Cannabis in hospitals: coming soon?

medical marijuanaGrowing numbers around the United States and the world are using cannabis to treat a wide spectrum of medical conditions, and legal space is widening for them to do so. So it's a particular irony that hospitals as a rule bar cannabis from their premises. More voices in the medical industry are now grappling with this dilemma.

Patients around the world every day use cannabis to treat everything from glaucoma to chronic pain to nausea from chemotherapy treatments. Yet even in places like California, which pioneered legal medical marijuana in 1996, hospital policy has not caught up with the law. Cannabis remains officially barred from hospital premises.

A personal "Plea for Cannabis in Hospitals" by writer Jessica Assaf on the Healthcare in America website frames the issue poignantly. She wrote in her January 2018 appeal for a new policy: "Two weeks ago, I spent the night in the Intensive Care Unit at Memorial Sloan Kettering Cancer Center in New York City watching my partner's father die of colon cancer. After two years of failed chemotherapy and radiation, this prominent New York City lawyer weighed 130 pounds and could no longer talk nor move... Though this patient had a medical recommendation for cannabis use in New York and vaporized THC and CBD daily to manage his pain, he could not use his medicine while he was stuck in the hospital. Instead, he was administered Fentanyl."

False promise in California
The first sign of progress in addressing this paradox came in September 2016, when the board of California's Marin Healthcare District voted 2-0, with three members abstaining, on a resolution to study allowing patient cannabis use at Marin General Hospital, in the town of Greenbrae outside San Rafael. A series of public forums were to be held to discuss the proposal.

The resolution was introduced by retired emergency room physician Dr. Larry Bedard, who had served on the California Medical Association cannabis task force that led to the association recommending legalization in 2011. “We ought to be on the cutting edge for our patients, allowing them to openly and appropriately use medicinal cannabis,” Bedard told San Francisco's KPIX at the time of the Marin resolution.

Speaking at the board meeting in support of the resolution was Lynnette Shaw, who opened the first licensed medical marijuana dispensary in Marin County back in 1997. She told KPIX she had been sneaking pot brownies into Marin General for 20 years, and that most doctors there were perfectly aware of the practice.  

"This is something they know about," said Shaw. "I think it’s time for Marin General to step up, because this is a revolution for better health... For goodness sake, help the patients! Save lives!"

However, that was more than three years ago—and little has come of it. Reached for comment in Marin County by Cannabis Now, Bedard says the resolution has seen no progress. "The hospital administrators basically said 'C'mon Larry, its a Schedule 1 drug, the Trump administration would take away our Medicare provider number and we'd have to close," Bedard tells us.

He points out that any hospital that handles Medicare patients must be certified with such a number by the federal Department of Health & Human Services. And while there is an activist push to get Medicare to cover medical marijuana, there are few prospects for this happening under the current White House.

An attempted remedy at the state level has also failed. Last year, Senate Bill 305, the "Compassionate Access to Medical Cannabis Act," unanimously passed both chambers of California's Legislature. It would have prohibited healthcare facilities from interfering with a terminally ill patient's use of medical cannabis. It was also dubbed "Ryan's Law," after Ryan James Bartell, a San Diego native who had died of pancreatic cancer in April 2018. But in October, it was "begrudgingly" vetoed by Gov. Gavin Newsom.

"This bill would create significant conflicts between federal and state laws that cannot be taken lightly," Newsom wrote in a veto statement, noting that "health facilities certified to receive payment from the from the federal Center for Medicare and Medicaid Services must comply with all federal laws."

But his statement also took aim at those federal laws. "It is inconceivable that the federal government continues to regard cannabis as having no medicinal value," Newsom wrote, adding that this "ludicrous stance puts patients and those who care for them in an unconscionable position."

Medical establishment grappling
Clearly, the stakes in this question are high due to the illegality of cannabis at the federal level. California generally legalized cannabis in by popular referendum in 2016—exactly 20 years after the state's voters approved medical marijuana. But the feds still hold significant sway over hospital policy.

A primer on the question on the website of the National Center for Biotechnology Information (NCBI) states: "Hospitals potentially carry enormous risk for allowing cannabis use by patients because cannabis is illegal under federal law." Because they are accredited through the Center for Medicare & Medicaid Services (CMS), "hospitals could be found to be in violation, lose federal funding, and face penalties."

Clinicians are also prohibited from prescribing or providing cannabis in a hospital because it is not approved by the US Food and Drug Administration (FDA). "Yet, hospitals in more states are asked to create cannabis policies as voters decriminalize cannabis for medical use. There is no recognized supplier of medicinal cannabis, so hospitals are often asked to allow patients to bring in their own supply for their own use."

But in a kind of Catch 22, hospitals then risk running afoul of a guideline established by the Joint Commission, the national body that sets standards for medical facilities. Joint Commission Standard MM.03.01.05 states: "The hospital safely controls medications brought into the hospital by patients, their families, or licensed independent practitioners.” It includes the admonition: "The hospital informs the prescriber and patient if the medication brought into the hospital by patients, their families, or licensed independent practitioners is not permitted."

As the NCBI primer states: "Some hospitals have considered cannabis policies that could adequately address this standard, but several questions remain. For example, how is the product identified, how does the institution verify its integrity, and how is a federally illegal drug 'permitted'?"

In another discussion of the question, the Patient Safety & Quality Healthcare (PSQH) website interviewed Dr. Benjamin Caplan, founder of the CED Clinic and a representative of the group Doctors for Cannabis Regulation.

Dr. Caplan took a laissez-faire approach, calling it "a policy question for hospitals."

"I think there’s a legal question and an ethical question," Caplan elaborated. "State laws are telling medical patients that they are allowed to have a choice to use this particular medicine. Hospital policies are quite different, and for good reason. In order for doctors to best manage illnesses carefully, and to the best of our abilities, we must know as much as we can [about] what a patient is taking. But it's very common for patients to sneak cannabis in back rooms or under the radar, which is really unfortunate for everyone. I think the hospital perspective should be embracing what patients find helpful."

Emphasizing the ethical dimension, Caplan added: "To have cases where patients are having seizures in a hospital and they can’t get the medicine that they want (and find helpful) as an outpatient is a real cultural disconnect for the medical establishment. I think the solution is for people to not sneak around; the solution is for hospitals to open their arms to patients who find a medication helpful."

This question is a particular concern for military veterans—many of whom use cannabis to treat PTSD, yet are more directly dependent on the federal government for their healthcare. The US Department of Veterans Affairs has remained largely intransigent on the question, despite growing pressure. As the veterans' affairs website writes: "[M]oving to make cannabis available through VA hospitals or other go-to sources of care is difficult. Doctors at VA facilities aren't just prohibited from prescribing marijuana: The drug is still listed as 'Schedule 1,' so these health care professionals can't even speak about it with their patients.".

The question has something of an analogue in alcohol—minus, of course, the factor of federal illegality. National Public Radio's health policy series, Shots, notes that Parkview Ortho Hospital in Fort Wayne allows patients or family members to bring alcohol into the hospital if doctors have approved it. And although "most hospitals are dry, the Parkview Ortho isn't the only one where patients may be able to wrangle a tipple." Shots learned from the Association for Healthcare Foodservice that the Henry County Medical Center in Paris, Tenn., and "many other healthcare facilities" stock beer, wine and even liquor to dispense to patients with their physician's approval.

The most significant opening appears to come from the Mayo Clinic, the national network of medical treatment and research facilities. The Mayo Clinic website recognizes that "medical cannabis has possible benefit for several conditions." It notes that three states—Arizona, Florida and Minnesota—have adopted some form of the "Right to Try Act," allowing access to "investigational" treatments, potentially including cannabis, for people with life-threatening conditions who have exhausted approved treatment options. In one of those states, the Mayo Clinic allows on-premises use: "Minnesota residents with a supply of medical cannabis from the Minnesota Medical Cannabis program may continue use during their Mayo Clinic visit or hospital admission."

Senior care centers and schools face same dilemma 

This dilemma is one that senior care centers are grappling with as well. Some have opted for tolerance, under controlled conditions, while others have remained unyielding—again citing potential loss of federal Medicare and Medicaid funding.

Seniors are the fastest growing group of medicinal cannabis users in the country, and a growing number of nursing homes from coast to coast are tolerating use of tinctures and extracts to combat dementia, insomnia and related ailments. Progress is reported at the Rossmoor retirement community in California's Walnut Creek. There, the Rossmoor Medical Marijuana Education & Support Club has won the right for some hundred members to use cannabis tincture.

There has similarly been some progress in allowing use of medicinal cannabis products on school grounds in California. A bill to permit such use was passed by the state Legislature in 2018—named Jojo’s Act, after a wheelchair-bound South San Francisco high school student who suffers from a severe form of epilepsy, and depends on regular doses of cannabis oil to prevent debilitating seizures. The bill was vetoed by then-governor Jerry Brown, but reintroduced in 2019 and signed into law by Gov. Newsom in October.

Cross-post to Cannabis Now

Graphic by Americans for Safe Access


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