United States: Moving Toward A Standard Of Care For Medical Marijuana

The Medical Board of California has recently issued updated guidelines for physicians to avoid disciplinary action related to the recommendation of cannabis to their patients for medical purposes. The board explicitly states that these guidelines are not intended to mandate the standard of care, and that the board "recognizes that deviations from these guidelines may occur and may be appropriate depending upon the unique needs of individual patients." These guidelines, and similar guidelines by other states, however, serve as the foundation for an emerging standard of care for medical cannabis. In legal terms, the standard of care is how similarly qualified practitioners would have managed the patient's care under the same or similar circumstances. As medical cannabis becomes more widespread and accepted as a legitimate treatment by the medical community, a uniform standard is needed to ensure consistency of care and patient safety.

Along with close attention to medical documentation, essential components of the California guidelines include:

  • An established physician-patient relationship
  • Adequate medical evaluation
  • Informed consent
  • A treatment plan and ongoing monitoring.

The Physician-Patient Relationship and Patient Evaluation

The guidelines outline the key factors and considerations for assessing the appropriateness of a physician's recommendation of medical cannabis and require the establishment of a physician-patient relationship prior to the recommendation of cannabis. It is expected that the physician shall not recommend medical cannabis unless the physician is the patient's "attending physician," meaning that he or she has taken responsibility for an aspect of the medical care, treatment, diagnosis, counseling or referral of a patient. The board requires documentation of a patient's history and an initial medical examination that includes considerations such as the history of the patient's present illness, social history, past medical and surgical history, alcohol/substance abuse history, family history on addiction, psychotic disorders, mental illness, therapies with inadequate response and the diagnosis supporting a cannabis recommendation.

Qualifying Medical Conditions

Though the California Compassionate Use Act of 1996 names certain medical conditions for which cannabis may be useful (including cancer, anorexia, AIDS, chronic pain, spasticity, glaucoma, arthritis and migraine), physicians are not limited to those specific conditions. The guidelines acknowledge that there is currently "a paucity of evidence for the efficacy of cannabis in treating certain medical conditions," but that recommending cannabis for any medical condition is nevertheless "at the professional discretion of the physician acting within the standard of care." The physician's recommendation "should be evaluated in accordance with standards of practice as they evolve over time." In an attempt to provide additional guidance on this issue to physicians, the board suggests that "the physician should base his or her determination on the results of clinical trials, if available, medical literature and reports, or on the experience of that physician or other physicians, or on credible patient reports," and that in all cases, the physician must determine that the risk−benefit ratio of cannabis is as good or better than other treatment options.

An Informed and Shared Decision-Making Process

The California guidelines emphasize the importance of an informed and shared decision-making process between the doctor and patient, which requires the physician to advise the patient on the variability and lack of standardization with cannabis. A discussion is encouraged on the use of cannabis and the varying effects it may have on different individuals. Other considerations important to the informed decision-making process are the potential cognitive effects, risks of driving under the influence, unknown risks to pregnancy or breastfeeding, and parental consent for minors.

The Treatment Plan and Medical Monitoring

The guidelines further stress the importance of a written treatment agreement for each patient that outlines the patient's individualized objectives, measurable goals and an exit strategy for discontinuing cannabis if necessary. This written treatment plan must document that the physician has advised the patient on options other than cannabis, reached a determination that the individual may benefit from cannabis, advised of the potential risks and provided an authorization for a period no greater than 12 months. The board also looks for an actual authorization, attestation or recommendation for cannabis; instructions to the patient regarding cannabis use; the results of the patient's assessment and ongoing monitoring; and a signed treatment agreement with instructions on safekeeping and the federal and state legal implications of sharing the prescribed cannabis.

Specialized Assessment for Substance Abuse and Mental Health Disorders

For any patient with a history of substance abuse disorder or a co-occurring mental health disorder, specialized assessment and treatment may be necessary. The physician is encouraged to seek consultation, as needed, with pain management, mental health or addiction specialists. The guidelines emphasize that a determination should be made that cannabis use is not masking symptoms of another condition or that cannabis use will lead to the worsening of an underlying condition.

Physician Conflicts of Interest

California's Business & Professions Code makes it unlawful for a physician who recommends cannabis for a medical purpose to accept, solicit or offer any form of remuneration from/to a facility if the physician or his/her immediate family has a financial interest in that facility. It is considered unprofessional conduct for the physician to be employed by or enter into any other agreement with any person or entity dispensing cannabis for medical purposes.

Risk Management Recommendations for Physicians

Any physician or medical group considering recommending medical cannabis to patients in California should ask several important questions, including whether there is a policy that:

  • Requires a physician-patient relationship to have been established?
  • Requires a medical examination of the patient?
  • Requires discussion of the risks and benefits of the use of cannabis with the patient, or if the patient is a minor or without decision-making capacity, with the patient's parent or guardian?
  • Requires specialized assessment and treatment for any patient who has a history of substance abuse disorder or a co-occurring mental health disorder?
  • Requires maintaining adequate and accurate medical records?
  • Requires that a written treatment plan be established?
  • Requires a regular assessment of the patient's response to the use of cannabis and overall health and level of function?
  • Prohibits the physician from recommending the medical cannabis for personal use or for use by family members?
  • Prohibits the physician from being employed by, holding a financial interest in or having a professional office located at any entity or facility that dispenses cannabis for medical purposes?

Toward an Accepted Standard of Care

Other states have issued similar guidelines for physicians when determining that medical marijuana is an appropriate treatment. For example:

  • Florida, New York, Washington and Ohio require physicians to complete continuing education training prior to obtaining certification to recommend cannabis.
  • Oregon requires that the physician be a specialized attending physician for one of the enumerate debilitating mental conditions pursuant to Oregon Revised Statute 475B.410.
  • Florida has comparable physician guidelines with regard to the written documentation requirements and specific documentation demonstrating that the medical use of marijuana likely outweighs potential health risks.
  • Washington's guidelines regarding treatment plans advise physicians to include a review of other measures attempted to treat the terminal or debilitating medical condition without the medical use of marijuana, the physician's advice regarding other treatment options and a determination the patient may benefit from medical use of marijuana.

The many variations and inconsistencies among the states demonstrate the need for an accepted standard of care for physicians when considering the medical use of cannabis for patients to ensure consistency of care and patient safety. Although the various state guidelines are an important step in this process, greater uniformity is needed as medical cannabis becomes more widespread and accepted as a legitimate treatment by the medical community.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on Mondaq.com.

Click to Login as an existing user or Register so you can print this article.

Similar Articles
Relevancy Powered by MondaqAI
In association with
Related Topics
Similar Articles
Relevancy Powered by MondaqAI
Related Articles
Related Video
Up-coming Events Search
Font Size:
Mondaq on Twitter
Mondaq Sign Up
Gain free access to lawyers expertise from more than 250 countries.
Email Address
Company Name
Confirm Password
Mondaq Newsalert
Select Topics
Select Regions
Registration (you must scroll down to set your data preferences)

Mondaq Ltd requires you to register and provide information that personally identifies you, including your content preferences, for three primary purposes (full details of Mondaq’s use of your personal data can be found in our Privacy and Cookies Notice):

  • To allow you to personalize the Mondaq websites you are visiting to show content ("Content") relevant to your interests.
  • To enable features such as password reminder, news alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our content providers ("Contributors") who contribute Content for free for your use.

Mondaq hopes that our registered users will support us in maintaining our free to view business model by consenting to our use of your personal data as described below.

Mondaq has a "free to view" business model. Our services are paid for by Contributors in exchange for Mondaq providing them with access to information about who accesses their content. Once personal data is transferred to our Contributors they become a data controller of this personal data. They use it to measure the response that their articles are receiving, as a form of market research. They may also use it to provide Mondaq users with information about their products and services.

Details of each Contributor to which your personal data will be transferred is clearly stated within the Content that you access. For full details of how this Contributor will use your personal data, you should review the Contributor’s own Privacy Notice.

Please indicate your preference below:

Yes, I am happy to support Mondaq in maintaining its free to view business model by agreeing to allow Mondaq to share my personal data with Contributors whose Content I access
No, I do not want Mondaq to share my personal data with Contributors

Also please let us know whether you are happy to receive communications promoting products and services offered by Mondaq:

Yes, I am happy to received promotional communications from Mondaq
No, please do not send me promotional communications from Mondaq
Terms & Conditions

Mondaq.com (the Website) is owned and managed by Mondaq Ltd (Mondaq). Mondaq grants you a non-exclusive, revocable licence to access the Website and associated services, such as the Mondaq News Alerts (Services), subject to and in consideration of your compliance with the following terms and conditions of use (Terms). Your use of the Website and/or Services constitutes your agreement to the Terms. Mondaq may terminate your use of the Website and Services if you are in breach of these Terms or if Mondaq decides to terminate the licence granted hereunder for any reason whatsoever.

Use of www.mondaq.com

To Use Mondaq.com you must be: eighteen (18) years old or over; legally capable of entering into binding contracts; and not in any way prohibited by the applicable law to enter into these Terms in the jurisdiction which you are currently located.

You may use the Website as an unregistered user, however, you are required to register as a user if you wish to read the full text of the Content or to receive the Services.

You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these Terms or with the prior written consent of Mondaq. You may not use electronic or other means to extract details or information from the Content. Nor shall you extract information about users or Contributors in order to offer them any services or products.

In your use of the Website and/or Services you shall: comply with all applicable laws, regulations, directives and legislations which apply to your Use of the Website and/or Services in whatever country you are physically located including without limitation any and all consumer law, export control laws and regulations; provide to us true, correct and accurate information and promptly inform us in the event that any information that you have provided to us changes or becomes inaccurate; notify Mondaq immediately of any circumstances where you have reason to believe that any Intellectual Property Rights or any other rights of any third party may have been infringed; co-operate with reasonable security or other checks or requests for information made by Mondaq from time to time; and at all times be fully liable for the breach of any of these Terms by a third party using your login details to access the Website and/or Services

however, you shall not: do anything likely to impair, interfere with or damage or cause harm or distress to any persons, or the network; do anything that will infringe any Intellectual Property Rights or other rights of Mondaq or any third party; or use the Website, Services and/or Content otherwise than in accordance with these Terms; use any trade marks or service marks of Mondaq or the Contributors, or do anything which may be seen to take unfair advantage of the reputation and goodwill of Mondaq or the Contributors, or the Website, Services and/or Content.

Mondaq reserves the right, in its sole discretion, to take any action that it deems necessary and appropriate in the event it considers that there is a breach or threatened breach of the Terms.

Mondaq’s Rights and Obligations

Unless otherwise expressly set out to the contrary, nothing in these Terms shall serve to transfer from Mondaq to you, any Intellectual Property Rights owned by and/or licensed to Mondaq and all rights, title and interest in and to such Intellectual Property Rights will remain exclusively with Mondaq and/or its licensors.

Mondaq shall use its reasonable endeavours to make the Website and Services available to you at all times, but we cannot guarantee an uninterrupted and fault free service.

Mondaq reserves the right to make changes to the services and/or the Website or part thereof, from time to time, and we may add, remove, modify and/or vary any elements of features and functionalities of the Website or the services.

Mondaq also reserves the right from time to time to monitor your Use of the Website and/or services.


The Content is general information only. It is not intended to constitute legal advice or seek to be the complete and comprehensive statement of the law, nor is it intended to address your specific requirements or provide advice on which reliance should be placed. Mondaq and/or its Contributors and other suppliers make no representations about the suitability of the information contained in the Content for any purpose. All Content provided "as is" without warranty of any kind. Mondaq and/or its Contributors and other suppliers hereby exclude and disclaim all representations, warranties or guarantees with regard to the Content, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. To the maximum extent permitted by law, Mondaq expressly excludes all representations, warranties, obligations, and liabilities arising out of or in connection with all Content. In no event shall Mondaq and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use of the Content or performance of Mondaq’s Services.


Mondaq may alter or amend these Terms by amending them on the Website. By continuing to Use the Services and/or the Website after such amendment, you will be deemed to have accepted any amendment to these Terms.

These Terms shall be governed by and construed in accordance with the laws of England and Wales and you irrevocably submit to the exclusive jurisdiction of the courts of England and Wales to settle any dispute which may arise out of or in connection with these Terms. If you live outside the United Kingdom, English law shall apply only to the extent that English law shall not deprive you of any legal protection accorded in accordance with the law of the place where you are habitually resident ("Local Law"). In the event English law deprives you of any legal protection which is accorded to you under Local Law, then these terms shall be governed by Local Law and any dispute or claim arising out of or in connection with these Terms shall be subject to the non-exclusive jurisdiction of the courts where you are habitually resident.

You may print and keep a copy of these Terms, which form the entire agreement between you and Mondaq and supersede any other communications or advertising in respect of the Service and/or the Website.

No delay in exercising or non-exercise by you and/or Mondaq of any of its rights under or in connection with these Terms shall operate as a waiver or release of each of your or Mondaq’s right. Rather, any such waiver or release must be specifically granted in writing signed by the party granting it.

If any part of these Terms is held unenforceable, that part shall be enforced to the maximum extent permissible so as to give effect to the intent of the parties, and the Terms shall continue in full force and effect.

Mondaq shall not incur any liability to you on account of any loss or damage resulting from any delay or failure to perform all or any part of these Terms if such delay or failure is caused, in whole or in part, by events, occurrences, or causes beyond the control of Mondaq. Such events, occurrences or causes will include, without limitation, acts of God, strikes, lockouts, server and network failure, riots, acts of war, earthquakes, fire and explosions.

By clicking Register you state you have read and agree to our Terms and Conditions