During her session on April 29, 2021, for the 46th Annual ONS Congress™, Lisa Withrow, APRN, FNP-C, ACHPN, of Palliativity Medical Group LLC, reviewed important practice considerations of APRNs in certifying health conditions for patients to qualify for medical marijuana programs.

Certifying Versus Prescribing Medical Marijuana

“Healthcare providers do not prescribe medical marijuana,” Withrow emphasized. “The medical provider is simply signing a paper certifying that the patient has a qualifying medical condition with at least one associated symptom.”

Every state has different rules about who can certify and processes to follow, and APRNs must understand the rules in their own states. In New Hampshire, where she practices, a certifying professional must:

• Be a physician, APRN, or physician assistant.
• Perform a full in-person medical assessment (telehealth may be used during the pandemic).
• Provide education about the potential effects of cannabis.
• Document the certification in various ways.
• Follow up with the patient to monitor effects.

Cannabinoid Basics

Cannabinoids are biologically active components in marijuana, Withrow explained. Moderate to strong evidence has shown that cannabinoids are effective at alleviating some symptoms that patients with cancer may experience, she said, but more research is needed to support its use for other symptoms.

The two most commonly studied components are delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is a psychoactive compound frequently used to treat nausea, stimulate appetite, and control muscle spasms. It is associated with the “high” or euphoria associated with marijuana use. CBD is often used to treat pain, inflammation, seizures, anxiety, and psychosis, and it can calm the euphoria from THC. Some patients may need both THC and CBD.

Cannabinoids are available in many different delivery methods:

• Inhalation (smoking, vaping and tinctures)
• Topical products such as salves and sprays
• Oral options, including capsules, edibles, and drinks
• Transdermal patches
• Suppositories

A Clinical Approach for APRNs

Withrow outlined the steps of an effective clinical approach to certify a patient for medical marijuana.

First, APRNs must understand the rules and regulations where they practice and where the patient resides. States vary widely regarding certification criteria, requirements for certifying healthcare providers, length of preexisting provider-patient relationship, and availability of different delivery methods.

Second, healthcare providers must understand and consider cannabinoid pharmacology and potential interactions. For example, Withrow said, CBD is a potential inhibitor of CYP34A and therefore may increase serum concentrations of certain other drugs, such as tamoxifen, antihistamines, and sildenafil.

Third, APRNs must understand and follow documentation processes. This includes knowing and meeting the criteria for therapeutic cannabis established in that particular state, obtaining informed consent, completing the written certification for submission, documenting it in the electronic medical record, and including the information in the prescription drug monitoring program if required.

Finally, APRNs must establish a plan for follow-up visits to monitor and evaluate efficacy and effects. Follow-up timing is individualized but may include an in-person visit a few weeks after the first trip to a dispensary, monthly check-ins (perhaps phone calls or home visits), re-evaluation at six months, and annual recertification.

The Patient Perspective

Throughout the process, APRNs should remain sensitive to the patient perspective and engage in shared decision-making. Patient concerns may include:

• Cost of cannabinoid products
• Worries about marijuana being federally illegal, or crossing between states with different rules
• Logistical role of the caregiver in getting access to cannabis, such as growing it or picking it up
• Ability to find a dispensary that is knowledgeable, friendly, and trustworthy

For additional resources, Withrow recommended the state department of health, staff at nearby dispensaries, and accredited, online continuing medical education through the Medical Cannabis Institute.