORIM and the Department of Public Health that relevant regulations include the following recommendations of the American Society on Addiction Medicine adopted April 12, 2010, that physicians who choose to provide certifications:
...Adhere to the established professional tenets of proper patient care, including
Development of a treatment plan with objectives;
Provision of informed consent, including discussion of side effects;
Periodic review of the treatment's efficacy;
Consultation, as necessary; and
Proper record keeping that supports the decision to recommend the use of cannabis
…should have a pre-existing and ongoing relationship with the patient as a treating physician
Ensure that the issuance of "recommendations" is not a disproportionately large (or even exclusive) aspect of their practice
Have adequate training in identifying substance abuse and addiction.
The MMS is aware that the DPH is going to public hearing on new regulations for its prescription monitoring program. We urge the DPH to make patient certifications available to prescribing physicians as part of the prescription monitoring program. Such information is clearly relevant both in certifying a patient and in assessing a patient for a prescription.
That the MMS advocate with the MA Department of Public Health and the MA Legislature that marijuana dispensing be integrated with, and therefore be part of, the existing DPH Prescription Monitoring Program.
Finally, the MMS urges the Department to consider how marijuana certifications for patients are relevant to specific occupations/
That the MMS advocate that the regulations take into consideration the implications of medical use of marijuana on occupational health and safety.
There are many issues which remain to be considered by the Department, including:
- Who advises patients on treatment dosages and administration routes?
- What is an appropriate supply?
- What is the duration of a certification?
- What are the non-profit criteria for dispensaries and is there a role for the Attorney General in certification of non-profit status?
- May licensed individuals participate in the certification process without concerns regarding their licenses?
- Do peer reporting requirements apply to physicians and other licensees who know physicians who issue certifications or are certified as marijuana patients themselves?
- The MMS will provide detailed testimony during upcoming regulatory hearings and will address the law in greater detail at that time.
We support the efforts of the Department to engage in listening sessions to help clarify interpretations of the referendum among a wide variety of parties.
