CNS Role in Creating Processes for
Patient Use of Medical Cannabis in
Hospital and Ambulatory Care Areas
Kris Negley, APRN, CNS
Jeanne Voll, APRN, CNS
Clinical Nurse Specialists
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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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Is It Time for Minnesota to Legalize Pot for Recreational Use?
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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
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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
Program Requirements and Limits
• Minnesota Medical Cannabis products limited to oral
capsule, oral tincture, oral oil, vaporized oil (nonsmokable)
 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
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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.
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/ourmedicines/
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www.blogs.mprnews.org
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minnesotamedicalsolutions.com
minnesota.cbslocal.com
Oils
Tinctures
Capsules
Vaporizers
mprnews.org
minnesotamedicalsolutions.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
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 52015
• 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/
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