Caregiver Roles in Caregiver Roles in the Use of the Use of Marijuana Marijuana

Division of Licensing and Division of Licensing and Regulatory ServicesRegulatory Services

July 2011July 2011

ConundrumConundrum

According to the According to the U.S. Attorney, U.S. Attorney, “Nor does this “Nor does this

guidance preclude guidance preclude investigation or investigation or

prosecution, even prosecution, even when there is clear when there is clear and unambiguous and unambiguous compliance with compliance with

existing state existing state law….”law….”

Federal PositionFederal PositionThe federal government The federal government

continues to be concerned about continues to be concerned about the growers and dispensers, not the growers and dispensers, not

the patients. In July, the the patients. In July, the Justice Department said that said that marijuana dispensaries and marijuana dispensaries and

licensed growers in states with licensed growers in states with medical marijuana laws could medical marijuana laws could face prosecution for violating face prosecution for violating

federal drug and money-federal drug and money-laundering laws.laundering laws.

Legally Prescribed MedsLegally Prescribed Meds

• MarinolMarinol – It comes in the form of a pill and is being – It comes in the form of a pill and is being studied by researchers for suitability via other studied by researchers for suitability via other delivery methods, such as an inhaler or patch. The delivery methods, such as an inhaler or patch. The active ingredient is synthetic THC, which has been active ingredient is synthetic THC, which has been found to relieve the nausea and vomiting associated found to relieve the nausea and vomiting associated with chemotherapy for cancer patients and to assist with chemotherapy for cancer patients and to assist with loss of appetite with AIDS patients. with loss of appetite with AIDS patients.

• Side effects – For some patients, it causes Side effects – For some patients, it causes confusion; decreased coordination; dizziness; confusion; decreased coordination; dizziness; drowsiness; elevated or relaxed mood; headache; drowsiness; elevated or relaxed mood; headache; nausea; stomach pain; trouble concentrating; nausea; stomach pain; trouble concentrating; vomiting; weakness.vomiting; weakness.

Drugs Under StudyDrugs Under Study

• Sativex Sativex - An oral spray approved outside the - An oral spray approved outside the U.S. and derived from the cannabis plant U.S. and derived from the cannabis plant (THC and cannabinoids) and not a synthetic. (THC and cannabinoids) and not a synthetic. For use in treating symptoms of MS. Trials For use in treating symptoms of MS. Trials underway for treating cancer pain.underway for treating cancer pain.

• Side Effects - Dizziness and tiredness. Some Side Effects - Dizziness and tiredness. Some people may also feel depressed or confused, people may also feel depressed or confused, may feel over-excited or lose touch with may feel over-excited or lose touch with reality, may have difficulties with memory or reality, may have difficulties with memory or trouble concentrating and may feel sleepy or trouble concentrating and may feel sleepy or giddy. giddy.

What is Marijuana What is Marijuana Authorized For?Authorized For?

• CancerCancer• GlaucomaGlaucoma• Positive Status for HIVPositive Status for HIV• Hepatitis CHepatitis C• ALSALS• Chron’sChron’s• Agitation of AlzheimersAgitation of Alzheimers• Nail-Patella SyndromeNail-Patella Syndrome• A chronic or A chronic or

debilitating debilitating disease/medical disease/medical condition or its condition or its treatment that treatment that produces intractable produces intractable pain.pain.

• Cachexia or wasting Cachexia or wasting syndromesyndrome

• Severe nauseaSevere nausea• Seizures Seizures

characteristic of characteristic of EpilepsyEpilepsy

• Severe and Severe and persistent spasms persistent spasms characteristic of MScharacteristic of MS

• Any other medical Any other medical condition or its condition or its treatment approved treatment approved by the Commissioner by the Commissioner of DHHSof DHHS

What the literature says:What the literature says:• Cancer – 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 – 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.

The literature……The literature……

• Positive Status for Positive Status for HIV – HIV – Some patients use marijuana to stimulate appetite and reduce nausea. Some may use it for the accompanying peripheral neuropathy.

• Hepatitis C - 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.

The literature……The literature……• ALS – 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.

The literature……The literature……

• Crohn’s - Crohn’s - anecdotal evidence that cannabis relieves some of the symptoms of inflammatory bowel disease

• Agitation of Agitation of Alzheimers – Alzheimers – Marinol has been used for this, but not everyone has good results with marinol.

The literature……The literature……

• Nail Patella Syndrome - Marijuana may help relieve the associated pain.

• Intractable Pain – Intractable Pain – The number one reason why physicians recommend marijuana. Anecdotally, patients reduce the use of narcotic pain medicines.

American Nurses Association

Position:

Pro to the question "Should marijuana be a medical option?"

Reasoning: "The American Nurses Association (ANA) recognizes that patients should have safe access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used medicinally for centuries. It has been shown to be effective in treating a wide range of symptoms and conditions." "Position Statement: Providing Patients Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association (ANA) website, Mar. 19, 2004

American Medical American Medical AssociationAssociation

Adopted a resolution in November Adopted a resolution in November 2009, calling for the government to 2009, calling for the government to

review its classification of marijuana, in review its classification of marijuana, in order to ease the way for more order to ease the way for more research into the use of medical research into the use of medical

marijuana. marijuana.

While the AMA, the largest physician's While the AMA, the largest physician's organization in the U.S., explicitly organization in the U.S., explicitly

states it does not endorse any current states it does not endorse any current state-based medical marijuana state-based medical marijuana programs or the legalization of programs or the legalization of

marijuana, the move is a significant marijuana, the move is a significant shift that continues a trend toward shift that continues a trend toward

support for easing restrictions against support for easing restrictions against the drug.the drug.

Routes of AdministrationRoutes of Administration

• Progress has been made in recent years to Progress has been made in recent years to reduce the disadvantages of certain routes reduce the disadvantages of certain routes of cannabis administration, notably the slow of cannabis administration, notably the slow onset of action with oral use and harm onset of action with oral use and harm associated with the inhalation of associated with the inhalation of combustion products when smoking combustion products when smoking cannabis. cannabis.

• "Inhalation of carcinogenic combustion "Inhalation of carcinogenic combustion products associated with smoking is products associated with smoking is generally regarded as the major health generally regarded as the major health hazard in connection with the medical use hazard in connection with the medical use of cannabis products.”of cannabis products.”

Consumers in NF’sConsumers 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)

Things Caregivers Need Things Caregivers Need to Knowto 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.

No Assisted Housing

ProhibitionsProhibitions

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

• 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.

ProtectionsProtections

PermissionsPermissions

• 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.

DHHS PositionDHHS 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.

Patients, Caregivers and Patients, Caregivers and DispensariesDispensaries

• On September 28, 2011, registration for On September 28, 2011, registration for patients became voluntary. Patients may patients became voluntary. Patients may voluntarily register and receive a voluntarily register and receive a registry identification card, or may registry identification card, or may choose to simply carry their written choose to simply carry their written physician certification form.physician certification form.

• Lawful acts include possession of no Lawful acts include possession of no more than 2.5 ounces of prepared more than 2.5 ounces of prepared marijuana and no more than 6 mature marijuana and no more than 6 mature flowering marijuana plants.flowering marijuana plants.

Unlawful ActsUnlawful Acts

• Undertake any task under the influence of Undertake any task under the influence of marijuana when doing so would constitute marijuana when doing so would constitute negligence or professional malpractice or negligence or professional malpractice or would otherwise violate any professional would otherwise violate any professional standard standard

• Possess marijuana or otherwise engage in Possess marijuana or otherwise engage in the medical use of marijuana:the medical use of marijuana:(1) In a school bus;(1) In a school bus;

(2) On the grounds of any preschool or primary or (2) On the grounds of any preschool or primary or secondary school; orsecondary school; or

(3) In any correctional facility; (3) In any correctional facility;

More Unlawful ActsMore Unlawful Acts

• Smoke marijuana:Smoke marijuana:(1) On any form of public transportation; or(1) On any form of public transportation; or

(2) In any public place; (2) In any public place;

• Operate, navigate or be in actual Operate, navigate or be in actual physical control of any motor vehicle, physical control of any motor vehicle, aircraft, motorboat, snowmobile or aircraft, motorboat, snowmobile or all-terrain vehicle while under the all-terrain vehicle while under the influence of marijuana; or influence of marijuana; or

• Use marijuana if that person does not Use marijuana if that person does not have a debilitating medical conditionhave a debilitating medical condition. .

ConfidentialityConfidentiality

• Information about patients, Information about patients, caregivers and physicians is caregivers and physicians is confidential.confidential.

• DHHS may verify to law DHHS may verify to law enforcement personnel whether enforcement personnel whether an identification card is valid.an identification card is valid.

• All existing medical information All existing medical information in DHHS records will be in DHHS records will be expunged in 6 months.expunged in 6 months.

Experience to DateExperience to Date

• Most patients who apply are very Most patients who apply are very sick and/or suffering individuals. sick and/or suffering individuals. Pain is the number one condition.Pain is the number one condition.

• Most have tried other forms of Most have tried other forms of treatment and/or medication for treatment and/or medication for their conditions without success. their conditions without success.

• Many favor marijuana over Many favor marijuana over scheduled drugs because of fewer scheduled drugs because of fewer side effects.side effects.

More ExperienceMore Experience

• More physicians than were anticipated More physicians than were anticipated are certifying patients and DHHS has are certifying patients and DHHS has given them authority to recommend given them authority to recommend marijuana for less than 12 months.marijuana for less than 12 months.

• An ounce of prepared marijuana is An ounce of prepared marijuana is enough for 70 joints. A patient may enough for 70 joints. A patient may have 2.5 ounces every 15 days.have 2.5 ounces every 15 days.

• The THC content in medical grade The THC content in medical grade marijuana is increasing 10% each year.marijuana is increasing 10% each year.

• Maine is seeing an increasing in Maine is seeing an increasing in treatment for marijuana addiction. treatment for marijuana addiction.

Facility ParticipationFacility Participation• Inpatient hospice providers and nursing Inpatient hospice providers and nursing

facilities may voluntarily participate in the facilities may voluntarily participate in the MMMP to assist registered patients. It is not MMMP to assist registered patients. It is not required.required.

• MMMP documentation is not included in the MMMP documentation is not included in the medical record, chart or medication medical record, chart or medication administration record that is required under administration record that is required under facility licensing and/or certification laws. facility licensing and/or certification laws.

• A registered patient’s MMMP record must be A registered patient’s MMMP record must be maintained at the facility as a separate maintained at the facility as a separate record and shall include but is not limited to record and shall include but is not limited to the inventory record, documentation of the inventory record, documentation of marijuana administration and the relief marijuana administration and the relief provided. provided.

ProcessProcess

• Patients designate the nursing Patients designate the nursing facility as a primary caregiver.facility as a primary caregiver.

• The physician certification of the The physician certification of the patient’s qualifying medical patient’s qualifying medical condition is required.condition is required.

• The nursing facility or inpatient The nursing facility or inpatient hospice must register with DLRS hospice must register with DLRS and registry identification cards and registry identification cards will be issued to staff who will will be issued to staff who will help the resident. help the resident.

More ProcessMore Process

• Sources of marijuana must be Sources of marijuana must be registered as caregivers or registered as caregivers or dispensaries, unless it is a family dispensaries, unless it is a family member, where no registration is member, where no registration is required. required.

• Facilities are not required to Facilities are not required to help in marijuana help in marijuana administration.administration.

More and More ProcessMore and More Process

• If the facility has a criminal If the facility has a criminal background record for an individual background record for an individual staff member within the last 12 staff member within the last 12 months, send it along to DLRS. If not, months, send it along to DLRS. If not, DLRS will request a background DLRS will request a background check. There is no charge.check. There is no charge.

• Staff are prohibited from assisting Staff are prohibited from assisting patients if there are drug offenses patients if there are drug offenses within the last 10 years of more than within the last 10 years of more than a misdemeanor.a misdemeanor.

More and MoreMore and More

• No staff member should remove No staff member should remove his or her card from the facility his or her card from the facility unless transporting marijuana unless transporting marijuana from a dispensary or caregiver.from a dispensary or caregiver.

• Marijuana from a dispensary will Marijuana from a dispensary will be labeled with a trip ticket be labeled with a trip ticket indicating the amount.indicating the amount.

• A facility may not cultivate A facility may not cultivate marijuana for a registered patient. marijuana for a registered patient.

More and MoreMore and More

• Dispensary may deliver.Dispensary may deliver.• A facility may not make marijuana into A facility may not make marijuana into

products to be ingested. Edibles may be products to be ingested. Edibles may be purchased from a dispensary or purchased from a dispensary or caregiver.caregiver.

• Edibles from a dispensary or a Edibles from a dispensary or a registered caregiver will be labeled as registered caregiver will be labeled as food products with ingredients and the food products with ingredients and the amount of marijuana in the dose. amount of marijuana in the dose. Family members are not required to do Family members are not required to do this.this.

More and MoreMore and More

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

More and MoreMore and More• When marijuana is removed from When marijuana is removed from

inventory, it must be signed out by inventory, it must be signed out by two licensed staff persons who have two licensed staff persons who have MMMP registry identification cards. MMMP registry identification cards. In the event there is only one licensed In the event there is only one licensed staff on duty, a CNA-M may be staff on duty, a CNA-M may be substituted once rules are changed.substituted once rules are changed.

• Unless the dispensary or the Unless the dispensary or the cultivating caregiver has provided the cultivating caregiver has provided the marijuana in unit doses, the facility marijuana in unit doses, the facility will need scales and other necessary will need scales and other necessary tools to monitor its marijuana tools to monitor its marijuana inventory.inventory.

More and MoreMore and More

• Prepared marijuana must be kept under Prepared marijuana must be kept under double lock and inventoried daily by double lock and inventoried daily by two staff persons who have MMMP two staff persons who have MMMP registry identification cards, one of registry identification cards, one of whom must be a licensed professional. whom must be a licensed professional.

• A medication technician or a nurse may A medication technician or a nurse may administer marijuana as long as he or administer marijuana as long as he or she has a registry identification card.she has a registry identification card.

• The registered patient’s cultivating The registered patient’s cultivating caregiver may not administer marijuana caregiver may not administer marijuana medication in the facility. medication in the facility.

More and MoreMore and More

• The fact that a patient is The fact that a patient is participating in the medical use of participating in the medical use of marijuana program is highly marijuana program is highly confidential and each facility serving confidential and each facility serving MMMP patients must develop “need MMMP patients must develop “need to know” protocols. to know” protocols.

• The registered patient will let the The registered patient will let the facility know what dosage gives facility know what dosage gives relief. The lowest dosage possible relief. The lowest dosage possible that gives the registered patient that gives the registered patient relief is optimal. relief is optimal.

More and MoreMore and More

• Patients who smoke marijuana are Patients who smoke marijuana are subject to the same facility policies as subject to the same facility policies as patients who smoke tobacco. The facility patients who smoke tobacco. The facility may encourage registered patients that may encourage registered patients that the use of alternative forms of marijuana the use of alternative forms of marijuana administration may be preferable.administration may be preferable.

• Follow established protocols for Follow established protocols for monitoring patient response to any monitoring patient response to any treatment or medication and observe the treatment or medication and observe the registered patient’s response to the registered patient’s response to the administration of marijuana.administration of marijuana.

More and MoreMore and More• A resident may not be discharged solely because the A resident may not be discharged solely because the

patient registers in the Maine Medical Use of patient registers in the Maine Medical Use of Marijuana Program. Marijuana Program.

• Unused, unadulterated marijuana in the possession of Unused, unadulterated marijuana in the possession of the registered patient, registered primary caregiver, a the registered patient, registered primary caregiver, a hospice provider or a nursing facility named as a hospice provider or a nursing facility named as a primary caregiver, or a registered dispensary that is no primary caregiver, or a registered dispensary that is no longer needed for the registered patient’s medical use longer needed for the registered patient’s medical use may be disposed of by:may be disposed of by:

Donating it to a registered patient; or Donating it to a registered patient; or Donating it to a registered primary caregiver; or Donating it to a registered primary caregiver; or Donating it to a registered dispensary.Donating it to a registered dispensary.

Unused marijuana may also be disposed of by Unused marijuana may also be disposed of by transporting the unused portion to a state or local law transporting the unused portion to a state or local law enforcement office. Presentation of a valid registry enforcement office. Presentation of a valid registry identification card and a Maine driver’s license or other identification card and a Maine driver’s license or other state-issued photo identification may be required.state-issued photo identification may be required.

ResourcesResources

www.maine.gov/dhhs/dlrswww.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be perfected in Maine.

Thank you!Thank you!

Be open mindedBe open minded

Be patient centeredBe patient centered