The CPSO has not released any new or updated physician guidance specifically addressing recreational cannabis, but has released a brief article on the subject. ¹ The CMPA issued an eBulletin to its members in October 2018. The CPSO indicates that physicians should continue to ask patients about tobacco, recreational drug and alcohol use as they would have prior to cannabis legislation.

The CMPA notes that the extent of changes to physicians’ practices owing to the legalization of recreational cannabis is difficult to predict at this time. Physicians may, however, experience a short-term increase in the number of police requests for blood samples. Physicians may also encounter more situations in which they must consider whether they need to report patients unfit to operate a motor vehicle due to the patient’s recreational use of cannabis.

The expectation on the part of the physician providing care does not change in any significant way now that recreational cannabis is legal. It is expected that physicians will remain up-to-date on  emerging issues, and maintain a level of knowledge required to have meaningful discussions with their patients.

The legal framework for access to medical cannabis, under which physicians can sign medical documents authorizing access (i.e. prescribe) for patients, was previously outlined in the Access to Cannabis for Medical Purposes Regulations (ACMPR), under the Controlled Substances Act. ^2,3 This legal framework remains the same after the legalization of recreational cannabis use; however, it is now outlined in the new Cannabis Regulations under the Cannabis Act. ^4,5

It continues to be up to each individual physician to decide whether or not to provide a medical document to a patient for medical cannabis. Cannabis is not a Health Canada approved therapeutic product, and has not been issued a Notice of Compliance or Drug Identification Number.⁶

Those physicians who authorize cannabis as a treatment option are expected to have the necessary knowledge to do so. The CPSO has provided an outline of expectations for Ontario physicians who are considering completing medical documents for medical cannabis (see Cannabis-Related Guidance From the CPSO section).

• Medical Cannabis-Related Advice from the CMPA

  The CMPA outlines its advice on cannabis for medical purposes in its Medical Cannabis: Considerations for Canadian Doctors article. These considerations remain relevant regardless of the legal status of recreational cannabis.⁷

  Key Points from the CMPA:

  • Physicians are not obligated to provide a medical document allowing a patient to access cannabis for medical purposes if they are unfamiliar with its use or management, or if they feel it is not medically appropriate for the patient.
  • Physicians are reminded of the importance of having the necessary clinical knowledge to engage in meaningful conversations with their patients about medical cannabis.
  • Physicians must be aware of the regulations governing cannabis, and of their provincial College’s relevant policies and guidelines when considering whether to provide a patient with a medical document to access cannabis for medical purposes.
  • Physicians who provide a patient with a medical document to access cannabis for medical purposes should rely on sound medical judgement.
  • Physicians are reminded to document all consent discussions in the patient’s medical records.

  
  

  For questions on the topic of cannabis, the CMPA encourages physicians to contact its support line.

  CMPA contact

  Toll Free: 1-800-267-6522
  In Ottawa area: 613-725-2000
  Telephone service hours: Monday to Friday, 8:30 a.m. to 4:30 p.m. ET

• Cannabis-Related Guidance Provided by the CPSO

  General guidance

  Physicians should be committed to lifelong learning and are responsible for maintaining the medical knowledge and clinical skills necessary to provide the highest possible quality care to patients. This includes responding to emerging practice issues, such as cannabis.

  Medical cannabis: for physicians who do not wish to prescribe

  Obligation to prescribe

  • Physicians are not obligated to prescribe cannabis if it is outside of their clinical competence, or if they do not believe it is clinically appropriate for the patient.

  
  

  Obligation to refer

  • Physicians are not obligated to refer patients to prescribing physicians where they do not believe that cannabis is clinically appropriate for the patient.

  
  

  Ending the physician-patient relationship

  • Physicians must not end the physician-patient relationship solely because a patient requests medical cannabis, or elects to consume cannabis for either medical or recreational purposes.

  
  

  Medical cannabis: for physicians who are willing to prescribe

  Assessing the appropriateness of cannabis as a treatment option

  • Physicians are expected to weigh evidence and consider risks when assessing the appropriateness of cannabis for their patients.
  • Prescription of cannabis to patients under the age of 25 is restricted, unless all other therapeutic options have failed to alleviate the patient’s symptoms. Even where other therapeutic options have failed, physicians must still be satisfied that the anticipated benefit of cannabis outweighs its risk of harm.

  
  

  Prescribing

  • Physicians must obtain informed consent and advise patients of the material risks and benefits, effects and interactions, material side-effects, contraindications, precautions, and any other information pertinent to the use of cannabis. As part of this discussion, physicians must caution all patients who engage in activities that require mental alertness that they may become impaired, such as driving.
  • It is recommended that physicians start treatment with a low quantity of cannabis that is low in the psychoactive compound delta-9-tetrahydrocannabinol (THC).
  • It is recommended that physicians implement office policies and/or practices around prescribing cannabis, including the use of written treatment agreements.

  
  

  Telemedicine and eClinics

  • Physicians must use their professional judgment to determine whether telemedicine is appropriate in a particular circumstance each and every time its use is contemplated for patient care, consultations, and referrals. In doing so, physicians must consider whether practising telemedicine will enable them to satisfy all relevant and applicable legal and professional obligations, and meet the standard of care.

  
  

  Fees

  • The College considers the medical document authorizing patient access to cannabis to be equivalent to a prescription. As prescriptions—together with activities related to prescriptions—are insured services, physicians are prohibited from charging fees to either the patient or to a licensed producer for completing the medical document, or for any activities related to completing the medical document (e.g. the patient assessment or counselling).

  
  

  Ongoing monitoring

  • As with any drug, physicians must monitor patients for emerging risks or complications, and discontinue prescribing where cannabis fails to meet the physician’s therapeutic goals, or the risks outweigh the benefits.

  
  

  Relevant Policies

  • Policy Statement: Cannabis for Medical Purposes
  • Policy Statement: Prescribing Drugs
  • Policy Statement: Ending the Physician-Patient Relationship
  • Policy Statement: Telemedicine

  
  

  Note from the OMA

  As noted above, there is no obligation to refer when you:

  1. have the relevant medical knowledge to consider cannabis as a therapeutic option
  2. have assessed the patient, and
  3. have deemed medical cannabis unsuitable for the patient

  
  

  If you are unfamiliar with the use or management of medical cannabis, or are opposed to considering cannabis as a medical treatment, consider referring your patient to a physician knowledgeable in the area for assessment. Documentation of all decisions and rationale is recommended.

• Note on Involvement in the Cannabis Industry and Crossing the U.S. Border

  • The sale, possession, production and distribution of cannabis remain illegal under U.S. federal law.
  • Canadian citizens who work, or are involved in the legal cannabis industry may travel to the U.S. as long as the reasons for travel are not related to the cannabis industry.
  • It is at the discretion of the individual border guard to ask questions and to prohibit entry to the US.⁸

• Billing Guidance

  As described in the CPSO policy on Cannabis for Medical Purposes, patients and licensed producers must not be charged for completion of forms or documents related to patient access/prescription of cannabis. These services are considered a constituent element of the associated insured service rendered to the patient.

  The OHIP Schedule of Benefits for Physicians (“Schedule”) does not list specific fee codes for physician services resulting in the prescription of cannabis for medical purposes. Physicians should bill OHIP the fee code that best represents the service rendered (e.g., assessment, counselling, etc.)