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Medical Marijuana and Ethical Dilemmas for CDP

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Title: Medical Marijuana and Ethical Dilemmas for CDP


1
Medical Marijuana and Ethical Dilemmas for CDPs
  • Paul Weatherly MA, CDP

2
Examine problems for the chemical dependency
counseling field related to medical marijuana,
standards of care and ethics.
  • Focus of Training

3
Goals
  1. To develop a better understanding of marijuana
    and its use as a medication
  2. To identify various dilemmas for CDP(T)s working
    with clients and patients who are using marijuana
    for medicinal purposes.
  3. To improve understanding of the pharmacology
    supporting marijuana for medicinal purposes.
  4. To begin the discussion for agencies and
    providers regarding policy and procedures
    regarding clients, patients and counselors using
    marijuana as a medication.

4
Topics for Todays Discussion
  1. Medical Marijuana Law
  2. CDP Law
  3. Uniform Disciplinary Act
  4. Americans With Disabilities Act
  5. Uniform Substance Control Act
  6. NAADAC Code of Ethics
  7. Overview of Medical Marijuana Pharmacology

5
Topics Not Included in Todays Discussion
  1. Decriminalization of Marijuana
  2. Legalization of Marijuana
  3. Impact of Marijuana Use on Adolescents and Adults
  4. Treatment Methodology for Marijuana Addiction

6
Medical Marijuana Law
  • Intent
  • There is medical evidence that some patients with
    terminal or debilitating medical conditions may,
    under their health care professional's care,
    benefit from the medical use of cannabis.
  • Humanitarian compassion necessitates that the
    decision to use cannabis by patients with
    terminal or debilitating medical conditions is a
    personal, individual decision, based upon their
    health care professional's professional medical
    judgment and discretion.

7
Medical Marijuana Law
  • Question
  • Is medical marijuana legal?
  • Answer
  • Marijuana possession is illegal in Washington.
    The medical marijuana law provides protection
    from arrest or other criminal sanctions for
    qualified patients and designated caregivers who
    are complying with the law. People who qualify
    have a valid reason to possess a 60-day supply of
    marijuana. However, medical marijuana is not
    legal under federal law. There is no protection
    for people who are arrested or charged under
    federal law.
  • http//www.doh.wa.gov/hsqa/medical-marijuana/FAQmo
    re.htm

8
Medical Marijuana Law
  • Question
  • Can a Patient be prescribed marijuana for medical
    use?
  • Answer
  • No!
  • Doctors may not "prescribe" marijuana for medical
    use under federal law, though they can
    "recommend" its use under the First Amendment.

9
Medical Marijuana Law
  • Question
  • How is a patient allowed to use marijuana as a
    medication if it is not prescribed?
  • Answer
  • A Health care professional licensed in WA may not
    be prosecuted for advising a qualifying patient
    about the risks and benefits of medical use of
    marijuana or that the qualifying patient may
    benefit from the medical use of marijuana.

10
Medical Marijuana Law
  • Question
  • What kinds of health care professionals are
    eligible to advise patients about medical uses of
    marijuana?
  • Answer
  • licensed physician
  • licensed physician assistant
  • licensed osteopathic physician
  • licensed osteopathic physicians' assistant
  • licensed naturopath
  • licensed advanced registered nurse practitioner

11
Medical Marijuana Law
  • Question
  • What conditions must the health care professional
    meet prior to recommending the use of marijuana
    as a medication?
  • Answer
  • A health care professional may only provide a
    patient with valid documentation if he or she has
    a newly initiated or existing documented
    relationship with the patient related to the
    diagnosis and ongoing treatment or monitoring of
    the patient's terminal or debilitating medical
    condition after
  • a physical examination of the patient as
    appropriate, based on the patient's condition and
    age
  • documented the terminal or debilitating medical
    condition of the patient in the patient's medical
    record and that the patient may benefit from
    treatment of this condition or its symptoms with
    medical use of cannabis
  • informed the patient of other options for
    treating the terminal or debilitating medical
    condition
  • documented other measures have been attempted to
    treat the terminal or debilitating medical
    condition that do not involve the medical use of
    cannabis

12
Medical Marijuana Law
  • Question
  • What does valid documentation mean (green card)?
  • Answer
  • Recommendations must be written on
    tamper-resistant paper. They must include an
    original signature by the healthcare provider, a
    date, and a statement that says in the healthcare
    provider's professional opinion the patient may
    benefit from the medical use of marijuana. The
    use of a copy of the patient's medical records in
    lieu of a recommendation is prohibited.

13
Medical Marijuana Law
  • Question
  • What does terminal or debilitating medical
    condition mean?
  • Answer
  • Cancer, human immunodeficiency virus (HIV),
    multiple sclerosis, epilepsy or other seizure
    disorder, or spasticity disorders
  • Intractable pain, limited for the purpose of
    this chapter to mean pain unrelieved by standard
    medical treatments and medications
  • Glaucoma, either acute or chronic, limited for
    the purpose of this chapter to mean increased
    intraocular pressure unrelieved by standard
    treatments and medications
  • Crohn's disease with debilitating symptoms
    unrelieved by standard treatments or medications
  • Hepatitis C with debilitating nausea or
    intractable pain unrelieved by standard
    treatments or medications
  • Diseases, including anorexia, which result in
    nausea, vomiting, wasting, appetite loss,
    cramping, seizures, muscle spasms, or spasticity,
    when these symptoms are unrelieved by standard
    treatments or medications

14
Medical Marijuana Law
  • Question
  • What are most researched medical conditions that
    are illustrate the most credible uses of
    marijuana as a medication?
  • Answer
  • Wasting syndrome associated with antiretroviral
    drugs and chemo/radiation therapy
  • Gastrointestinal disorders and diseases

15
Medical Marijuana Law
  • Question
  • How does an individual get a medical condition
    recognized for treatment with medical marijuana?
  • Answer
  • Anyone may petition the commission to add a
    condition to the list. By law, the commission
    will consult with the Board of Osteopathic
    Medicine and Surgery. For more information about
    this process, you may contact the commission at
  • Medical Quality Assurance CommissionP.O. Box
    47866Olympia, WA 98504-7866
  • http//www.doh.wa.gov/hsqa/medical-marijuana/FAQmo
    re.htm3

16
Medical Marijuana Law
  • Question
  • Can a person be arrested or prosecuted for
    possession of medical marijuana?
  • Answer
  • No, a patient in compliance with medical
    marijuana law may not be arrested or prosecuted.

17
Medical Marijuana Law
  • Question
  • What is non-compliance with this law?
  • Answer
  • The investigating peace officer does not possess
    evidence that
  • The designated provider has converted cannabis
    produced or obtained for the qualifying patient
    for his or her own personal use or benefit
  • The qualifying patient has converted cannabis
    produced or obtained for his or her own medical
    use to the qualifying patient's personal,
    nonmedical use or benefit
  • The designated provider has served as a
    designated provider to more than one qualifying
    patient within a fifteen-day period

18
Medical Marijuana Law
  • Question
  • How much medical marijuana may a patient or
    provider possess?
  • Answer
  • A qualifying patient or designated provider may
    have a 60-day supply of medical marijuana. A
    60-day supply is defined as 24 ounces and 15
    plants.

19
Medical Marijuana Law
  • Question
  • What is the average daily dose based on the
    definition of the 60 day supply?
  • Answer
  • 11.2 grams

20
Medical Marijuana Law
  • Question
  • What is considered a therapeutic dose?
  • Answer
  • The law and literature on the use of medical
    marijuana does not define a therapeutic dose.
  • A urinalysis test or blood test can not be used
    to determine if a patient is using as recommended
    or abusing marijuana.
  • The patient self doses based on achieving the
    desired result to relieve symptoms.

21
Medical Marijuana Law
  • Question
  • Does the law recommend a particular route of
    administration?
  • Answer
  • No, the patient can use marijuana in anyway he or
    she feels is the best to obtain the desired
    result.
  • Smoking or Inhaling
  • Oral Consumption
  • Transdermal Delivery

22
Side Effects of Medical Marijuana
  • Euphoria
  • Paranoia
  • Fatigue
  • Loss of Motivation
  • Memory Loss
  • Weight gain or loss

23
Side Effects of Medical Marijuana
  • Question
  • Do patients complain about the side effects of
    medical marijuana or cannabinoid derivative
    prescription drugs?
  • Answer
  • Yes!!!!!
  • The number one complaint was euphoria.

24
Cannabinoid Derivative Prescription Drugs
  • Dronabinol (Marinol)- synthetic form of
    delta-9-THC was approved by the FDA in 1985
  • Nabilone (Cesamet) This drug is a synthetic,
    substituted cannabinoid approved by the FDA in
    2006
  • Delta-9-THC/Cannabidiol (Sativex) Sativex was
    approved in Canada for treatment of neuropathic
    pain in patients with MS and as an adjunct for
    pain in cancer patients. It is currently
    undergoing clinical trials in the U.S. for cancer
    pain.
  • Rimonabant (Acomplia) FDA approval was denied
    and approval by the European Commission was
    withdrawn due to the emergence of side effects,
    including depression and suicidality.

25
Federal Controlled Substances Act
  • Question
  • What is a Schedule I drug?
  • Answer
  • The drug or other substance has a high potential
    for abuse.
  • The drug or other substance has no currently
    accepted medical use in treatment in the United
    States.
  • There is a lack of accepted safety for use of the
    drug or other substance under medical
    supervision.
  • http//www.deadiversion.usdoj.gov/21cfr/21usc/812.
    htm

26
Federal Controlled Substances Act
  • Question
  • Why is marijuana a schedule I drug?
  • Answer
  • Under the CSA, marijuana is classified as a
    Schedule I drug, which means that the federal
    government views marijuana as highly addictive
    and having no medical value.

27
Federal Controlled Substances Act
  • Question
  • What is a schedule II drug?
  • Answer
  • The drug or other substance has a high potential
    for abuse.
  • The drug or other substance has a currently
    accepted medical use in treatment in the United
    States or a currently accepted medical use with
    severe restrictions.
  • Abuse of the drug or other substances may lead to
    severe psychological or physical dependence.
  • http//www.deadiversion.usdoj.gov/21cfr/21usc/812.
    htm

28
Federal Controlled Substances Act
  • Question
  • If marijuana is being considered a medication,
    will it be moved to Schedule II?
  • Answer
  • The AMA, NORMAL, and various state attorney
    generals have petitioned the congress to do this
    but to date congress has denied the petitions.

29
The Nature of Dilemma
  • Dilemma occurs when laws and ethical guidelines
    are in conflict. The following laws create
    conflict for healthcare providers not protected
    by medical marijuana law
  • Uniform Disciplinary Act
  • Americans With Disabilities Act
  • Chemical Dependency Professional Law

30
Americans With Disabilities Act
  • Question
  • Are Alcoholics and Drug Addicts qualified
    individuals with a disability?
  • Answer
  • No, A qualified individual with a disability
    shall not include any employee or applicant who
    is currently engaging in the illegal use of
    drugs, when the covered entity (employer, school,
    treatment program, etc.) acts on the basis of
    such use.
  • http//www.ada.gov/pubs/adastatute08mark.htm12114
    a

31
Americans With Disabilities Act
  • Question
  • Are Alcoholics and Drug Addicts qualified
    individuals with a disability?
  • Answer
  • Yes, history of illegal drug use does not prevent
    an alcoholic or drug addict from being a
    qualified individual with a disability who
  • has successfully completed a supervised drug
    rehabilitation program and is no longer engaging
    in the illegal use of drugs, or has otherwise
    been rehabilitated successfully and is no longer
    engaging in such use
  • is participating in a supervised rehabilitation
    program and is no longer engaging in such use
  • is erroneously regarded as engaging in such use,
    but is not engaging in such use
  • It would not be a violation for a covered entity
    to adopt or administer reasonable policies or
    procedures, including but not limited to drug
    testing, designed to ensure that an individual
    described in paragraph (1) or (2) is no longer
    engaging in the illegal use of drugs.
  • http//www.ada.gov/pubs/adastatute08mark.htm12114
    a

32
Uniform Disciplinary Act
  • Question
  • Are there laws that govern the conduct, scope of
    practice and consumption of alcohol and drugs by
    CDP(T)S.
  • Answer
  • Yes!
  • There are stipulations regarding these areas in
    RCW 18.130.180.

33
Uniform Disciplinary Act
  • Three stipulations in RCW 18.130.180 have the
    potential to create conflicts for CDPs.
  • (7) Violation of any state or federal statute or
    administrative rule regulating the profession in
    question, including any statute or rule defining
    or establishing standards of patient care or
    professional conduct or practice
  • (12) Practice beyond the scope of practice as
    defined by law or rule
  • (23) Current misuse of(a) Alcohol(b)
    Controlled substances or(c) Legend drugs
  • http//apps.leg.wa.gov/RCW/default.aspx?cite18.13
    0.180

34
Chemical Dependency Professional Law
  • Question
  • What are the legally defined competencies of a
    CDP?
  • Answer
  • (6) "Core competencies of chemical dependency
    counseling" means competency in the nationally
    recognized knowledge, skills, and attitudes of
    professional practice, including assessment and
    diagnosis of chemical dependency, chemical
    dependency treatment planning and referral,
    patient and family education in the disease of
    chemical dependency, individual and group
    counseling with alcoholic and drug addicted
    individuals, relapse prevention counseling, and
    case management, all oriented to assist alcoholic
    and drug addicted patients to achieve and
    maintain abstinence from mood-altering substances
    and develop independent support systems.
  • http//apps.leg.wa.gov/RCW/default.aspx?cite18.20
    5.020

35
NAADAC Code of Ethics
  • Question
  • Does the code of ethics for the chemical
    dependency field offer guidance regarding
    patients who use marijuana for medical
    conditions?
  • Answer
  • Yes!
  • Five of the nine principles in the code offer
    implicit insight regarding medical marijuana but
    offer no solutions.

36
NAADAC Code of Ethics
  • Principle 4 Trustworthiness
  • I understand that effectiveness in my profession
    is largely based on the ability to be worthy of
    trust, and I shall work to the best of my ability
    to act consistently within the bounds of a known
    moral universe, to faithfully fulfill the terms
    of both personal and professional commitments,
    to safeguard fiduciary relationships
    consistently, and to speak the truth as it is
    known to me.
  • I shall never misrepresent my credentials or
    experience.
  • I shall make no unsubstantiated claims for the
    efficacy of the services I provide and make no
    statements about the nature and course of
    addictive disorders that have not been verified
    by scientific inquiry.
  • I shall constantly strive for a better
    understanding of addictive disorders and refuse
    to accept supposition and prejudice as if it were
    the truth.

37
NAADAC Code of Ethics
  • Principle 5 Compliance with Law
  • I understand that laws and regulations exist for
    the good ordering of society and for the
    restraint of harm and evil, and I am aware of
    those laws and regulations that are relevant both
    personally and professionally and follow them,
    while reserving the right to commit civil
    disobedience.
  • I understand that the determination that a law or
    regulation is unjust is not a matter of
    preference or opinion but a matter of rational
    investigation, deliberation, and dispute.
  • I willingly accept that there may be a penalty
    for justified civil disobedience, and I must
    weigh the personal harm of that penalty against
    the good done by civil protest.

38
NAADAC Code of Ethics
  • Principle 6 Rights and Duties
  • I understand that personal and professional
    commitments and relationships create a network of
    rights and corresponding duties. I shall work to
    the best of my ability to safeguard the natural
    and consensual rights of each individual and
    fulfill those duties required of me.
  • I understand that justice extends beyond
    individual relationships to the community and
    society therefore, I shall participate in
    activities that promote the health of my
    community and profession.
  • I shall, to the best of my ability, actively
    engage in the legislative processes, educational
    institutions, and the general public to change
    public policy and legislation to make possible
    opportunities and choice of service for all human
    beings of any ethnic or social background whose
    lives are impaired by alcoholism and drug abuse.

39
NAADAC Code of Ethics
  • Principle 8 Preventing Harm
  • I understand that every decision and action has
    ethical implication leading either to benefit or
    harm, and I shall carefully consider whether any
    of my decisions or actions has the potential to
    produce harm of a physical, psychological,
    financial, legal, or spiritual nature before
    implementing them.
  • I shall terminate a counseling or consulting
    relationship when it is reasonably clear that the
    client is not benefiting from the relationship.
  • I understand an obligation to protect
    individuals, institutions, and the profession
    from harm that might be done by others.
    Consequently, I am aware that the conduct of
    another individual is an actual or likely source
    of harm to clients, colleagues, institutions, or
    the profession, and that I have an ethical
    obligation to report such conduct to competent
    authorities.

40
NAADAC Code of Ethics
  • Principle 9 Duty of Care
  • I shall operate under the principle of Duty of
    Care and shall maintain a working/therapeutic
    environment in which clients, colleagues, and
    employees can be safe from the threat of
    physical, emotional or intellectual harm.
  • I respect the right of others to hold opinions,
    beliefs, and values different from my own.
  • I shall strive for understanding and the
    establishment of common ground rather than for
    the ascendancy of one opinion over another.
  • I shall maintain competence in the area of my
    practice through continuing education, constantly
    improving my knowledge and skills in those
    approaches most effective with my specific
    clients.
  • I shall scrupulously avoid practicing in any
    area outside of my competence.
  • http//www.ndbace.org/forms/NAADACCodeofEthics-200
    4.pdf

41
Looking for Solutions
  • The Problem
  • Marijuana is a schedule I drug.
  • The job of a CDP is to assist the patient in
    finding ways to maintain abstinence and create a
    clean and sober support system.
  • CDPs are not identified as protected as health
    care providers in the medical marijuana law.
  • The UDA requires CDPs to follow all state and
    federal laws related to the profession.

42
Looking for Solutions
  • The foundation to the implementing a solution to
    the dilemmas presented lies in
  • Developing agency policy and procedure that
    clearly identifies the criteria for accepting a
    medical marijuana patient for addiction treatment
    or for referring a medical marijuana patient to
    another addiction treatment agency.

43
Looking for Solutions
  • Policy and Procedure for Referral
  • Create criteria to determine a medical marijuana
    patients eligibility for assessment and
    evaluation of a substance use disorder.
  • Create procedures for documenting assessment
    outcomes that include marijuana abuse and
    dependence for medical marijuana patient.
  • Create procedure for documenting diagnostic
    impressions used to determine assessment
    outcomes.
  • Document Urinalysis or Blood test results.

44
Looking for Solutions
  • Policy and Procedure for admission to Treatment
  • Develop policy defining the agencys philosophy
    regarding medical marijuana
  • Develop policy defining the role of a CDP
    treating medical marijuana patients.
  • Create criteria to determine a medical marijuana
    patients eligibility for assessment and
    evaluation of a substance use disorder.
  • Create procedure for documenting diagnostic
    impressions used to determine assessment
    outcomes.
  • Create procedures to determine patients use
    periods prior to care, during care and post-care.

45
Looking for Solutions
  • Policy and Procedure for admission to Treatment
    (cont)
  • Create procedures to determine patients use
    periods prior to care, during care and post-care.
  • Develop treatment planning guidelines that
    clearly demonstrate the ongoing benefits of
    maintaining the therapeutic relationship.
  • Create policies that define levels of acceptable
    THC metabolites present in a UA and how to
    address spikes in the THC creatinine ratio

46
Looking for Solutions
  • Policy and Procedure for admission to Treatment
    (cont)
  • Develop policies that define purpose and
    frequency of urinalysis
  • Develop policies to define relapse on medical
    marijuana and procedures for documenting the
    relapse.
  • Develop policies that define expectations for
    participation in treatment and mandatory
    reporting responsibilities if a medical marijuana
    patient violates the conditions that qualify them
    as a medical marijuana patient.

47
Looking for Solutions
  • Problem Retaining a CDP using medical marijuana
  • Counselor in Recovery is recommended medical
    marijuana for a medical condition.
  • Develop agency philosophy defining being in
    recovery.
  • Develop agency definition of impaired
    professional including acceptable times for use
    pre and post work hours, UA tolerance levels and
    creatinine ratios.
  • Develop policy defining duties in agency and
    stipulations on serving different patient
    populations.

48
Looking for Solutions
  • Problem Zero tolerance for CDP using medical
    marijuana and Counselor in Recovery is
    recommended medical marijuana for a medical
    condition.
  • Develop policy and procedure for documenting
    termination and reporting use to DOH.
  • Develop policy and procedure for documenting
    leave of absence and completion of WHPS program.

49
Looking for Solutions
  • Problem CDP not in recovery who would not meet
    diagnostic criteria for substance abuse or
    dependence is recommended to use medical
    marijuana for a medical condition.
  • Question
  • Should agencies have different standards for
    CDPs who are in recovery from standards for
    CDPs who do not meet criteria warranting the
    need to be in recovery?

50
Looking for Solutions
  • Problem
  • Medical marijuana patient leaves treatment and
    gets in an accident
  • Question Is the agency liable knowing a patient
    potentially is leaving treatment under the
    influence.
  • Hint Use of medical marijuana is not an
    affirmative defense for driving under the
    influence.

51
Medical Marijuana and Ethical Dilemmas for CDPs
  • Thank you for your Time and Interest in the
    topic!!!
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