Most states allow the use of cannabis-related products for a variety of medical conditions in adults and in children with parental permission. Following is an overview of the medical and legal implications for pediatricians and risk management advice.
Because this article is not giving clinical guidance or summarizing the taxonomy of marijuana and cannabis-related substances, the term cannabis-related products (CRP) will be used as a generic term, with the caveat that distinctions are made in state laws. Physicians need to abide by relevant state statutes to avoid legal and medical licensure repercussions.
Variations among states
It is important that physicians know the language of the statutes in the state where the patient resides and they are licensed because the legal definitions of products vary and sometimes are not precise from a scientific standpoint.
Similarly, the qualifying health conditions for CRP use vary by state. In several states, “debilitating epilepsy” is the only legally qualifying diagnosis. In other states, numerous “terminal and debilitating” medical and psychological conditions are qualifying diagnoses.
The Department of Justice/Drug Enforcement Agency fact sheet states: “Marijuana is a Schedule I substance under the Controlled Substances Act, meaning that it has a high potential for abuse, no currently accepted medical use in treatment in the United States, and a lack of accepted safety for use under medical supervision.” As such, doctors cannot prescribe CRP under federal law. However, patient use for terminal or debilitating medical conditions is the patient’s or patient’s parent’s decision within the parameters of state statutes.
States vary in how they define CRP and the medical conditions that meet criteria to receive authorization to purchase products at dispensaries. A few states allow people with a medical authorization to grow small amounts for personal use. Some jurisdictions designate providers who are not medical professionals to attest that a patient has a qualifying health condition for CRP use.
Even if physicians note that a patient uses CRP in the home environment, clinic and hospital staff clinicians cannot prescribe or be responsible for verifying the content of the CRP, storing it on site at a facility or documenting the product’s efficacy.
Products approved by FDA
In 2015, the AAP updated its policy statement The Impact of Marijuana Policies on Youth: Clinical, Research, and Legal Updateas follows: “The AAP opposes ‘medical marijuana’ outside the regulatory process of the US Food and Drug Administration. Notwithstanding this opposition to use, the AAP recognizes that marijuana may currently be an option for cannabinoid administration for children with life-limiting or severely debilitating conditions and for whom current therapies are inadequate.”
Epidiolex (cannabidiol [CBD]), which contains a purified form of cannabidiol derived from cannabis, is the only prescription CBD approved by the Food and Drug Administration (FDA). It is approved for the treatment of seizures associated with Lennox-Gastaut syndrome, Dravet syndrome or tuberous sclerosis complex in patients 1 year of age and older.
The FDA also has approved Marinol and Syndros, which contain dronabinol (synthetic tetrahydrocannabinol [THC]), and Cesamet, which contains nabilone (a synthetic substance similar to THC). Dronabinol and nabilone are used to treat nausea and vomiting caused by cancer chemotherapy and loss of appetite and weight loss in people with HIV/AIDS.
Adverse effects
A rigorous review of the health impacts of CRP by the National Academies of Science, Engineering and Medicine in 2017 noted that marijuana and cannabis substances can cause negative effects to cognition and contribute to the development of mental illnesses and psychosis (https://bit.ly/2V3X2Bd).
CRP purchased at dispensaries are not regulated, are not consistent and are not guaranteed to contain specific amounts cannabinoids, unlike FDA-regulated drugs, where the safe doses are known. Because youths seem to be most vulnerable to cannabis’ effects, studies are needed to evaluate reproducible health benefits.
Medical liability risk management pointers
- Know and abide by your state laws and medical licensure regulations regarding how CRP are defined and for what medical conditions.
- If published guidance regarding CRP is unclear, discuss questions with your state medical board.
- Understand that even though many state laws permit CRP use, the federal government has jurisdiction and discretion to charge and prosecute those who prescribe, use and/or distribute them.
- Consistently document your patient’s:
- medical history;
- physical examination, diagnostic test results and diagnoses;
- concurrent treatments and prescribed medications; and
- informed consent discussions and decisions noting that it was explained that it is the parent’s and patient’s responsibility to monitor the patient’s use of CRP.
- Depending on your state’s regulations, a physician’s attestation, authorization or recommendation for CRP may need to include the date, expiration and additional information. An attestation signed by the patient or patient’s legal representative also may be required. Sometimes, a patient’s CRP use must be entered into a state registry.
- Advising parents and patients to disclose cannabis-related product use during all medical encounters is prudent counsel and may prevent adverse reactions to new or ongoing treatments.
Dr. Terry is a member of the AAP Committee on Medical Liability and Risk Management.
