The Marijuana Conundrum - Paul Weatherly -

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The Marijuana Conundrum - Paul Weatherly - Powered By Docstoc
					Paul Weatherly MA, CDP
Focus of Training
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
1)   Medical Marijuana Law
2)   CDP Law
3)   Uniform Disciplinary Act
4)   American’s With Disabilities Act
5)   Uniform Substance Control Act
6)   NAADAC Code of Ethics
7)   Overview of Medical Marijuana
1)   Decriminalization of Marijuana
2)   Legalization of Marijuana
3)   Impact of Marijuana Use on
     Adolescents and Adults
4)   Treatment Methodology for
     Marijuana Addiction
1.   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.
2.   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.
Is medical marijuana legal?
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.
Can a Patient be prescribed marijuana
           for medical use?
Doctors may not "prescribe" marijuana
   for medical use under federal law,
 though they can "recommend" its use
      under the First Amendment.
How is a patient allowed to use marijuana as a
medication if it is not prescribed?
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.
What kinds of health care professionals are eligible to
advise patients about medical uses of marijuana?
 licensed physician
 licensed physician assistant
 licensed osteopathic physician
 licensed osteopathic physicians' assistant
 licensed naturopath
 licensed advanced registered nurse practitioner
What conditions must the health care professional meet prior to recommending
the use of marijuana as a medication?
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
What does valid documentation mean (green card)?
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.
What does terminal or debilitating medical condition mean?
 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
 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
What are most researched medical conditions that are
illustrate the most credible uses of marijuana as a
 Wasting syndrome associated with antiretroviral
   drugs and chemo/radiation therapy
 Gastrointestinal disorders and diseases
How does an individual get a medical condition recognized
for treatment with medical marijuana?
  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 Commission
                         P.O. Box 47866
                    Olympia, WA 98504-7866
Can a person be arrested or prosecuted
for possession of medical marijuana?
No, a patient in compliance with medical
marijuana law may not be arrested or
What is non-compliance with this law?
The investigating peace officer does not possess evidence that:
1.  The designated provider has converted cannabis produced
    or obtained for the qualifying patient for his or her own
    personal use or benefit
2.  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
3.  The designated provider has served as a designated
    provider to more than one qualifying patient within a
    fifteen-day period
How much medical marijuana may a patient
or provider possess?
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.
What is the average daily dose based on
the definition of the 60 day supply?

     11.2 grams
What is considered a therapeutic dose?
The law and literature on the use of medical
marijuana does not define a therapeutic dose.
1. A urinalysis test or blood test can not be used to
   determine if a patient is using as recommended or
   abusing marijuana.
2. The patient self doses based on achieving the
   desired result to relieve symptoms.
Does the law recommend a particular route of
No, the patient can use marijuana in anyway he or she
feels is the best to obtain the desired result.
1. Smoking or Inhaling
2. Oral Consumption
3. Transdermal Delivery
 Euphoria
 Paranoia
 Fatigue
 Lossof Motivation
 Memory Loss
 Weight gain or loss
Do patients complain about the side effects of
medical marijuana or cannabinoid derivative
prescription drugs?
   The number one complaint was
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.
What is a Schedule I drug?
1. The drug or other substance has a high potential for
2. The drug or other substance has no currently accepted
   medical use in treatment in the United States.
3. There is a lack of accepted safety for use of the drug or
   other substance under medical supervision.

Why is marijuana a schedule I drug?
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
What is a schedule II drug?
1. The drug or other substance has a high potential for
2. 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.
3. Abuse of the drug or other substances may lead to severe
   psychological or physical dependence.

If marijuana is being considered a medication, will it
be moved to Schedule II?
The AMA, NORMAL, and various state attorney
generals have petitioned the congress to do this but to
date congress has denied the petitions.
Dilemma occurs when laws and ethical
guidelines are in conflict. The following laws
create conflict for healthcare providers not
protected by medical marijuana law:
1. Uniform Disciplinary Act
2. Americans With Disabilities Act
3. Chemical Dependency Professional Law
Are Alcoholics and Drug Addicts qualified individuals
with a disability?
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.
Are Alcoholics and Drug Addicts qualified individuals with a disability?
Yes, history of illegal drug use does not prevent an alcoholic or drug addict
from being a qualified individual with a disability who
1.    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
2.    is participating in a supervised rehabilitation program and is no longer
      engaging in such use
3.    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.
Are there laws that govern the conduct, scope
of practice and consumption of alcohol and
drugs by CDP(T)’S.
 There are stipulations regarding these areas
              in RCW 18.130.180.
Three stipulations in RCW 18.130.180 have the potential
to create conflicts for CDP’s.
(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
(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
What are the legally defined competencies of a CDP?
(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.

Does the code of ethics for the chemical dependency
field offer guidance regarding patients who use
marijuana for medical conditions?
Five of the nine principles in the code offer implicit
insight regarding medical marijuana but offer no
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.

1.   I shall never misrepresent my credentials or experience.

1.   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.

1.   I shall constantly strive for a better understanding of addictive disorders
     and refuse to accept supposition and prejudice as if it were the truth.
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.
1.  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.
2.  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.
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.
1.   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
2.   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.
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.
1. I shall terminate a counseling or consulting relationship when it is
    reasonably clear that the client is not benefiting from the relationship.
2. 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.
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
1.    I respect the right of others to hold opinions, beliefs, and values
     different from my own.
2.    I shall strive for understanding and the establishment of common
     ground rather than for the ascendancy of one opinion over another.
3.    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.
4.    I shall scrupulously avoid practicing in any area outside of my
The Problem:
1. Marijuana is a schedule I drug.
2. The job of a CDP is to assist the patient in finding
   ways to maintain abstinence and create a clean
   and sober support system.
3. CDP’s are not identified as protected as health care
   providers in the medical marijuana law.
4. The UDA requires CDP’s to follow all state and
   federal laws related to the profession.
The foundation to the implementing a solution to the
dilemmas presented lies in:
1. 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.
Policy and Procedure for Referral:
1. Create criteria to determine a medical marijuana
    patient’s eligibility for assessment and evaluation
    of a substance use disorder.
2. Create procedures for documenting assessment
    outcomes that include marijuana abuse and
    dependence for medical marijuana patient.
3. Create procedure for documenting diagnostic
    impressions used to determine assessment
4. Document Urinalysis or Blood test results.
Policy and Procedure for admission to Treatment
1.  Develop policy defining the agency’s philosophy
    regarding medical marijuana
2.  Develop policy defining the role of a CDP treating
    medical marijuana patients.
3.  Create criteria to determine a medical marijuana
    patient’s eligibility for assessment and evaluation of a
    substance use disorder.
4.  Create procedure for documenting diagnostic
    impressions used to determine assessment outcomes.
5.  Create procedures to determine patient’s use periods
    prior to care, during care and post-care.
Policy and Procedure for admission to Treatment
1. Create procedures to determine patient’s use
    periods prior to care, during care and post-care.
2. Develop treatment planning guidelines that clearly
    demonstrate the ongoing benefits of maintaining
    the therapeutic relationship.
3. Create policies that define levels of acceptable
    THC metabolites present in a UA and how to
    address spikes in the THC creatinine ratio
Policy and Procedure for admission to Treatment (cont)
1.  Develop policies that define purpose and frequency of
2.  Develop policies to define relapse on medical
    marijuana and procedures for documenting the
3.  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.
Problem: Retaining a CDP using medical marijuana
Counselor in Recovery is recommended medical
marijuana for a medical condition.
1. Develop agency philosophy defining “being in
2. Develop agency definition of impaired professional
   including acceptable times for use pre and post work
   hours, UA tolerance levels and creatinine ratios.
3. Develop policy defining duties in agency and
   stipulations on serving different patient populations.
Problem: Zero tolerance for CDP using medical
marijuana and Counselor in Recovery is
recommended medical marijuana for a medical
1. Develop policy and procedure for documenting
   termination and reporting use to DOH.
2. Develop policy and procedure for documenting
   leave of absence and completion of WHPS
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.
Should agencies have different standards for CDP’s
who are in recovery from standards for CDP’s who do
not meet criteria warranting the need to be in
 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.
   Allows for the licensure and regulation of
    marijuana production, distribution, and
    possession for persons over twenty-one
   Removes state-law criminal and civil
    penalties for activities that it authorizes
   Taxes marijuana sales
   Earmarks marijuana-related revenues

   Source: I-502
The new law:
   Removes state-law prohibitions against producing,
    processing, and selling marijuana, subject to licensing and
    regulation by the liquor control board
   Allows limited possession of marijuana by persons aged
    twenty-one and over (up to one oz of processed marijuana)
   Imposes 25% excise taxes on wholesale and retail sales of
    marijuana, earmarking revenue for purposes that include
    substance-abuse prevention, research, education, and
   Laws prohibiting driving under the influence would be
    amended to include maximum thresholds for THC blood
What is the intent of the law?
   Create Regulations for the purchase and
    possession of marijuana
   Generate State Revenues
   Create Protections for Public Safety
   Creates Safeguards for Medical Marijuana Patients
What is the legal age to buy and
possess marijuana?
Adults age 21 and older and selling
marijuana to minors will remain a
How will legalizing marijuana protect our
   Selling marijuana to minors will remain a felony
   Restricts advertising and bans advertising in places
    frequented by youth.
   New tax revenue is dedicated to proven community
    and school-based prevention programs.
How will the state liquor board obtain marijuana to
sell to adults over the age of 21?
 Washington farmers and businesses will be allowed
  to apply for special licenses to grow and sell
  marijuana. Washington farmers and businesses will
  be allowed to apply for special licenses to grow and
  sell marijuana.
 State employees will not be involved in growing,
  distributing, or selling marijuana.
How will the State of Washington regulate the
growth and sales of marijuana?
State agencies will regulate numbers of stores
per county, operating hours, security, quality
control, labeling, and other health and safety
How does the law regulate the advertising and
sales of marijuana?
Marijuana will only be available in stores that
sell no other products, are located at least
1,000 feet from schools, playgrounds, and
parks, and do not display marijuana in a way
that is visible to the public.
How does the law regulate the use and growing
of marijuana?
 Prohibits public use and display of
 Does not allow home growing for
  people who are not medical marijuana
How does the law make are roads safe from
marijuana users?
 A new marijuana DUI standard that operates
  like the alcohol DUI standard will be
 Sets a science-based limit of 5ng/ml active
  THC blood concentration.
Where will the revenue the law generates come
According to the state Office of Financial
Management, a new 25% marijuana excise tax,
combined with retail sales and B&O tax, will
generate more than half a billion dollars in new
revenue each year.
How will all of the revenue generated be
 40% of the new revenues will go to the state
  general fund and local budgets.
 60% will be dedicated to substance-abuse
  prevention, research, education and health
   The problem with Reefer Madness.
   The problem with Hemp for Victory.
   The problem with medical marijuana.
   The problem with legalizing marijuana.
      The problem with adolescents and young
   Underdeveloped prefrontal cortex’s.
   Adolescent defense mechanisms are
    amygdala based.
   Mixed messages are most commonly broken down and
    evaluated for relevance in the adolescent brain by source
    ◦ Peers
    ◦ Siblings
    ◦ Parents
    ◦ Disciplinarians-Tell story of Silver Bow Sheriff and boys balls will fall off
    ◦ Teachers
    ◦ Coaches
    ◦ Counselors
       Youthful counselors say 20 to 30-cool aunts and uncles
       Older counselors say 45 to 65- grandparents
       Middle adult counselors 30 to 45- mom and dad
What is the most problematic aspect of doing
credible research on the short and long term
effects of marijuana?
 Complex biochemistry of marijuana
 A Dutch Dr. once described the biochemical
  experience of using marijuana as being as
  individual as a snowflake.
Thank you for your Time and
   Interest in the topic!!!

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