The Marijuana Conundrum

1
The Marijuana Conundrum

• Paul Weatherly MA, CDP

2
Examine problems for the chemical dependency
counseling field related to medical marijuana,
standards of care and ethics.

• Focus of Training

3
Goals

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 medication.

4
Topics for Todays Discussion

1. Medical Marijuana Law
2. CDP Law
3. Uniform Disciplinary Act
4. Americans With Disabilities Act
5. Uniform Substance Control Act
6. NAADAC Code of Ethics
7. Overview of Medical Marijuana Pharmacology

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Topics Not Included in Todays Discussion

1. Decriminalization of Marijuana
2. Legalization of Marijuana
3. Impact of Marijuana Use on Adolescents and Adults
4. Treatment Methodology for Marijuana Addiction

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Medical Marijuana Law

• Intent
• 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.
• 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.

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Medical Marijuana Law

• Question
• Is medical marijuana legal?
• Answer
• 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.
• http//www.doh.wa.gov/hsqa/medical-marijuana/FAQmo
  re.htm

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Medical Marijuana Law

• Question
• Can a Patient be prescribed marijuana for medical
  use?
• Answer
• No!
• Doctors may not "prescribe" marijuana for medical
  use under federal law, though they can
  "recommend" its use under the First Amendment.

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Medical Marijuana Law

• Question
• How is a patient allowed to use marijuana as a
  medication if it is not prescribed?
• Answer
• 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.

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Medical Marijuana Law

• Question
• What kinds of health care professionals are
  eligible to advise patients about medical uses of
  marijuana?
• Answer
• licensed physician
• licensed physician assistant
• licensed osteopathic physician
• licensed osteopathic physicians' assistant
• licensed naturopath
• licensed advanced registered nurse practitioner

11
Medical Marijuana Law

• Question
• What conditions must the health care professional
  meet prior to recommending the use of marijuana
  as a medication?
• Answer
• 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

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Medical Marijuana Law

• Question
• What does valid documentation mean (green card)?
• Answer
• 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.

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Medical Marijuana Law

• Question
• What does terminal or debilitating medical
  condition mean?
• Answer
• 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 medications
• 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

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Medical Marijuana Law

• Question
• What are most researched medical conditions that
  are illustrate the most credible uses of
  marijuana as a medication?
• Answer
• Wasting syndrome associated with antiretroviral
  drugs and chemo/radiation therapy
• Gastrointestinal disorders and diseases

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Medical Marijuana Law

• Question
• How does an individual get a medical condition
  recognized for treatment with medical marijuana?
• Answer
• 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 CommissionP.O. Box
  47866Olympia, WA 98504-7866
• http//www.doh.wa.gov/hsqa/medical-marijuana/FAQmo
  re.htm3

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Medical Marijuana Law

• Question
• Can a person be arrested or prosecuted for
  possession of medical marijuana?
• Answer
• No, a patient in compliance with medical
  marijuana law may not be arrested or prosecuted.

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Medical Marijuana Law

• Question
• What is non-compliance with this law?
• Answer
• The investigating peace officer does not possess
  evidence that
• The designated provider has converted cannabis
  produced or obtained for the qualifying patient
  for his or her own personal use or benefit
• 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
• The designated provider has served as a
  designated provider to more than one qualifying
  patient within a fifteen-day period

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Medical Marijuana Law

• Question
• How much medical marijuana may a patient or
  provider possess?
• Answer
• 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.

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Medical Marijuana Law

• Question
• What is the average daily dose based on the
  definition of the 60 day supply?
• Answer
• 11.2 grams

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Medical Marijuana Law

• Question
• What is considered a therapeutic dose?
• Answer
• The law and literature on the use of medical
  marijuana does not define a therapeutic dose.
• A urinalysis test or blood test can not be used
  to determine if a patient is using as recommended
  or abusing marijuana.
• The patient self doses based on achieving the
  desired result to relieve symptoms.

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Medical Marijuana Law

• Question
• Does the law recommend a particular route of
  administration?
• Answer
• No, the patient can use marijuana in anyway he or
  she feels is the best to obtain the desired
  result.
• Smoking or Inhaling
• Oral Consumption
• Transdermal Delivery

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Side Effects of Medical Marijuana

• Euphoria
• Paranoia
• Fatigue
• Loss of Motivation
• Memory Loss
• Weight gain or loss

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Side Effects of Medical Marijuana

• Question
• Do patients complain about the side effects of
  medical marijuana or cannabinoid derivative
  prescription drugs?
• Answer
• Yes!!!!!
• The number one complaint was euphoria.

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Cannabinoid Derivative Prescription Drugs

• 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.

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Federal Controlled Substances Act

• Question
• What is a Schedule I drug?
• Answer
• The drug or other substance has a high potential
  for abuse.
• The drug or other substance has no currently
  accepted medical use in treatment in the United
  States.
• There is a lack of accepted safety for use of the
  drug or other substance under medical
  supervision.
• http//www.deadiversion.usdoj.gov/21cfr/21usc/812.
  htm

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Federal Controlled Substances Act

• Question
• Why is marijuana a schedule I drug?
• Answer
• 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 value.

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Federal Controlled Substances Act

• Question
• What is a schedule II drug?
• Answer
• The drug or other substance has a high potential
  for abuse.
• 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.
• Abuse of the drug or other substances may lead to
  severe psychological or physical dependence.
• http//www.deadiversion.usdoj.gov/21cfr/21usc/812.
  htm

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Federal Controlled Substances Act

• Question
• If marijuana is being considered a medication,
  will it be moved to Schedule II?
• Answer
• The AMA, NORMAL, and various state attorney
  generals have petitioned the congress to do this
  but to date congress has denied the petitions.

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The Nature of Dilemma

• Dilemma occurs when laws and ethical guidelines
  are in conflict. The following laws create
  conflict for healthcare providers not protected
  by medical marijuana law
• Uniform Disciplinary Act
• Americans With Disabilities Act
• Chemical Dependency Professional Law

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Americans With Disabilities Act

• Question
• Are Alcoholics and Drug Addicts qualified
  individuals with a disability?
• Answer
• 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.
• http//www.ada.gov/pubs/adastatute08mark.htm12114
  a

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Americans With Disabilities Act

• Question
• Are Alcoholics and Drug Addicts qualified
  individuals with a disability?
• Answer
• Yes, history of illegal drug use does not prevent
  an alcoholic or drug addict from being a
  qualified individual with a disability who
• 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
• is participating in a supervised rehabilitation
  program and is no longer engaging in such use
• 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.
• http//www.ada.gov/pubs/adastatute08mark.htm12114
  a

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Uniform Disciplinary Act

• Question
• Are there laws that govern the conduct, scope of
  practice and consumption of alcohol and drugs by
  CDP(T)S.
• Answer
• Yes!
• There are stipulations regarding these areas in
  RCW 18.130.180.

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Uniform Disciplinary Act

• Three stipulations in RCW 18.130.180 have the
  potential to create conflicts for CDPs.
• (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 practice
• (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
• http//apps.leg.wa.gov/RCW/default.aspx?cite18.13
  0.180

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Chemical Dependency Professional Law

• Question
• What are the legally defined competencies of a
  CDP?
• Answer
• (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.
• http//apps.leg.wa.gov/RCW/default.aspx?cite18.20
  5.020

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NAADAC Code of Ethics

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

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NAADAC Code of Ethics

• 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.
• I shall never misrepresent my credentials or
  experience.
• 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.
• I shall constantly strive for a better
  understanding of addictive disorders and refuse
  to accept supposition and prejudice as if it were
  the truth.

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NAADAC Code of Ethics

• 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.
• 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.
• 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.

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NAADAC Code of Ethics

• 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.
• 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 profession.
• 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.

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NAADAC Code of Ethics

• 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.
• I shall terminate a counseling or consulting
  relationship when it is reasonably clear that the
  client is not benefiting from the relationship.
  
• 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.

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NAADAC Code of Ethics

• 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 harm.
• I respect the right of others to hold opinions,
  beliefs, and values different from my own.
• I shall strive for understanding and the
  establishment of common ground rather than for
  the ascendancy of one opinion over another.
• 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.
• I shall scrupulously avoid practicing in any
  area outside of my competence.
• http//www.ndbace.org/forms/NAADACCodeofEthics-200
  4.pdf

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Looking for Solutions

• The Problem
• Marijuana is a schedule I drug.
• The job of a CDP is to assist the patient in
  finding ways to maintain abstinence and create a
  clean and sober support system.
• CDPs are not identified as protected as health
  care providers in the medical marijuana law.
• The UDA requires CDPs to follow all state and
  federal laws related to the profession.

42
Looking for Solutions

• The foundation to the implementing a solution to
  the dilemmas presented lies in
• 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.

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Looking for Solutions

• Policy and Procedure for Referral
• Create criteria to determine a medical marijuana
  patients eligibility for assessment and
  evaluation of a substance use disorder.
• Create procedures for documenting assessment
  outcomes that include marijuana abuse and
  dependence for medical marijuana patient.
• Create procedure for documenting diagnostic
  impressions used to determine assessment
  outcomes.
• Document Urinalysis or Blood test results.

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Looking for Solutions

• Policy and Procedure for admission to Treatment
• Develop policy defining the agencys philosophy
  regarding medical marijuana
• Develop policy defining the role of a CDP
  treating medical marijuana patients.
• Create criteria to determine a medical marijuana
  patients eligibility for assessment and
  evaluation of a substance use disorder.
• Create procedure for documenting diagnostic
  impressions used to determine assessment
  outcomes.
• Create procedures to determine patients use
  periods prior to care, during care and post-care.

45
Looking for Solutions

• Policy and Procedure for admission to Treatment
  (cont)
• Create procedures to determine patients use
  periods prior to care, during care and post-care.
• Develop treatment planning guidelines that
  clearly demonstrate the ongoing benefits of
  maintaining the therapeutic relationship.
• Create policies that define levels of acceptable
  THC metabolites present in a UA and how to
  address spikes in the THC creatinine ratio

46
Looking for Solutions

• Policy and Procedure for admission to Treatment
  (cont)
• Develop policies that define purpose and
  frequency of urinalysis
• Develop policies to define relapse on medical
  marijuana and procedures for documenting the
  relapse.
• 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.

47
Looking for Solutions

• Problem Retaining a CDP using medical marijuana
• Counselor in Recovery is recommended medical
  marijuana for a medical condition.
• Develop agency philosophy defining being in
  recovery.
• Develop agency definition of impaired
  professional including acceptable times for use
  pre and post work hours, UA tolerance levels and
  creatinine ratios.
• Develop policy defining duties in agency and
  stipulations on serving different patient
  populations.

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Looking for Solutions

• Problem Zero tolerance for CDP using medical
  marijuana and Counselor in Recovery is
  recommended medical marijuana for a medical
  condition.
• Develop policy and procedure for documenting
  termination and reporting use to DOH.
• Develop policy and procedure for documenting
  leave of absence and completion of WHPS program.

49
Looking for Solutions

• 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.
• Question
• Should agencies have different standards for
  CDPs who are in recovery from standards for
  CDPs who do not meet criteria warranting the
  need to be in recovery?

50
Looking for Solutions

• Problem
• 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.

51
Legalizing Marijuana

• 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

52
Legalizing Marijuana

• 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 healthcare.
• Laws prohibiting driving under the influence
  would be amended to include maximum thresholds
  for THC blood concentration.

53
Legalizing Marijuana

• Question
• What is the intent of the law?
• Answer
• Create Regulations for the purchase and
  possession of marijuana
• Generate State Revenues
• Create Protections for Public Safety
• Creates Safeguards for Medical Marijuana Patients

54
Legalizing Marijuana

• Question
• What is the legal age to buy and possess
  marijuana?
• Answer
• Adults age 21 and older and selling marijuana to
  minors will remain a felony

55
Legalizing Marijuana

• Question
• How will legalizing marijuana protect our youth?
• Answer
• 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.

56
Legalizing Marijuana

• Question
• How will the state liquor board obtain marijuana
  to sell to adults over the age of 21?
• Answer
• 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.

57
Legalizing Marijuana

• Question
• How will the State of Washington regulate the
  growth and sales of marijuana?
• Answer
• State agencies will regulate numbers of stores
  per county, operating hours, security, quality
  control, labeling, and other health and safety
  issues.

58
Legalizing Marijuana

• Question
• How does the law regulate the advertising and
  sales of marijuana?
• Answer
• 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.

59
Legalizing Marijuana

• Question
• How does the law regulate the use and growing of
  marijuana?
• Answer
• Prohibits public use and display of marijuana.
• Does not allow home growing for people who are
  not medical marijuana patients.

60
Legalizing Marijuana

• Question
• How does the law make are roads safe from
  marijuana users?
• Answer
• A new marijuana DUI standard that operates like
  the alcohol DUI standard will be established.
• Sets a science-based limit of 5ng/ml active THC
  blood concentration.

61
Legalizing Marijuana

• Question
• Where will the revenue the law generates come
  from?
• Answer
• According to the state Office of Financial
  Management, a new 25 marijuana excise tax,
  combined with retail sales and BO tax, will
  generate more than half a billion dollars in new
  revenue each year.

62
Legalizing Marijuana

• Question
• How will all of the revenue generated be
  dispersed?
• Answer
• 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 care.

63
THE PROBLEMS WITH MIXED MESSAGES

• 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 adults.
• Underdeveloped prefrontal cortexs.
• Adolescent defense mechanisms are amygdala based.

64
THE PROBLEMS WITH MIXED MESSAGES

• 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

65
THE PROBLEMS WITH MIXED MESSAGES

• Question
• What is the most problematic aspect of doing
  credible research on the short and long term
  effects of marijuana?
• Answer
• DNA
• Complex biochemistry of marijuana
• A Dutch Dr. once described the biochemical
  experience of using marijuana as being as
  individual as a snowflake.

66
The Marijuana Conundrum

• Thank you for your Time and Interest in the
  topic!!!