By Carmel Barrau, M.D., Violina Bhattacharyya, M.D., Jeffrey Block, M.D., Julie Kantor, M.D., Jorge Pardo, M.D., Smith Joseph, D.O.
Dade County Medical Association’s 2021 Physician Leadership Academy
Address correspondence to: Jeffrey S. Block, M.D. Phone: 305-793-9222
Conflict of Interest: The authors have no conflicts of interest to disclose
Florida’s previous decade concerning legal Schedule 2 (controlled) substances demonstrated systemic failure controlling a proliferation of “oxycontin pill mills” that resulted in tragic patient outcomes throughout the United States. Responsible guidance from the Florida Medical Association (FMA) prompted legislation to establish standards for pain
management clinics. This resulted in more stringent licensure requirements, established a limit on the amount that could be prescribed when patients pay cash, and required tamper-resistant prescription forms.1 The authors respect Federal Controlled Substances Act2 laws designating Cannabis as an illegal Schedule 1 (prohibited) substance and recognize how Cannabis’ recent legal availability has expanded in Florida to now include in excess of half a million of our citizen-patients.3 Physician leaders are rightfully concerned with how the past four years generated such dramatic increases of medical marijuana patients to become the fastest growing Cannabis program in the nation.
At this particularly formidable time, the authors maintain that the FMA should proactively address Cannabis-related issues. Key recent systemic failures that collectively compromise the rendering of safe and effective healthcare impacting Florida physicians’ practice of medicine have been identified.
Medical Cannabis as a new industry in Florida has significantly advanced unabated largely because:
- The Florida Legislature has been unable to address constraints on Cannabis products,A 4
- The Florida Department of Health has not produced required rules impacting physician practice
A Florida’s 2021 legislative initiatives were unable to regulate medical marijuana through either identical bills SB1958 or HB1455 The bills died in the Senate Judiciary Committee, and the House Health and Human Services Committee respectively on April 30, 2021. https://www.flsenate.gov/Session/Bill/2021/1958 and https://www.myfloridahouse.gov/Sections/Bills/billsdetail.aspx?BillId=72700&SessionId=90
Despite rapidly changing parameters concerning medical marijuana, the COVID-19 pandemic has understandably forced physicians to acutely focus on healthcare’s most urgent needs. Policy positions have essentially remained unchanged over the past five years. The authors seek organizational solutions in 2021 that will optimally inform and guide the education of colleagues, patients, and legislators; and have accordingly focused on two key issues in need of organizational development:
- Consistent Updates to the FMA Policy Positions – This initiative’s purpose is intended to evolve proactive healthcare policies that reflect current scientific knowledge and current legal parameters impacting Florida physicians’ goal to render safe and effective patient
- Optimizing the Education of Florida Physicians – Endorsing high-quality physician educational content responsibly provides Florida’s consumer-patients with unbiased and vetted information to facilitate their independent healthcare knowledge and decision-
The FMA Public Policy Compendium currently provides consensus opinions involving five medical marijuana statements. These consensus opinions originated in response to Florida’s evolving legislative5 proposals that contrasted with prevailing federal law; and were established beginning in 2012 as cited in P307.001-005.6
The authors are concerned that currently neither Florida’s legal access to medical Cannabis or the supporting evidence-based science are acknowledged within the existing FMA policy positions. Because outdated FMA policies do not reflect the realities of contemporary patient care or the basis of Florida law, the authors support and emphasize frequent revisions. The authors also firmly believe that Florida expert physicians’ opinions deserve more timely input to help advance inextricably connected societal healthcare issues.
The growing body of evidence-based data and changing Florida laws, rules, and regulations that surround Cannabis presents a moral imperative for its duly licensed healers to provide responsible guiding leadership as required by and expected from licensed physicians in Florida.
The authors recognize that “marijuana” is a complex subject extending beyond rendering basic healthcare. Marijuana additionally involves societal issues that necessarily include legal, agricultural, and industrial considerations. Whereas Florida law specifically allows qualified citizens to receive restricted access to medical marijuana; the authors understand that Florida’s licensed medical doctors are uniquely qualified to provide such societal leadership. Because the medicalization of Cannabis is currently incomplete, the ideal solution is an enduring platform to evolve policy initiatives from which Florida’s expert physicians should proactively respond to evidence-based data, future research, and changing state and federal legal constraints.
This ultimately helps physicians develop standards of care that favorably impact patient outcomes.
Substance use and abuse issues frequently challenge a physician’s ability to effectively treat pain as an intolerable symptom of physical, psychological, or spiritual nature. Bioethical considerations can be shared through organized medicine’s proactive leadership. In contrast to medical-legal ethical guidance often selectively championed by doctors and lawyers respectively, bioethical leadership’s perspectives involve a full community’s meaningful discussion that intentionally includes patients, clergy, and law enforcement among others. Such a broad conversation is universally helpful to render impactful healthcare that ultimately seeks to not simply improve an individual patient’s outcome, but also societal outcomes as well.
Physicians as caring individuals always strive to “do the right thing,” even as complicated societal situations challenge clinical acumen. This passage from the textbook ‘Advanced Therapeutics in Pain Medicine’ (CRC Press 2020) articulates a dilemma with how physicians manage pain:
“Primum non nocere” (first do no harm) is a guiding maxim for clinicians, and concern for balancing risk with benefit is central to treatment decisions in patient care. Most responsible clinicians will not advise their patients to pursue a particular treatment regimen without conclusive clinical evidence and peer review confirmation regarding the relative safety and efficacy of a given treatment. Yet the compassionate physician will also be mindful of the ethical obligation to ease suffering with whatever tools might be available, and wherever possible. In this context, the medicinal use of Cannabis currently presents a conundrum in need of bioethical rationale.
The clinician faced with a patient in intolerable pain has an obligation to not just feel compassion, but to do what is possible to alleviate that suffering without causing harm. As the limitations of opioid options become more evident, the search for safe and effective solutions has rightfully included cannabinoid medicines. Despite barriers to research, randomized clinical trials provide substantial evidence of the analgesic potential of cannabinoids that confirm animal experiments, laboratory science, and what is known about the purpose of the endocannabinoid receptor system.
As clinicians consider how to apply these discoveries, we may do well to heed the ethical standards which physicians have historically promised to uphold, whether the Hippocratic oath to “apply for the benefit of the sick all measures that are required,” or that of Maimonides to seek the strength, time and opportunity to correct acquired beliefs and extend the domain of knowledge.”7
Responsible health professionals require high-quality education to help transition patients’ use away from existing practices of self-titration-oriented medical Cannabis consumption.
Physicians deserve to be provided with necessary information to help guide their patients’ limited Cannabis use for safe and well-understood purposes; and as a means of understanding contraindications, drug interactions, and dosing guidelines that account for the wide diversity of bioactive plant chemical standards that bring potential for inconsistent effects. While there is evolving research designed to discern and demonstrate medical Cannabis’ safe dosing and control protocols, the current limitations of evidence-based data concerning Cannabis when used as a medicine signal a significant need for additional ongoing research.8
Floridians presently consume Cannabis regardless of legality, and regardless of a clear legal distinction between medical and recreational Cannabis use. Florida’s citizen-patients not only currently use legally dispensed medical Cannabis products as permitted under Florida law, but also continue to use illicit-market products. Of note is that immediately before the COVID-19 pandemic perilously compromised the availability of intensive care unit ventilators, news reports throughout the United States featured previously healthy individuals, predominately youth, who inhaled vaporized Cannabis oil products and developed chemical burns resulting in life- threatening reactive-airway pneumonitis. The Centers for Disease Control and Prevention determined that this resulted from illegal Cannabis oil concentrates that were contaminated with harmful cutting agents.
If a Florida physician recognizes that their patient might have a medical condition that — within reasonable medical judgment — could potentially benefit from carefully supervised medical Cannabis regimens, only when policy follows clinical research to ensure safety and efficacy, and when regulations are present that discourage misuse and ensure accountability, that physician should consider their citizen-patient’s informed consent access to Cannabis plant- derived chemicals’ use for medical purposes.
Organized medicine has a practical obligation to promote public health awareness and education concerning the expanding legalization of Cannabis by clearly acknowledging current scientific research regarding its non-medical use. We believe the FMA should continue to work with policy makers to avoid broadening access to the recreational use of Cannabis, especially among youth. The FMA should encourage opportunities to participate in clinical evaluations of legitimate medical Cannabis use provided that they are consistent with how patients are actually using it. The FMA should continue to oppose resolving issues of Cannabis consumption — medicinally or recreationally — through citizens’ ballot initiatives; and the FMA should oppose all related legislation not accompanied by a process of FMA approval. Because the ever- increasing numbers of Floridians using either legal or illegal Cannabis products understandably will expect to receive physicians’ non-discriminatory comprehensive healthcare, the urgency of Dade County and Broward County physicians’ compassionate patient guidance concerning Cannabis is readily apparent.
- Centers for Disease Control and Drug overdose deaths – Florida 2003-2009. MMWR Morb Mortal Wkly Rep. 2011 Jul 8;60(26):869-72.
- Drug Enforcement The Controlled Substances Act [Internet]. Available from: https://www.dea.gov/drug-information/csa.
- Physician Certification Pattern Review Panel, Board of Medicine, Board of Osteopathic Physician Certification Pattern Review 2021 Annual Report. Tallahassee (FL): Department of Health; 2020 Sep 30-2019 Oct 1. 33 p.
- Roach The fight to save Florida’s medical marijuana program. Florida Politics. 2021 Apr 7.
- Medical use of 2021 Florida Statute 381.986. Available from: http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0300- 0399/0381/Sections/0381.986.html.
- Florida Medical Association Public Policy Compendium. Tallahassee (FL); 2019 Oct, updated 2020 Jan Part 307, Medical Marijuana; p. 98.
- Swidan S, Bennett Advanced Therapeutics in Pain Medicine. Boca Raton: CRC Press; c2020. Chapter 4, Endocannabinoid Receptors and Medical Cannabis; 30 p.
- Hemingway K, Martorella G, Schluck G, et Medical Marijuana in Florida: The Knowledge, Practices, and Attitudes of Providers. Cannabis Clinical Outcomes Research Conference. 2021 Apr; Gainesville, Florida.
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