Medical marijuana ... in the hospital?

As states legalize marijuana, hospitals develop policies on inpatient use

Hospitals have been going green, in the sense of sustainability, for a while, but recently the term has taken on a whole new meaning. With medical marijuana (aka cannabis) laws now in effect in more than half the country, hospitals are seeing more patients who have been certified to use the drug, and they are developing policies and practices in response.

Although marijuana remains illegal under federal law as a Schedule I drug, more states voted last November to give the green light to recreational (California, Maine, Massachusetts, and Nevada) and medical (Florida, North Dakota, and Arkansas) cannabis use, bringing the overall recreational count to eight states and the medical count to 28 states and Washington, D.C.

At the same time, surveys show Americans becoming more tolerant of and open to medical marijuana. About 75% believe medical marijuana should be legal in the U.S., and 33% would be likely to use it to treat pain if advised by a physician, according to a 2016 Prevention Magazine survey of 1,025 U.S. adults. A 2014 WebMD poll of 1,544 doctors also found support for medical marijuana, with 67% believing it should be a medical option for patients on a local level and 56% supporting nationwide legalization.

So even if your hospital isn't in a green state, it may be time to start considering what an inpatient medical marijuana policy would look like. Which patients are permitted to receive the substance, where should it be stored, who should administer it, and should it be documented in the EHR?

Opting in

In 2015, the Minnesota Hospital Association crafted some answers to those questions after the state legalized medical use. The association came up with three sample policies in line with three clear stances that hospitals can take on the issue, according to Rahul Koranne, MD, MBA, FACP, chief medical officer for the Minnesota Hospital Association (see sidebar).

“There was a very broad contingent of leaders—and I'm really proud of them—that said, ‘This particular substance is being shown to help some of our patients, especially the pediatric patients. Our mission is to serve our patients and their families, so we just cannot say broadly this will not be allowed within our walls,’ which is why these three policies materialized,” he said.

To create the policy templates, the association organized a medical cannabis committee and began a series of meetings, gaining continuous feedback from the state's health systems along the way, Dr. Koranne said. “It was very clear right off the bat that ... this particular workflow involves every department within the health system: the primary care clinics, specialty clinics, ED, ICU, medical units,” he said.

Photo by Thinkstock
Photo by Thinkstock

In addition to physicians, nurses, and pharmacists, representatives from external agencies (e.g., drug diversion, members of various professional boards) must be involved from the beginning in crafting such a policy, Dr. Koranne said, noting the importance of including legal counsel. The state's medical cannabis manufacturers were also involved. “We asked them to bring in the bottle, the product, and the label so our members and we could start becoming more familiar with what our patients and families will be bringing in,” he said.

At Mayo Clinic's hospitals in Rochester, Minn., medical cannabis use is permitted among patients registered with the state's program who come in with a product in its original container as dispensed by the state's approved cannabis patient centers, said Peter J. Post, PharmD, director of pharmacy quality and compliance. To date, more than 3,700 patients are actively enrolled in the program, according to the Minnesota Department of Health's Office of Medical Cannabis.

If such a patient is hospitalized, the admitting physician must decide whether continuation of the therapy is appropriate for the hospital stay, Dr. Post said. If the decision is made to continue the therapy, the physician would write an order for its continuation to communicate approved continued use during the hospital stay to the nursing and pharmacy staff, integrating that decision into the medication use process support systems, he said. Dr. Post also noted that only capsules and oral liquid are allowed, that the medication is not stored in or dispensed by the pharmacy, and that patients are not permitted to self-administer.

So far, medical cannabis use at Mayo's Minnesota hospitals isn't common. “Less than two patients per month on average to date. It wasn't the big crush that we thought it might've been,” Dr. Post said. He noted inpatient use has been most common in pediatric patients.

One factor that may have made it easier for Minnesota hospitals to open up to medical cannabis is that the state's standards for ensuring quality control are quite strong, and manufacturers are required to demonstrate consistency of product content, purity, stability, and accuracy of labeling, Dr. Post noted. “That's something that you don't see in many other states, in essence of that level of having some of the principles of medication quality control standards,” he said.

Opting out

In Maine, medical cannabis has been legal for years, but hospitals across the state commonly prohibit the use of the drug in their facilities.

Such policies are put to the test when patients intentionally or accidentally violate them. In 2015, a Maine registered medical marijuana patient, hospitalized for two weeks with a blood infection, tried to treat himself by rubbing an infused lotion onto his hands to relieve pain and stiffness from carpal tunnel. The hospital told the patient he needed to remove the substance from the hospital or it would be confiscated, the Portland Press Herald reported.

The hospital's prohibitive policy was related to concerns about losing its federal license, which does not allow for a Schedule I controlled substance to be on the premises, a hospital spokesman told the newspaper. These concerns are prevalent among other Maine hospitals, as well, said lobbyist Jeffrey A. Austin, vice president of governmental affairs and communications for the Maine Hospital Association in Augusta. “As long as CMS doesn't allow it and the FDA doesn't allow it to be prescribed, our members feel fairly confident that they need to continue to prohibit its use,” he said.

Although the risk of a hospital losing licensure or CMS certification for violating this regulation is small, the consequences could be enormous, Mr. Austin said. “When the state has considered this, we've always said, ‘OK, it is a remote risk, but who's bearing it? The hospital is. Would the state like to bear it and fully compensate the hospital for its loss of licensure?’... And nobody's ever taken me up on it,” he said.

Beyond legal concerns, hospital physicians contemplating medical marijuana use in their patients often have clinical worries, Mr. Austin said. “Most patients wouldn't just start taking something; they'd ask, ‘I'm sick, you've put me on all these IVs and drugs, can I keep taking my marijuana?’ A lot of clinicians wouldn't know how to answer that question because of the lack of research on cannabis, drug interactions, and so forth,” he said.

Mr. Austin noted that hospital administrators in the state aren't necessarily “dead set” against medical marijuana and that they'd like to see it go through the FDA process of rigorous review, which is stymied by its Schedule I status.

The only area where Maine hospitals have clear inconsistencies in medical marijuana policies is otherwise-untreatable pediatric epilepsy, he said. According to patient reports, “You'll find some hospitals that openly accept it, some that sort of shut the curtain and recognize that you may be doing it, and others that continue to say no,” Mr. Austin said.

Shifting rules

Clinicians do not prescribe or dispense medical marijuana; they recommend it in accordance with state law. Before making such a recommendation, they must typically certify a patient as having a state-approved qualifying medical condition (e.g., HIV/AIDS, inflammatory bowel disease).

Although the certification process typically occurs outside the hospital, states are including hospitals in related legislation. As of May 2016, state laws in Connecticut and Maine permit the use of medical marijuana by hospitalized patients and give some state-level legal protection for clinicians who administer it. “That's appreciated because certainly some hospitals are allowing some usage, particularly in the pediatric epilepsy world,” Mr. Austin said.

Such regulations may make clinicians and hospitals somewhat more comfortable allowing medical marijuana, but the federal prohibition is still a significant issue. “The feds, unquestionably, have to lead on this issue,” said Mr. Austin. Even if there isn't a statewide policy on how hospitals should act in the context of medical marijuana, individual hospitals should work to create policies and enact them across the institution, said Jeanette Marie Tetrault, MD, FACP, associate professor of medicine at the Yale School of Medicine in New Haven, Conn. “Hospitals should come up with...a multidisciplinary committee to really think these questions through because I think we're going to start seeing it more and more,” she said, listing addiction specialists, pain clinicians, and psychiatrists as important participants.

Dr. Tetrault pointed out that many states vote by referendum on which medical indications are able to be treated with medical marijuana. “This is not physicians sitting at the table, deciding what the indications are going to be.... We weren't allowed to be at the table when the laws were being made, so it'd be nice to be at the table when the hospitals are trying to make a policy about it,” she said.