©2013 MFMER | 1 Kris Negley, APRN, CNS Jeanne Voll, APRN, CNS Clinical Nurse Specialists CNS Role in Creating Processes for Patient Use of Medical Cannabis in Hospital and Ambulatory Care Areas

©2013 MFMER | 2 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

©2013 MFMER | 3 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

©2013 MFMER | 4 June 1,

©2013 MFMER | 5 Minnesota Medical Cannabis Program Overview Want to learn more: Minnesota Department of Health website on Medical CannabisMinnesota Department of Health website

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

©2013 MFMER | 8 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.

©2013 MFMER | 9 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 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.

©2013 MFMER | 11 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

©2013 MFMER | 12 THC-CBD ratios medicines/ medicines/

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©2013 MFMER | 14 OilsTincturesCapsulesVaporizers mprnews.org minnesotamedicalsolutions.com minnesota.cbslocal.com

©2013 MFMER | 15 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

©2013 MFMER | 16 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

©2013 MFMER | 17 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

©2013 MFMER | 18 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

©2013 MFMER | 19 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.

©2013 MFMER | 20 Telehealth Considerations Allied Health Staff provided with education Direct patient inquires to:  MDH Medical Cannabis web site at  Patient’s Provider – “Is my Doctor/NP/CNS/PA certifying?”

©2013 MFMER | 21 Patient/Client Sphere The primary value of Mayo Clinic is the needs of the patient come first Photo used with permission: MAUD

©2013 MFMER | 22 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

©2013 MFMER | 23 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

©2013 MFMER | 24 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

©2013 MFMER | 25 Minnesota Law What is certifying provider’s responsibility? What is nursing’s responsibility? What is pharmacy’s role?

©2013 MFMER | 26 Consideration of Current Medication Practices Treat like other controlled substances Treat like other situations in which patient provides their own “medication”

©2013 MFMER | 27 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

©2013 MFMER | 28 In The News…

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©2013 MFMER | 30 Resources Medical Cannabis Special Issue: Minnesota Medicine Supplement Medical Cannabis Special Issue: Minnesota Medicine Supplement The Minnesota Department of Health Medical Cannabis Web site has links to the following Medical Cannabis Clinical Information ResourcesMinnesota Department of Health Medical Cannabis Web site A Review of Medical Cannabis Studies relating to Chemical Compositions and Dosages for Qualifying Medical Conditions: MN Office of Medical Cannabis A Review of Medical Cannabis Studies relating to Chemical Compositions and Dosages for Qualifying Medical Conditions: MN Office of Medical Cannabis Information for Health Care Professionals: Cannabis and the Cannabinoids: Health Canada Information for Health Care Professionals: Cannabis and the Cannabinoids: Health Canada Sativex® product monograph Canadian product monograph provides information roughly equivalent to an FDA label information in the United States.Sativex® product monograph Complete web site listing of MN Department of Health Medical Cannabis Clinical Information ResourcesComplete web site listing of MN Department of Health Medical Cannabis Clinical Information Resources Minnesota Medical Solutions: Leafline Labs: