Article Figures & Data
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- Figure 1.
Certification process for patients in Pennsylvania to use medical cannabis.
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Theme Sub-Theme Illustrative Quote Training Quality Satisfactory (n = 12) “The course was some interviews with physicians going over kind of the pharmacokinetics of medical marijuana. I thought probably what was most helpful is like the clinical perspective of prescribing and just talking to patients about the principles of just going low and slow, combination of THC versus CBD and how those will be incorporated and how the dispensary pharmacists or physicians will talk about their symptoms and determine the ratio and how much to start with because it’s, unfortunately, still not a perfect science in terms of dosing. Talking with patients, we don’t prescribe a dose, but we prescribe a consultation there at the dispensary and then you will make a combination that’s going to fit your needs.” -#14 Unsatisfactory (n = 5) “The training, I thought was pretty bogus. It was about six hours, and I really didn’t learn much about cannabis, but learned more about the laws around cannabis.” -#1 “No. I actually took a four-hour course. Initially, there were only two vendors for the initial course, the four-hour certification course. I took one of the two and I walked away thinking, well, they really didn’t tell me a ton more than I already knew, and I’m really not sure that I’m ready to do this. So I actually went and took the other course as well. So I did two four-hour certification courses. And by the second one, I felt kind of much more confident.” -#11 Training Gaps Navigating the system (n = 10) “A lot of products in Pennsylvania really are extreme versions of cannabis products, meaning they’re going to induce a lot of intoxication. And I think there are very few medical conditions that might require certain concentrated products…If you have patients that are looking to use this as a legitimate medication and they are looking to avoid intoxication as much as possible, you need to be able to explain how to look at a menu and how to pick out products that are considered lower dosages, and again, medically appropriate.” -#10 “I really think the biggest thing is not knowing what to expect from a dispensary…” -#15 Practice set-up (n = 13) “Nobody came to me and said, ‘Hey, you should do this or we should structure it this way.’…So I just did it…I didn't really know what I was doing.” -#15 “Okay. So, the gate keeping part is an important part for people to learn. Maybe as part of thatcertification training processes, is learning the comfort to say no.” -#21 “But as far as certifying, I didn’t think that there was any resource available, aside from using my common sense and ingenuity…I can learn about some of the research that’s done in Canada and Sweden and Israel and all the other places, about the utility and the medical stuff. But as far as the practical conducting of my practice as a physician, there’s really nothing out there that I found.” -#22 “I think the gaps that would have been best addressed in that would have been, one, not even in the training thing, but like a supplement that says, ‘Here are your regulatory requirements when you certify somebody. Here are the things that you must document and must do. Check the PDMP. Document that they have whatever condition it is and that they can or cannot go to the dispensary themselves. Document their certification number.’ All of that stuff…Having just like a quick overview sheet of like, ‘These are the things you got to do.’”-#23 Evidence-based practices (n = 22) “Drug interactions would be somewhat helpful. I know there’s some of that. The one study, at least that I know of that looks at, I think nivolumab and medical cannabis, it’s not a great study, but it suggests that somebody who’s using cannabis and on nivolumab, that the efficacy is 35% less than it would be.” -#5 “I would like what I think a lot of us would, I’d like to see a lot more research showing me conclusively or reasonably conclusively for which conditions medical marijuana is helpful, for which ones it is not. And in cases where it is helpful, what components of medical marijuana? Is it a THC? Is a cannabidiol? Is it a combination, if so in what proportions…A lot of the research type questions I think would be very helpful so that can provide better care for people.” -#12 “It was too much basic science on like, ‘Here’s what the THC molecule does to the cannabinoid receptor, and here’s the cellular cascade.’ That doesn't help me. I need to know how do I fix someone’s nausea? How do I fix their pain? How do I help them eat more? How do I keep them be more alert? Those are the pertinent things that I think are really useful.” -#23 System-level issues Communication Issues Patients (n = 16) “So the problem is most of the people, the first real education in marijuana is when they talk with pharmacists in the dispensary, because everything else they’ve probably heard is phooey. Then they talk to these guys in the dispensary, they’re talking about the endocannabinoids and the terpenes and things like that, so it’s tough. It’s something from zero to a 100 and it takes a while.” -#4 “A lot of actually my folks will come in expecting that it's going to help them with their chronic pain and their PTSD and their depression and their anxiety and their sleep and their anger. And I have to tend to put the kibosh on that and say no. So I think there’s a lot of education that needs to be done. This is a tool that we use, like anything else.” -#6 “I think people are still getting sometimes inappropriate advice at the dispensary on occasion.” -#10 Dispensaries (n = 11) “…I'm always asking my patients exactly what are you taking. Take a picture of the label. What does it look like…That would be nice to just be able to log in and see exactly what did somebody get and what is that product…I know there's a wall, intentionally, between the certifier and the dispensary, and it's a pretty robust wall.” -#8 “I used to write all sorts of notes to the pharmacist in these certifications, and I don’t know that they’re really reading them or looking at them. And then the other real huge problem is that physicians have no access to the products that their patients are using.” -#10 “I’ve had several patients tell me that that's happening because the pharmacy, the dispensary, sorry, runs out of a certain strain. And then again, I’m not like privy to the ins and outs of how their supply chain works. But if they run out of a strain, what do they do? Do they go and try to purchase a similar strain? Do they just tell patients, ‘Well, you're out of luck. Here something that's not same.’” -#13 “I ask patients what happens, and they give me the information, but I would love to actually go in there and speak to a pharmacist. I also think it may not be a bad idea for me to have some capabilities, if not responsibilities, to educate patients about what I think would be good for them so when they go in they’re armed with medical information, and not just rely on a sales person's information.” -#16 “I want them to meet with a pharmacist, but I also want the pharmacist to be restricted to what I’m telling them and not be like, well patients say dry leaf works better because that's what they’ve smoked for the past 20 years so that’s they get. No, they have horrible CPOD, don’t inhale this stuff anymore, please.” -#21 Technical Issues (n = 18) “…there’s a lot of technical limitations that can be pretty frustrating for some of these patients who are elderly and are not really used to using computers…and the help desk is almost nonexistent.” -#2 “There’s issues with documentation, there’s issues with scheduling, there’s issues with the website itself.” -#3 “…I have a great admin that will actually go online for the patients when they were in-house and they would help them, sit right next to them. And now that COVID, we’re doing a hundred percent online and it makes it very difficult for our patients' population that does not have computers or is computer illiterate…I just had a patient today that has been trying to get renewed since June and finally got through. And so they have to deal with the state and the state's very difficult to get through to them.” -#7 “I mean, we have to explain to everyone ahead of time how to register with the health department, it’s not really intuitive. The website’s not great. It doesn’t explain in really detail how to put in all your information exactly the way it reads on your license in capital letters, including abbreviations. People didn’t know that. And so they would say ‘I tried and failed to register, and I called the health department and no one called me back.’ So that’s a huge problem, especially for our less computer literate people, but it has happened to young folks who are very computer literate as well. So I think really detailed information about how to register with the health department or a simpler way of doing it.” -#10 Legal and ethical issues (n = 10) “I would much rather have a situation where it was legal recreationally, and someone who wanted to use it to help treat their pain could do that on their own and not be in a situation where it feels like I'm giving them permission as their physician.” -#2 “…[T]he second big medical problem is my patients that are off of opioids and get admitted to the hospital. And the hospital says no marijuana. And they prefer opioids, which is, I think a really big moral dilemma for me. And it is a shame that we're doing that, but that's just, and I've talked to the CEOs and the lawyers of these hospitals. The lawyers say no, CMOs users say yes, but the lawyers win out.” -#7 “Most of the medical malpractice companies with whom I’ve spoken will exclude any liability that happens as a result of you prescribing medical marijuana. I have found a couple of brokers who are in touch with people who will underwrite policies exclusively for medical marijuana. They’re not terribly expensive. And truthfully, I have no idea what the liability is…But I think in talking with some other physicians, that’s also been a reason why some of them have not gotten certified.” -#12 “…It’s very similar to vanco per pharmacy where you’re just having a pharmacist manage it. I don’t want to write the prescription, I can’t even imagine what a prescription would look like. I’m sure it would look heinous. Nothing like what other meds look like. I’m glad I don’t have to dictate exactly what it is, but I think it's a very different dynamic from a physician standpoint in terms of what this looks like, and you don’t have that fine amount of control over the meds that are the illusion of a fine amount of control. Who knows what happens when still pick up meds…” -#21 “I always go through the legality of crossing state borders with it because some of the patients are from close to Ohio and traveling, flight, that kind of thing. But I don’t take too deep of a dive into the legality, other than telling them that it's a Schedule I substance and that there are federal rules about the use of marijuana, and that it's only valid in the state of Pennsylvania pretty much.” -#23 Practice Setup Approach within practice (n = 24) “I incorporate this as part of my patient panel care…This is a tool that we use, like anything else.” -#6 “So I’ve tried to restrict, for the most part, the patients that I see for certification to GI patients, so people with inflammatory bowel disease or Crohn’s disease…I try and stick within the GI timeframe because I do know the studies and literature on that.” -#7 “there was the option to become certified and my partner that I had joined was certified as well. So I took the opportunity and became certified to better serve my patients…Our patients are those who we are treating for active malignancy. So our practice has made a policy that we do not see patients outside of those who are receiving cancer care for us, for medical marijuana.” -#14 “When I got my certification through [training program], it also said not just who they are, but also through the state website, not to give much information to patient to leave it up to between them and the medical professional at the dispensary.” -#16 “…I thought, well, this is actually a nice side income as I enter retirement…So I decided to open my own little telemedicine thing. So I have a very small thing on my own, just in case. And basically, I just gave out cards at the local dispensary and did a couple of Google ads and that was it.” -#17 “Yeah, so we created some parameters around who we had certified that's a little bit different than what is I guess what anybody can do. So when we, as a practice, we had some concerns about certifying and our main concerns came around we didn’t want patients to come to us thinking that with the understanding that cannabis would be their only treatment for their cancer… And then, because the education around cannabis and cancer was really limited and that information is really limited, we decided a practice we would only certify patients with incurable malignancies who are either on treatment or who were in that transition to hospice care.” -#18 Insurance and payment (n = 19) “…For all patients it’s yearly, and then for any patient who is interested in seeing me more frequently, I certainly offer it, and say I’m available for them…but for the certification process it’s a year.” -#2 “…It’s usually billed under, I do put medical marijuana in there, and I haven’t gotten any rejects back yet, or any patient calling me upset that the bill didn’t get covered.” -#6 “Once they get the certification, they can go anywhere to get anybody to certify it. But if they want me to do it, they'll see me yearly.” -#8 “I got fee for service” -#11 “No, we don’t go through insurance. It’s strictly cash.” -#16 “…I called…the head from Pennsylvania. And she said I can do it based on the diagnosis code and insurance will cover the visit based on the diagnosis code.” -#19 “Insurance does not cover these visits. I know that insurance companies are sanctioned by the federal government, because they’re affordable, and the federal government considers marijuana legal. So I don’t mix insurance based visits with medical cannabis visits, because I don’t want it to be out of compliance. I understand that if the insurance company discovers that you’re certifying people and discussing medical marijuana, they can not only pull that money back that they paid you for that visit, but they can fine you. At least that’s the way it was when I first started. I don’t know if statutes and other new legislation has changed that situation, but I’m just separating them.” -#22 Tools and support (n = 13) “…Our nurse coordinator calls the patient ahead of time.” -#5 “I have a great admin that will actually go online for the patients when they were in-house and they would help them, sit right next to them. And now that COVID, we’re doing a hundred percent online and it makes it very difficult for our patients’ population that does not have computers or is computer illiterate.” -#7 “…We have a website that we created as well, called [Name]…It’s a great way to give patients information.” -#9 “I developed the questionnaire with [a colleague] and also an informational sheet that I designed that I give people that has some information about the major cannabinoids, and the different routes of delivery, and some tips on how to minimize intoxication with regards to product selection and dosing.” -#10 Mentorship (n = 22) “[A colleague] told me how she organized her things, and I just set it up that way and then made little amendments, and where other people in other departments also wanted to do it, I told them how we had set it up…” -#3 “I was in the first wave, and I didn’t reach out people in other states…” -#12 “I didn’t really know what I was doing and just to talk to someone and hear what other experiences in setting it up, and getting patients [would have been helpful].” -#15 Abbreviations: CBD, Cannabidiol; THC, delta-9-tetrahydrocannabinol; PDMP, Prescription drug monitoring program; PTSD, Post-traumatic stress disorder.
