Minimum Practice Standard for Medical Cannabis Recommendation/Approval

for Compliance with the California Compassionate Use Act of 1996.

Portions of this page are extracted from Fred Gardner's March 2004, piece, published in the Anderson Valley Advertiser:

CMA Takes A Step Forward (Maybe)

Delegates to the California Medical Association's annual meeting, held at the San Francisco Hilton March 21-25, agreed to seek clear guidelines from the state Medical Board regarding the recommendation and approval of  cannabis use by patients.  A proposal for "minimum practice standards" was  introduced by Tod Mikuriya, MD, and supported by Frank Lucido, MD, in  remarks to the CMA's Science and Public Health Reference Committee. R. Stephen Ellis, MD, of San Francisco also spoke in favor of Mikuriya's resolution, which read:

1. The initial examination is face-to-face, in person, confidential, and live.  (Periodic follow-up may be via video, photographic, telephonic, or email means.)
2. The examination is memorialized with elements of the patient's name, sex, birthdate, address, phone number, date of examination, and coded diagnoses.
3. There is documentation supporting the diagnoses.
4. Compliance with HIPAA [the Health Insurance Portability and Accountability Act] where required.

Opposition came from two CMA members who reiterated the medical establishment's party line: "There are potentially legitimate medical applications for these cannabinoids. However, we… cannot support smoking marijuana because of other health effects on the lung."

Mikuriya had proposed a second resolution: "That CMA urge the Medical Board of California to cease harassing physicians and comply with the recent federal injunctive decision protecting physicians who recommend and approve medical marijuana…"

The reference to harassment drew a sharp retort from Ronald L. Morton, MD, a CMA delegate who also serves on the Medical Board. "I disagree with resolution two because it is not factually accurate," said Morton. "I sit on the MQ [Medical Quality] panel and I read the cases that come across. Some examples, rather than persecution, represent people that are offering no examination, have no equipment -just a receipt book- and are charging $250 for a recommendation. I don't think that's what we think is good medicine." Morton was wearing a shirt with a camouflage pattern -"in support of the troops," he said-  and made a crack about "the sideshow that the people of San Francisco have put on for us."  But he explicitly supported the call for minimum practice standards. "I agree with resolution one.  I think it is helpful to set standards."

A San Francisco physician named ... [Webmaster's note: ... indicates the physicians request for anonymity] introduced a "friendly amendment" to the original resolutions, which he steered through the reference committee (after Mikuriya and his colleagues had departed).  The end result read as follows:

"Resolved: that the CMA urge the Medical Board to revise its guidelines regarding medical marijuana so that the guidelines include the requirements for a good faith exam with diagnosis, treatment and follow-up recommendations, and more fully clarify and affirm the legitimate role of physicians in recommending marijuana to appropriate patients, "and be it further resolved: that the CMA urge the Medical Board to apply clinically appropriate standards of care to all physicians, and not to apply a higher standard of care or to require a higher degree of evidence in cases where medical marijuana is involved.

"Reasons for substitution: Committee believes that the author has identified a significant problem and that physicians who recommend marijuana who have an appropriate physician-patient relationship should be judged by the same standards of care as those physicians recommending any other form of treatment."

This version passed the full House of Delegates on the "consent calendar" (meaning the reference committee didn't consider it controversial enough to warrant further discussion).  Although it wasn't the unambiguous set of standards he was seeking, Mikuriya called the vote a significant step in the right direction. "Last time I attended a CMA convention was in 1996, and I was all alone in supporting Prop 215, which they refused to endorse.  This time I had numerous allies and there's a clear sense among my colleagues that, in order to implement the Compassionate Use Act, the Medical Board has to issue simple, unambiguous practice standards."

Mikuriya is one of several physicians who have sanctioned cannabis use by a large number of patients and is being investigated by the Medical Board. None of the complaints against him or any of his colleagues comes from a patient or the loved one or caregiver of a patient; all were filed by law enforcement officers. Nor do any of the complaints allege that a given patient was harmed by using cannabis, only that the recommendation seemed unwarranted.

Stephen Ellis was less optimistic about the CMA's ability to influence the Medical Board, pointing out that "the 'good faith exam' bit... is woefully lacking in concrete specifics as far as legal definitions go." 

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