Patients using and doctors recommending medical marijuana have begun to see the changes from two recent Provincial Colleges of Physicians guidelines released this March.
The Ontario College of Physicians and Surgeons and the College of Physicians and Surgeons of British Columbia both released updated standards and guidelines for medical professionals in March highlighting issues like caps on 'prescribed' THC levels, recommendations for users under 25, and whether doctors can charge patients or producers for a'medical document'.
The College of Physicians and Surgeons of British Columbia recently released, and then temporarily removed, their Professional Standards and Guidelines for Marijuana for Medical Purposes, highlighting guidelines and rules for doctors in the province around the recommendation of medical marijuana to patients. BC is the second College to release such guidelines this year, following the Ontario College's (CPSO) release earlier in 2015, with some patients and doctors already beginning to feel the results.
The PDF has been removed from the College's website since last Friday after apparent feedback from BC doctors that the regulations and guidelines were too strict and did not allow enough leeway for special cases.
The BC College's "Professional Standards and Guidelines" highlighted new rules for British Columbia doctors, stating marijuana for medical purposes is not appropriate for patients who are under the age of 25, have a personal history or strong family history of psychosis, have a current or past cannabis use disorder, have an active substance use disorder, have cardiovascular or respiratory disease or are pregnant, planning to become pregnant or are breastfeeding.
The Ontario (CPSO) Policy Statement, by comparison, is slightly more lenient, for example, noting that physicians must not prescribe dried marijuana to people under 25 "unless all other conventional therapeutic options have been attempted and have failed to alleviate the patient’s symptoms," but does also require doctors to limit to strains that are "low in THC". The document does not dictate what 'low' means.
"It seems paternalistic to deny a consenting adult any medical treatment up until the age of 25, and possibly against the Charter of Rights and Freedoms given that the Supreme Court decided that Canadians have a right to access medical cannabis. In modern patient centered medicine, physicians have a discussion with the patient about the risks and benefits of a treatment, as in the Ontario guidelines." -Dr. Ian Mitchell
Like the Ontario College's own ruling, the BC College also states that they consider the "medical document" to be equivalent to a prescription, specifically prohibiting doctors from charging patients or physicians for filling one out, or any associated and related services like helping patients choose producers or strains, etc.
The results of this ruling are already beginning to be felt in the patient and medical community, with some medical marijuana patients reporting that they are being given prescriptions with limited levels of THC, or being denied a medical document in general for being under 25.
Ian Mitchel, a doctor in Kamloops BC, says he feels some of the new BC guidelines present a barrier to access for patients who either have a GP who isn't receptive to marijuana, or, as in the case in many rural areas in Canada, simply don't have a GP at all. Rather than encouraging medical marijuana users to seek guidance from their doctor, these new rules potentially drive them to the 'grey' or black market, says Mitchell.
"My community is rife with chronic pain patients with no family doctor," says Mitchell. "They come to the emergency department to get refills of their morphine or Percocet because they have nowhere else to go. They are desperate to get off their opiates and explore an alternative, less dangerous treatment, but these restrictions make gaining access to medical cannabis increasingly difficult. Instead they are getting approvals from naturopaths and using dispensaries, without any medical oversight.
"It seems paternalistic to deny a consenting adult any medical treatment up until the age of 25, and possibly against the Charter of Rights and Freedoms given that the Supreme Court decided that Canadians have a right to access medical cannabis," he continues. "In modern patient centered medicine, physicians have a discussion with the patient about the risks and benefits of a treatment, as in the Ontario guidelines."
Patients are also feeling the pinch. We've heard form several patients over the past few weeks who have been told that they can't have a medical document if they are under 25, or are having their THC levels capped anywhere from "CBD Only (not THC)" to 15%. One Ontario patient, who asked to remain anonymous, described their experience under these new rules.
"A cannabis practice opened in my neighbourhood about a year ago and I made an appointment. I was asked a variety of screening questions, had a brief exam and left with a 3 month prescription for 1g/day of medical marijuana. Follow up appointments and urine test every three months for a year with no caps or restrictions beyond the 2 grams / day which was fine with me. Over time I ordered from 3 different suppliers of cannibis with THC between 20 and 25% concentration.
"At my last visit I was advised that because of guidelines issued by the Ontario College of Physicians and Surgeons, that my new prescription would indicate a cap on the THC of 15%. I was told 1) that if this proved to be insufficient for my needs that perhaps a medical case could be made in the future for a higher percentage, and 2) that before I had a prescription I didn’t know what he percentage was anyway when I bought from the street and 3) that there are over 300 compounds in cannabis and THC isn’t the only indicator of effectiveness."
"For the vast majority of physicians who do not have any knowledge or experience in prescribing cannabinoids, these are good recommendations for doctors to abide by, as it does promote the best patient care. It’s going to make physicians more comfortable to have guidelines." - Dr. Danial Schecter
Dr. Danial Schecter, who runs the Cannabinoid Medical Clinic in downtown Toronto, says he feels the Ontario College's guidelines are helpful to doctors because they help give them guidance on a relatively new medicine that many may not have extensive knowledge on, as long as they are framed as guidelines, and not steadfast rules.
“It’s important to remember that the CFPC guidance document (College of Family Physicians of Canada, which the Provincial Colleges base their guidelines on) are recommendations based on expert opinion," says Schecter. "For the vast majority of physicians who do not have any knowledge or experience in prescribing cannabinoids, these are good recommendations for doctors to abide by, as it does promote the best patient care. It’s going to make physicians more comfortable to have guidelines. The more information they have, the easier it is to feel comfortable writing a medical document that is supposed to be tantamount to a prescription.
“Because the BC college (in their initial guidelines) have put absolutes around prescribing to certain conditions or age groups; this potentially limits patients who have failed conventional treatment and may benefit from incorporating cannabis into their treatment regimen.”
The College of Physicians and Surgeons of British Columbia was unavailable for comment as of press time. The College's guidelines are expected as soon as next week. Stay tuned to Lift for further updates, and if you are a patient or doctor who would like to share your story on the subject further, please contact Lift.
Featured image from vancouver.24hours.ca