PREPARED BY CAROLINE FERRIS, MD, CCFP, FCFP

FOR THE CANADIAN CONSORTIUM FOR INVESTIGATION OF CANNABINOIDS, JUNE 2009

SECTION 1: THE MMAR PROGRAM
WHAT IS THE MMAR PROGRAM?

The Medical Marijuana Access Regulations provide for the legal possession and growing of marijuana (cannabis) for patients who find it beneficial for relief of various symptoms. It is a program administered by Health Canada, and has been in existence since 1999.

BUT ISN’T CANNABIS A DRUG OF ABUSE?
Many therapeutic medications have the potential for misuse and abuse, and cannabis is no exception. However, cannabis has been used by humans for thousands of years for the relief of pain and for other medical conditions. Tincture of cannabis was a standard in the pharmacopoeia until the early 20th century (as was tincture of opium), until politics pushed cannabis out of pharmacies and onto the streets. Today, approximately 4500 Canadians have obtained a Health Canada license to use medical cannabis, and there are thousands more who are using it for medicinal purposes despite not being licensed.

IS THERE ANY EVIDENCE THAT CANNABIS IS AN EFFECTIVE
MEDICATION?
Yes. Research on cannabinoids and the endocannabinoid system has exploded in recent years. Marijuana has shown efficacy for the nausea and anorexia associated with cancer chemotherapy and HIV chemotherapy, as well as for the pain associated with spinal cord injury, severe arthritis, and multiple sclerosis. Epilepsy and glaucoma are two other common diagnoses for which cannabis has shown benefit. Cannabis and its derivatives is part of the therapeutic armamentarium in palliative care. There are now three commerciallyavailable preparations derived from cannabis, produced by pharmaceutical companies.

SHOULDN’T I JUST PRESCRIBE THE COMMERCIAL PRODUCTS?
By all means, a trial of the commercially available preparations is advisable for selected patients, ie for those who can afford it, and certainly for those who do not wish to smoke cannabis but may benefit from alternate pain therapies. However, many patients are already using herbal cannabis with good benefit, and signing an MMAR for them protects them against legal difficulties. In addition, many people prefer to use herbal remedies rather than pharmaceuticals; according to the principles of herbal medicine the whole plant is more efficacious and better tolerated than the purified chemical constituents. Another consideration is cost: commercial products are a benefit under most provincial plans, but are still very expensive for those who do not have full coverage or extended benefits. It is much cheaper for patients to
grow their own medicine!

ISN’T MY COLLEGE AGAINST CANNABIS?
BC College of Physicians and Surgeons’ recommendation, as well as the CMPA position, is that physicians may prescribe marijuana if they feel comfortable with it. The MMAR forms are a confidential document between Health Canada, the physician and the patient. The information is not shared with the College or with the RCMP. No doctor has ever gone to court or faced prosecution for filling out a form or for prescribing medical cannabis.

ISN’T THE CMA AGAINST CANNABIS?
You may be recalling earlier statements by the Canadian Medical Association that cannabis has no proven medical benefits. However, in light of recent research, they modified this statement (in 2006) to recommend that doctors prescribe cannabis to appropriate patients if they feel qualified to do so. They do acknowledge that dose calculation may be a major stumbling block to physicians in this respect.

BUT HOW DO I KNOW MY PATIENT ISN’T JUST A POTHEAD?
As with any medication, the physician is in the best position to assess whether his patient has a legitimate medical diagnosis, and is attaining benefit from a given therapy. Ongoing assessment of benefit would be part of the process. In light of the new research and evidence, it would be uncompassionate to say the least to deny effective therapy to those suffering with chronic pain and other conditions, especially if standard therapies were not effective or tolerated.

SECTION 2: THE MMAR FORMS
Don’t be intimidated by the MMAR forms. They are really quite simple and the only ones you need to worry about are the B1 (for Category 1 patients) and the B2 (for Category 2 patients). The other forms are for the patient to fill out and you don’t even need to know about them (unless you’re interested, of course). Filling out the forms is not an insured service, and as always the decision to charge for them is at the discretion of the individual doctor.

B1 FORMS
This form may be filled out by a GP or a specialist. They are for patients with the following diagnoses: Multiple Sclerosis, Epilepsy, Spinal Cord injury or Spinal Cord disease, cancer, HIV/AIDS or severe arthritis. B1 forms may also be used for patients who are terminally ill, for compassionate end-of-life care, no matter what the diagnosis.

Part 1: Simplest just to use your office stamp with your name, licence number, address etc.
Part 2: Fill in the patient’s name, birthdate and phone number, and check the appropriate box for diagnosis-write in the diagnosis if the patient is terminally ill.
Part 3: Proposed Daily Amount
Calculating the dose can be done by determining how much the patient currently smokes. One could ask the patient how much they bought last time and how long that amount lasted; for example if they bought an ounce (approx. 30 grams) and it lasted a month that is one gram a day. An average cannabis cigarette ranges from 0.5 g to 1.0 g, so 3 cigarettes a day would weigh a maximum of 3 grams. Health Canada does allow up to 5 grams a day under most circumstances.

HIV patients tend to smoke more than that, and Health Canada may
allow up to 10 grams a day for these patients. Calculating the dose for oral ingestion is a little trickier. If the patient is using a standardized product, for example baked goods or encapsulated herb from a Compassion Club, try to find out what the standard dose is. For example, they may ingest a brownie containing 100 mg of THC 3 times a day for a total of 300 mg. Assuming the
plant contains 12.5% THC (the Health Canada standard), that would be 125 mg/gram, so 300 mg would be derived from 2.4 grams (300 mg divided by 125 mg/gram).

Of note, most “street” marijuana including that from compassion clubs
is in the 15-20% THC range so this should be considered when calculating dose. In addition, patients do develop a tolerance to THC, so a long-time user may well need the higher end of the dosing range. By the same token, a cannabis-naive user may only need a couple of puffs to get good analgesic effect, and should be cautious with baked goods in order to avoid an unpleasant experience. A good suggestion with the cannabis-naive patient who wishes to ingest oral cannabis preparations is to start low and go slow, for example to try 1/4 of a cookie or brownie to start, or 10 mg of standardized oral cannabis.

An additional note: the safety profile of marijuana is actually quite good; overdose may be unpleasant but never fatal and is virtuallyalways via the oral route of ingestion. Symptoms may include drowsiness, dizziness, nausea and sometimes vomiting.

Part 4: is usually not filled out unless the patient’s life expectancy is less than a year

Part 5: sign and date the form

B2 FORMS

The B2 form can be filled out by a specialist in a field appropriate to the patient’s medical condition, or by a general practitioner if the GP has consulted an appropriate specialist who is aware that marijuana is being considered as an alternative treatment.

Examples would include a gastroenterologist or ID specialist for HCVrelated anorexia and cachexia; a neurologist or physiatrist for dystonic syndromes or for neurogenic pain not related to spinal cord injury, or a psychiatrist for anxiety disorder or insomnia. It is important to note that the practitioner does not need to condone or agree with the patient’s use of marijuana for a given diagnosis. One simply has to state that they are aware that conventional treatments have not worked, and the patient is using or wishes to consider using marijuana as an alternative therapy.

Part 1: Office stamp
Part 2: Write the name of the medical condition and the symptoms (no
ticky boxes here)
Part 3: Same as for the B1 form
Part 5: sign and date

SECTION 3: Useful resources
Information on current research, indications etc:
Canadian Consortium for Investigation of Cannabinoids www.ccic.net
Information for Health Care Professionals, Health Canada website
www.hc-sc.gc.ca/dhp-mps/marihuana/index_e.html
CMPA Release form for Medical Practitioners
This form is to be signed by the patient to release the physician from
any liability arising from the application for MMAR or use of marijuana
https://www.cmpaacpm.ca/cmpapd04/docs/submissions_papers/pdf/com_release...