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Kris Negley, APRN, CNSJeanne Voll, APRN, CNS

Clinical Nurse Specialists

CNS Role in Creating Processes for Patient Use of Medical Cannabis in Hospital and

Ambulatory Care Areas

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Objectives:Upon completion of this program, participants will be able to:• Describe Minnesota's Medical Cannabis

Program• Describe impact of program on nursing

practice• Describe how the CNS functioned within the

spheres of influence to implement the medical cannabis program in a large healthcare system

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In The News . . .

CEOs of Minnesota's Medical Marijuana Companies Discuss the State's Program

Is It Time for Minnesota to Legalize Pot for Recreational Use?

Medical Marijuana Dispensaries Open

for Minnesota Patients Medical Marijuana Manufacturers Hope to Erase Stigma of Drug

More Than 100 Health Providers

Sign On to Medical Marijuana

Program in First Week

Survey: Minnesota Doctors Taking Wait-And-See

Approach to Medical Marijuana

Patients Share Tales from First Months of Medical Marijuana

Three Months In, Cannabis Users Complain of

High Costs, Difficult Access

Rochester Family Sees

Results

From Medical Marijuana

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June 1, 2015

www.patientsoutoftime.org

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Minnesota Medical Cannabis Program Overview

Want to learn more: Minnesota Department of Health website on Medical Cannabis

Qualifying Conditions for Certification• Cancer associated with severe/chronic pain, nausea or severe

vomiting, or cachexia or severe wasting

• Glaucoma

• HIV/AIDS

• Tourette Syndrome

• Amyotrophic Lateral Sclerosis (ALS)

• Seizures, including those characteristic of epilepsy

• Severe and persistent muscle spasms, including those characteristic of multiple sclerosis

• Crohn’s Disease

• Terminal illness, with a life expectancy of less than one year, if the illness or treatment produces severe/chronic pain, nausea or severe vomiting,cachexia or severe wasting

Program Requirements and Limits• Health Care Practitioners may register and certify patients

with qualifying conditions. – Physicians, Physician Assistants, Advanced Practice Registered

Nurses with MN license and DEA number. – Providers are not required to participate in the program– Maintain a medical relationship with the patient

• Patient must be a Minnesota resident. – Patient provides evidence of residency to state during their on

line registration. – Patient may have a parent/legal guardian/designated caregiver

registered in the program to assist with medical cannabis product procurement and administration.

• Certification is good for one year– Annual enrollment fee

• Out of pocket expense—no insurance coverage

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Program Requirements and Limits

• Minnesota Medical Cannabis products limited to oral capsule, oral tincture, oral oil, vaporized oil (non-smokable)

Minnesota’s program very regulated; most states give leaves, buds or plants

Medical Cannabis products are manufactured by two approved manufacturers and distributed in quantities of 30 day supply to patients through the eight approved Cannabis Patient Centers.

Health care practitioners do not write a prescription nor determine product selection or dosing. Product selection and dosing is managed by a Pharmacist at the Cannabis Patient Center.

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Cannabis Centers• Two approved manufacturers in state

Leafline Labs Minnesota Medical Solutions

• Eight approved dispensaries Hibbing, Moorhead, St. Cloud,

Minneapolis, St. Paul, Eden Prairie, Rochester

3 Step Patient Process

1. Certify: • A health care practitioner certifies the patient’s condition.2. Register:• Minnesota Department of Health's Office of Medical

Cannabis (OMC) will contact the patient (and applicable the patient’s parent/legal guardian/ designated caregiver) via email communication to complete the registration process.

• After completion of the registration process the patient and parent/legal guardian/designated caregiver will receive notification from the OMC of their registration approval or denial.

3. Receive:• If approved the patient presents to the Cannabis Patient

Centers with registration approval, current medication list, and visit summary.

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THC—CBD ratios• THC=delta 9tetrahydrocannabinol

Marijuana’s main mind altering ingredient

HIV/AIDs, nausea, cachexia, pain• CBD=cannabidiol

No mind altering effects Epilepsy/seizures, inflammatory

conditions• THC/CBD

Muscle spasms, Crohn’s disease• Pharmacist at the cannabis patient centers

will determine ratio, formulation, and dose

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THC-CBD ratios• http://leaflinelabs.com/our-medicine/

• http://www.minnesotamedicalsolutions.com/our-medicines/

©2013 MFMER | 13www.blogs.mprnews.org

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OilsTincturesCapsulesVaporizers

mprnews.org minnesotamedicalsolutions.com

minnesotamedicalsolutions.com

minnesota.cbslocal.com

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Inpatient Use of MN Medical Cannabis at Mayo Clinic Rochester• Multidisciplinary team developed

policy/procedures• May only be used

Through the Minnesota Medical Cannabis program (medical cannabis from other states cannot be used)

FDA approved compassionate use/expanded access program

IRB approved study• Use of patient’s own supply of cannabis

Vaporized products may not be used in clinics/hospitals due to MN Clean Air Act

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Inpatient Use of MN Medical Cannabis at Mayo Clinic Rochester• Medication Reconciliation• Provider Order of Medical Cannabis

Product dosage form, strength, dose, frequency, indication, use of patient’s own supply

• Dosing regimen cannot be changed or altered during hospital stay

• Primary service may choose to hold use during hospitalization as clinically appropriate

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Inpatient Use of MN Medical Cannabis at Mayo Clinic Rochester• Pharmacist verification

Reviews product to verify identity and pharmaceutical integrity

• Storage and Inventory Nurse obtains cannabis and signs it in and stores

in locked controlled substance cabinet Nursing verification/witness required for initial

product received, shift inventory count, any wasting of product or returning to patient upon dismissal

• Documentation in medical record with each dose administered

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Outpatient Use of MN Medical Cannabis at Mayo Clinic Rochester

Principles• Provide a process as consistent as possible

to our standard medication use processes • Treat like other controlled substances

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Outpatient Use of MN Medical Cannabis at Mayo Clinic Rochester

• Include in medication reconciliation• The patient or their designated caregiver is

responsible for provision, storage, preparation, and administration of the medical cannabis within the ambulatory clinic setting, during hospital outpatient visits, Emergency Department visits.

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Telehealth Considerations

• Allied Health Staff provided with education • Direct patient inquires to:

MDH Medical Cannabis web site at http://www.health.state.mn.us/topics/cannabis/

Patient’s Provider – “Is my Doctor/NP/CNS/PA certifying?”

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Patient/Client Sphere• The primary value of Mayo Clinic is the needs

of the patient come first

Forever Caring

By:Gloria Tew

Photo used with permission: MAUD

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Nurses and Nursing Practice Sphere

• Considerations when determining nurse’s role with administration of medical cannabis. Federal Law Minnesota Law Consideration of current medication

practices

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Federal Law

• US Department of Justice Memorandum dated February 27, 2015 states those entities following individual state law are not in jeopardy of prosecution

• Budget Bill states no monies can be utilized by the Department of Justice to prosecute those persons following their state’s medical cannabis laws

• The Joint Commission

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Minnesota Law

• On May 18, 2015 legislature passed a bill containing the inclusive language for hospitals and hospital staff to accommodate patients who participate in the Minnesota medical cannabis program and will continue their therapy if hospitalized

• Consulted with Minnesota Board of Nursing

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Minnesota Law

• What is certifying provider’s responsibility?

• What is nursing’s responsibility?• What is pharmacy’s role?

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Consideration of Current Medication Practices

• Treat like other controlled substances• Treat like other situations in which patient

provides their own “medication”

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Organization/Systems Sphere

• Determined how to implement new nursing practice across the System/Organizational

• Served as consultants for health system locations as they developed their procedure statements Policy statements developed for state

of Minnesota Mayo Clinic Health System and

Rochester, MN developed their own procedure statements

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In The News…

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http://www.health.state.mn.us/topics/cannabis/about/stats.html

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Resources• Medical Cannabis  Special Issue: Minnesota Medicine Supplement

5-2015  

• The Minnesota Department of Health Medical Cannabis Web site has links to the following Medical Cannabis Clinical Information Resources

• A Review of Medical Cannabis Studies relating to Chemical Compositions and Dosages for Qualifying Medical Conditions:  MN Office of Medical Cannabis 12-2014.

• Information for Health Care Professionals: Cannabis and the Cannabinoids:  Health Canada 2-2013.  

• Sativex® product monograph 3-2015.  Canadian product monograph provides information roughly equivalent to an FDA label information in the United States.

• Complete web site listing of MN Department of Health Medical Cannabis Clinical Information Resources

• Minnesota Medical Solutions: http://minnesotamedicalsolutions.com/

• Leafline Labs:  http://leaflinelabs.com/