The prescribing of medical marijuana is still a federal crime, yet several states across the nation have enacted laws that allow prescribers to recommend medical marijuana to their patients. Under the authority of the Louisiana Legislature, the Louisiana State Board of Medical Examiners (LSBME) has been implementing rules regulating the recommendation of medical marijuana by Louisiana physicians since 2016. With the signing of Act 286, which becomes effective on August 1, 2020, these rules are expected to be repealed or scaled back since the LSBME is no longer charged with promulgating marijuana rules.
The Act redefines the term “recommend” as the opinion of a physician licensed by and in good standing with the LSBME, provided within a bona fide doctor-patient relationship, that, in the sincere judgment of the physician, therapeutic cannabis may be helpful to the patient’s condition or symptoms and is communicated by a means allowed by the Louisiana Board of Pharmacy (LBP). Guidance from the LBP on this is forthcoming.
Physicians in good standing and licensed by the LSBME may recommend medical marijuana for “any condition … that a physician in his medical opinion considers debilitating to an individual patient and is qualified through his medical education and training to treat.” In addition, debilitating conditions listed in Act 286 now include:
- Alzheimer’s disease
- Amyotrophic lateral sclerosis
- Huntington’s disease
- Lewy body dementia
- Motor neuron disease
- Parkinson’s disease
- Spinal muscular atrophy
- Traumatic brain injury
- A concussion diagnosed by a physician
- Chronic pain associated with fibromyalgia
- Chronic pain associated with sickle cell disease
- Any condition for which a patient is receiving hospice care or palliative care
Risk Management Considerations
The following risk management considerations are adopted in part from the Federation of State Medical Boards’ Model Guidelines for the Recommendation of Marijuana in Patient Care.
Physician-Patient Relationship. Physicians must have documented that an appropriate physician-patient relationship has been established, prior to providing a recommendation for marijuana to the patient.
Patient Evaluation and Prescription Monitoring Program (PMP). Physicians who recommend marijuana shall review the patient’s information in the database of the PMP. Document the patient medical evaluation and relevant clinical history. At minimum, the evaluation should include the patient’s history of present illness, social history, past medical and surgical history, alcohol and substance use history, family history with emphasis on addiction or mental illness/psychotic disorders, physical exam, documentation of therapies with inadequate response, and diagnosis requiring the marijuana recommendation.
Informed and Shared Decision Making. Provide the patient with information about the known and unknown risks and benefits of marijuana. Patients should be advised of the variability and lack of standardization of marijuana preparations and the known effects of marijuana. Patients should be reminded not to drive or operate heavy machinery while under the influence of cannabis. Document to the extent that this discussion occurred and that information was provided to the patient.
Qualifying Conditions. Recommending marijuana for certain medical conditions is at the professional discretion of the physician. Verify and document the qualifying conditions enumerated in La Rev. Stat. §40:1046(2)(a), or if the condition is not listed, document the rationale as to why the physician considers the condition debilitating based on the medical education and training of the physician.
Treatment Agreement and Plan. Physicians should consider documenting the written treatment plan, which can include:
- Review of other attempts to ease the suffering caused by the medical condition that do not involve the recommendation of cannabinoids.
- Advice about other options for managing the condition.
- Determination that a terminal or debilitating medical condition may benefit from marijuana.
- Advice about the potential risks of the medical use of cannabis.
- The variability of quality and concentration of marijuana;
- The risk of cannabis use disorder;
- Exacerbation of psychotic disorders and adverse cognitive effects for children and young adults;
- Adverse events, exacerbation of psychotic disorder, adverse cognitive effects for children and young adults, and other risks, including falls or fractures;
- Use of marijuana during pregnancy or breast feeding;
- The need to safeguard all marijuana and marijuana-infused products from children and pets or domestic animals; and
- The need to notify the patient that the marijuana is for the patient’s use only and the marijuana should not be donated or otherwise supplied to another individual.
- Additional diagnostic evaluations or other planned treatments.
- A specific duration for the marijuana for a period no longer than twelve months.
- A specific ongoing treatment plan as medically appropriate.
Consultation and Referral. Consult and refer patients with a history of substance abuse or mental health disorders. A patient who has a history of substance use disorder or a concomitant mental health disorder may be at a higher risk than others using cannabis. As such, physicians should consider referring these patients to a pain management specialist, psychiatrist, or to an addiction/mental health specialist.
Medical Records. Maintain accurate and complete medical records, which should include but not necessarily be limited to:
- The patient’s complete medical history
- Results of the physical examination, patient evaluation, diagnostic, therapeutic, and laboratory results
- Other treatments and prescribed medications
- Authorization, attestation or recommendation for marijuana (include date, expiration, and any additional information required by state statute)
- Instructions to the patient, including discussions of risks and benefits, side effects and variable effects
- Results of ongoing assessment and monitoring of patient’s response to marijuana
- A copy of the signed Treatment Agreement, including instructions on safekeeping and not diverting.
The Louisiana Pharmacy Board is expected to promulgate rules within the next few weeks relating to the form in which marijuana recommendations can be made and dispensing limitations. LAMMICO is monitoring information from the Louisiana Pharmacy Board and the Louisiana State Board of Medical Examiners and will update the resources as more information becomes available.
"Part 2: Louisiana Board of Pharmacy Releases Marijuana Emergency Rules" of this article series is available here.