Assessing Delawarean Physicians' Perspectives and Knowledge ...

Assessing Delawarean Physicians' Perspectives and Knowledge ...

Assessing Delawarean Physicians Perspectives and Knowledge of Medical Marijuana Barret Michalec, PhD; Laura Rapp, PhD; Tanya Whittle, MA Center for Drug and Health Studies, University of Delaware Fall 2015 Symposium Overview of Presentati on 1.Background on Delawares Medical Marijuana Program 2.Findings from CDHS survey on Physician Perspective and Knowledge 3.Future Directions for Research and Collaboration Delaware Medical Marijuana Act WHAT DOES THE ACT SAY? Signed into law by Gov. Jack Markell on May 13, 2011. Patients 18 and older with certain debilitating conditions may possess up to six ounces of marijuana with a doctor's written recommendation. WHO ARE THE PLAYERS? The Division of Public Healths (DPH) Health Systems Protection Section (HSP) is responsible for the policy development and operation of the Medical Marijuana Program (MMP). The HSPs Office of Medical Marijuana (OMM) initiated activities, such as issuing the RFP for the compassion center and oversees operations.

First State Compassion Center was awarded the contract and has a dispensary location in Wilmington, DE. Timeline of Major Events July 2011: Delaware Medical Marijuana Act took effect July 2012: Registry Card Program began receiving applications February 2012: Compassion Centers put on hold September 2012: 1st patient card issued August 2013: Program Relaunched December 2013: RFP is published August 2014: DHSS and First State Compassion Center ratified contract June 2015: Compassion Center Opens in Wilmington Qualifying Debilitating Medical Conditions THE FOLLOWING MEDICAL CONDITIONS OR TREATMENT OF THESE CONDITIONS: A CHRONIC OR DEBILITATING DISEASE, MEDICAL CONDITION, OR ITS TREATMENT THAT PRODUCES ONE OR MORE OF THE FOLLOWING: Cancer Cachexia or wasting syndrome Positive status for human immunodeficiency virus (HIV) Severe, debilitating pain that has not responded to previously prescribed medication or surgical measures for more than three months or for which other treatment options produced serious side effects Acquired immune deficiency syndrome (AIDS)

Decompensated cirrhosis (hepatitis C) Amyotrophic lateral sclerosis (ALS or Lou Gehrigs Disease) Post-traumatic stress disorder (PTSD) Agitation of Alzheimers disease Intractable nausea Seizures Sever and persistent muscle spasms, including but not limited to those characteristic of multiple sclerosis Changes & Additions in 2015 In 2015, additional changes were made to the Act: Inclusion of Autism with Self-Injurious Behavior was recently added to the list Testing and research of medical marijuana Senate Bill 138, Signed 7/27/2015 Access for minors to medical marijuana oils (cannabidiol oil and THC-A oil) specific conditions Rylies Law (epilepsy or dystonia) Senate Bill 90, Signed 6/23/2015 Inaugural meeting of the Oversight Committee Senate Bill 7, signed 4/21/2015 Inaugural Meeting October 27, 2015 Procedure to Access MMP FOR PATIENTS: Patient must have a State of Delaware driver's license or ID, be 18 or older Be under care of a Delaware licensed physician Possesses a physicians certification indicating a qualifying debilitating medical condition Patient must fill out and submit an application Patient gives permission for the MMP to contact the physician to verify credentials and patient-doctor relationship

If approved by the State, patient will be issues a registry card Must renew annually FOR PHYSICIANS: The Physician does not write a prescription nor need to meet any special criteria to participate in the program Physician has to be licensed in Delaware The physician must have a bona fide relationship with the patient and care for the patients qualifying condition N umber of Cards Issued MMP Cards Issued by State Fiscal Month & Year FY13 FY14 FY15 FY17 100 80 60 40 20 0 July August September

October November December January February March April May June Months of the State Fiscal Year Information Presented at Medical Marijuana Act Oversight Committee Meeting First State Compassion Center FSCC Available Products Information Presented at Medical Marijuana Act Oversight Committee Meeting Current Active Patients by Debilitating Condition 400 350 300 250 200

399 150 100 50 190 74 21 0 S er D c I n a /A C V HI 33 p He C 4 S AL e zl h A

2 's er im PT 18 SD he c Ca 25 xia Se 52 re e v in a P ea s u Na 28 s es m r

as zu i p S Se lc e us M Information Presented at Medical Marijuana Act Oversight Committee Meeting Active Patients by County, Gender and Age NCC 402 67% Male 335 55.74% KC 87 14.48% SC 112 18.64% 50-69 293 49.08% Female 266

44% 30-49 231 38.69% 18-29 42 7% 70-100 31 5.19% Information Presented at Medical Marijuana Act Oversight Committee Meeting Existing Literature on Physicians and Medical Marijuana Few studies focus on physicians Physicians serve as gatekeepers to MMJ access Confusion/Uncertainty among physicians Efficacy Rigor of clinical research Standardization of concepts Legality Potentiality/Probability for abuse Survey Methods and Sample The Delaware Medical Journal (November 2014)

87 respondents Questions Demographics Likert scale Open-ended follow-up questions DE Physicians Knowledge of MEDICAL MARIJUANAS USE AS A TREATMENT 3.79% DELAWARES MEDICAL MARIJUANA ACT 7.39% 8.78% 16.27% 34.93% Little/No Knowledge Minimal Knowledge Somewhat Knowledgeable Knowledgeable Very knowledgeable 9.89% 20.98% 23.48% 36.23% 38.26% Delaware Physicians SelfReported LIKELINESS TO AUTHORIZE MEDICAL

MARIJUANA USE 17.74% 33.27% 16.33% 16.33% Very Unlikey Likely 16.33% Unlikely Very Likely Possibly MOST FREQUENTLY CITED SOURCES TO INFORM SELF ABOUT MEDICAL MARIJUANA 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% M 72.4% 52.9% 43.5%

l ca i ed r iL te ur at e u ct e L nd a s re m Se s ar in w Ne sM ia ed

TABLE 1: Most Frequently Reported Category (and %s) for Knowledge of Medical Marijuana, Likelihood to Authorize, & Sources of Information by Age, Years of Practice, & Specialty Grouping GROUP (n) KNOWLEDGE ABOUT MEDICAL MARIJUANA KNOWLEDGE ABOUT DE MEDICAL MARIJUANA ACT LIKELIHOOD TO AUTHORIZE SOURCES OF INFORMATION* 25-35 (2) Minimal Knowledge (50%), Knowledgeable (50%) Minimal Knowledge (50%), Knowledgeable (50%) Very Unlikely (50%), Possibly (50%) Medical literature (50%), News Media (50%), Other Physicians (50%), lecture/Seminars (50%), DHSS (50%) 36-45 (14) Knowledgeable (46.2%)

Somewhat Knowledgeable (38.5%) Very Unlikely (33.3%) Medical literature (64.3%) 46-55 (19) Somewhat Knowledgeable (37.5%) Somewhat Knowledgeable (56.3%) Very Unlikely (42.9%) Medical literature (73.7%) 56-65 (32) Somewhat Knowledgeable (43.3%) Knowledgeable (30%) Very Unlikely (25%), Possibly (25%) Medical literature (75%) 66+ (19) Knowledgeable (38.9%) Somewhat Knowledgeable

(42.1%) Very Unlikely (41.2%) Lectures/Seminars (73.7%) 1-10 (9) Knowledgeable (62.5%) Knowledgeable (37.5%) Very Unlikely (25%), Possibly (25%), Very likely (25%) Lectures/Seminars (66.7%) 11-20 (19) Somewhat Knowledgeable (44.4%) Somewhat Knowledgeable (50%) Very Unlikely (46.7%) Medical literature (78.9%) 21-30 (25) Somewhat Knowledgeable (45.5%) Somewhat Knowledgeable (39.1%)

Very Unlikely (28.6%) Medical literature (76%) 31-40 (27) Somewhat Knowledgeable (44%) Minimal Knowledge (32%), Knowledgeable (32%) Very Unlikely (26.1%), Likely (26.1%) Medical literature (77.8%) 41+ (7) Knowledgeable (71.4%) Somewhat Knowledgeable (42.9%) Very Unlikely (57.1%) Lecture/Seminars (100%) *Respondents were able to select more than one Source of Information. TABLE 1 (Cont.): Most Frequently Reported Category (and %s) for Knowledge of Medical Marijuana, Likelihood to Authorize, & Sources of Information by Age, Years of Practice, & Specialty Grouping GROUP (n) KNOWLEDGE ABOUT

MEDICAL MARIJUANA KNOWLEDGE ABOUT DE MEDICAL MARIJUANA ACT LIKELIHOOD TO AUTHORIZE SOURCES OF INFORMATION* Specialties Likely to Encounter (22) Knowledgeable (40.9%) Somewhat Knowledgeable (50%) Very Unlikely (38.9%) Medical literature (90.9%) Specialties Unlikely to Encounter (17) Somewhat Knowledgeable (41.7%) Somewhat Knowledgeable (46.2%) Very Unlikely (40%) Medical literature (58.8%)

Primary Care / Generalists (37) Somewhat Knowledgeable (40%) Minimal Knowledge (31.4%) Very Unlikely (34.3%) Medical literature (64.9%) Medical literature (100%) Medical literature (66.7%) Emerg. Med (4) Knowledgeable (50%) Somewhat Knowledgeable (75%) Very Unlikely (25%), Unlikely (25%), Possibly (25%), likely (25%) Pediatricians (6) Knowledgeable (50%) Knowledgeable (50%) Possibly (33.3%), Very likely (33.3%)

*Respondents were able to select more than one Source of Information. TABLE 2: Frequency of Categorized Responses DOMAIN Comfort with Authorizing (WOULD NOT) CATEGORY FREQ. PARTICIPANTS STATEMENTS Lack of knowledge 18 Not comfortable with prescribing something about which I have virtually no knowledge. would need to know more about law and indications. I would not consider myself knowledgeable enough about the medication to prescribe or educate patients. Not prescriber/Unlikely to see patients 13 Not a prescribing care giver. I typically do not treat any patients with those disease. Unlikely to see patients in this stage of illness. Potential for

abuse/misuse When other Rx fail 8 Liberalizing its use will only open the door to more serious drug abuse! Increased odds of being abused and shared with someone else. I have already had an incident where the patient suffered from one of the listed ailments and their caregiver wanted to sign that they indeed had this ailment. It was obvious to me that the caregiver actually wanted it for themselves and the patient was not interest in it. I cannot imagine myself giving or facilitating a prescription to smoke. 18 As a hospice physician, I am certain to run into patients with the qualifying conditions whose symptoms are not being relieved with more standard therapies. at that point, I am OK with a pt trying medical marijuana. I often care for patients with chronic cancer pain or other chronic pain syndromes for which I feel they may ultimately benefit from medical marijuana, if other treatments have failed or have been maximized. I see patients with diseases that I do not have a treatment for. If there is research suggesting that Med Marijuana may be effective for these patients I am likely to offer that as a treatment option. 16 These are serious, chronic diseases, many that are fatal. These are legitimate reasons for marijuana usage and humane. There is no question in my mind that marijuana is beneficial for patients which chronic/ debilitating illnesses. It should be should be administered via a vaporizer as a supplement to other medication. Indeed, it would probably be more effective, less expensive, and less addicting than the more traditional medications. For the right patient, medical marijuana can provide relief from pain. Patients should be given an alternative to the usual medications presently available. Comfort with

Authorizing (WOULD) Effectiveness/Benefits/ Humane treatment TABLE 2 (Cont.): Frequency of Categorized Responses DOMAIN CATEGORY FREQ. Potential for abuse/misuse /diversion Specific Concerns with Authorizing Helpful to Learn More 25 Legality issues (for patient and provider) 8 Lack of standardization (quantity & quality) 7 Education: Courses (online and CMEsponsored), seminars, lectures, pamphlets,

reviews of DE law Clinical/Empirical research PARTICIPANTS STATEMENTS My concern would be that people, other than the intended person, would use the drug. It should not be used for recreational purposes. As with any other controlled substance, diversion is an area to be aware of. Patients coming in requesting medical marijuana for abuse purposes under the guise of vague conditions like intractable nausea that I cannot prove is occurring. Legal related to state and federal prosecution for supplier and pt. Concern is what can the patient do if questioned by police. Marijuana is still illegal in the United States of America, of which Delaware remains a part. The DEA a federal agency, gives us our licenses to prescribe controlled substances. Marijuana is still considered a category one narcotic, meaning there is no legitimate medical use. Thus, I am concerned that recommending a schedule one narcotic to my patients, could in theory, put my DEA license at risk and possibly subject me to federal criminal sanctions. How to ensure that the marijuana isnt tainted. How to rate ones response to it. How to quantify usage. Will not authorize. No standard dosing. It is a mind altering substance, and the quality control varies from batch to batch. 27 Concise written educational material. Online course sponsored by the State and MSD. A review of the law, as to how the dispensaries will work, how patients will be able to fill and refill, rX limits, and a review of the literature about medical marijuana. 12 Clinical studies indicating effectiveness, rage of use as a treatment modality. Well-designed studies to show safety and efficacy and give dosing and strain information. More independent research on the effects of Med marijuana in specific disease states.

Conclusions Majority of participating physicians feel less than knowledgeable about medical marijuana as a treatment option and know even less about DEs medical marijuana law Only about participants would possibly consider authorizing patients to attain medical marijuana Not imperative to increase # of physicians likely to authorize BUT if State says medical marijuana is legitimate treatment option then it is problematic/detrimental that those will the ability to authorize lack knowledge and are even unwilling to consider it Participants cited Lack of Knowledge and Potential for Abuse/Misuse/Diversion as the most significant concerns regarding authorizing patients Literature concerning potential abuse and diversion is somewhat mixed grey area of research, no black/white or yes/no response Increasing, enhancing, and maintaining knowledge of medical marijuana and state-specific medical marijuana laws is a promising and manageable directive Hindered by the current FDA classification of marijuana as a Schedule I substance Imperative that state governments and medical organizations (e.g., AMA) offer providers and patients educational programs to increase awareness of and adherence to policy guidelines Future Directions Lack of Research Most on potential adverse social effects/consequences (esp. with youth/adolescents) of enacted medical marijuana laws Increase in use Connections with alcohol Other risk factors What is lacking: Effective Strain-Symptom (Ingestion Method) Matching Patient Goals Patient Activity (i.e., purchasing patterns and preferences) Patients Perceptions of FSCC

Patients Perceptions of DE Medical Marijuana Program Next Steps: Proposal A Study of Patients Goals, Practices, and Perceptions Regarding Medical Marijuana Work with DHSS, FSCC, DE Medical Marijuana Oversight Committee, and Delaware Patient Network Develop/Administer Survey to authorized patients Use with current FSCC Patient Profile information and Inventory Tracking Software Use with DHSS Request for Authorization forms Interviews with sub-sample of patients Interviews with FSCC staff Next Steps Based in-part on our data DHSS 2 training sessions: DE Med Society & Bay Health Follow-up with DE Physicians in 6-12months Use data from collaboration with DHSS & FSCC to: Bridge gap(s) between DHSS, FSCC, Patients DHSS acknowledges gaps and putting forth efforts to bridge divides Seek federal funding* for more robust study/assessment on Patient practices/perceptions Various aspects of Compassion Center Health outcomes related to medical marijuana use Overlap geocoding: med marijuana use/availability, Rx drug use (PMP), alcohol Assist in the planning, development, and implementation of future DE Compassion Centers Assist in further development of Medical Marijuana law in DE

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