With the passing of Florida’s Amendment 2 (the approval of medical marijuana) by 71% of Florida voters, we can expect a substantial increase in the number of patients certified to use medical marijuana in hospitals.1 As a result, it is imperative that hospitals take a proactive step to develop organization-wide written policies and procedures regarding the use, storage, and delivery of medical marijuana within the hospital setting. The intention of this article is not to persuade hospital decision-makers to adopt any specific course of action or organizational policy. Rather, its goal is to bring to the forefront operational topics hospitals should consider to successfully navigate Florida’s new medical marijuana frontier.

Under Amendment 2, a Florida resident may be certified for the use of medical marijuana if he or she is diagnosed with a debilitating medical condition, receives a written certification from a licensed Florida physician, and obtains an ID card from the Florida Department of Health.2 A debilitating medical condition is defined as “cancer, epilepsy, glaucoma, positive status for human immunodeficiency virus (HIV), acquired immune deficiency syndrome (AIDS), post-traumatic stress disorder (PTSD), amyotrophic lateral sclerosis (ALS), Crohn’s disease, Parkinson’s disease, multiple sclerosis, or other debilitating medical conditions of the same kind or class as a or comparable to those enumerated, and for which a physician believes that the medical use of marijuana would likely outweigh the potential health risks for a patient.3 ” A physician may issue a certification only after the physician conducts a full examination of the patient and a full assessment of the patient’s medical history.4
 
Florida is currently developing its new state medical marijuana program which expressly protects certifying physicians from criminal and civil liability and sanctions, so long as the physician certifies the use of medical marijuana within a reasonable standard of care.5 However, it is important to keep in mind that marijuana remains a Schedule I controlled substance under the federal Controlled Substances Act. Although there are significant clinical indications6 that medical marijuana can successfully manage and treat numerous medical conditions, the federal government still defines marijuana as a drug that has no accepted medical use for treating disease.7 Notwithstanding medical marijuana’s illegal status under federal law, the federal government has indicated that prosecution for medical marijuana use is not a federal priority and that it will not use its resources to interfere with state medical marijuana programs.8
 
Although there is evidence that the federal government would not prosecute a hospital for permitting the use of medical marijuana9 on site, a dichotomy between federal and state law will exist as long as medical marijuana is labelled an illicit drug under federal law. This causes serious challenges for a hospital, which must strike a delicate balance between limiting federal liability for itself and its practitioners and minimizing disruption to a patient’s successful course of treatment.
 
Establishing policies and procedures that address the hospital’s position on the use, storage, and delivery of medical marijuana ensures practitioners and staff act in accordance with the hospital’s predetermined acceptable levels of risk and refrain from taking actions that could increase federal liability for the hospital. The adoption and communication of uniform policies and procedures also (i) minimizes confusion amongst the hospital’s practitioners and staff by giving direction as to what to do when confronted with a patient certified to use medical marijuana; (ii) streamlines care to patients certified to use medical marijuana; and (iii) ensures patients and their caregivers have realistic expectations for use of medical marijuana while using the hospital’s services.
 
Establishing a Workgroup
Participation from multiple facets of the organization is key to creating workable medical marijuana policies and procedures. The hospital should consider establishing a multidisciplinary workgroup comprised not only of the board of directors and senior management decision-makers but also representatives from the emergency department, specialty departments, research departments, and other medical units. Physicians and nurses across medical specialties, addiction specialists, pharmacists, and mental health professionals should also be included in the conversation. Additionally, the hospital should also consider inviting outside parties, including legal counsel, consultants, and representatives from local and state professional boards to the workgroup.
 
Strong differing opinions from workgroup members should be expected. Compromise, voting, and outside assistance may be necessary to construct policies and procedures that the hospital’s board of directors and its practitioners and staff are amenable to and are willing to comply with. As difficult as it may be, it is imperative that at the end of the day, the hospital adopts a uniform position about medical marijuana. This uniformity will ensure practitioners and staff throughout the hospital are capable of successfully handling encounters with patients, patient advocates, and the community at large with regard to medical marijuana.
 
Topics for Consideration
The workgroup should consider, at a minimum, the following:
 
• Will the hospital permit the use of medical marijuana within the hospital, and if so, what type of delivery mechanisms will be permitted? For example, will medical marijuana use be permissible in vapor form? What about pill or edible form?
 
• Who may use medical marijuana in the hospital? Will only certified inpatients be permitted to use medical marijuana or will outpatients be permitted to use medical marijuana as well? Will the hospital adopt special policies for inpatient mental health and substance abuse patients?
 
• Where in the hospital will medical marijuana use be permitted? Will patients have access to medical marijuana in the emergency department or intensive care unit or only in patients’ private or semi-private rooms? Alternatively, will the hospital have designated rooms for medical marijuana intake (this may be relevant if the hospital permits vapor use)?
 
• Will hospital staff and practitioners ask the patient whether he or she is taking medical marijuana during intake and request a copy of the patient’s medical marijuana ID card or will the hospital adopt a don’t ask don’t tell policy?
 
• Will the hospital permit practitioners to register as caregivers to assist patients with the administration of medical marijuana or will only self-administration of medical marijuana be permitted?
 
• Where will the medical marijuana be stored during the inpatient’s stay? Will it be required to remain with the patient at all times or will it be stored on the floor with other scheduled drugs or in the hospital’s pharmacy? Will special labelling and/or packaging of the medical marijuana be required?
 
• Will the hospital permit its physicians to certify medical marijuana or re-fill a medical marijuana order for the patient while he or she is under the hospital physician’s care?
 
• What is the hospital’s policy on destruction of medical marijuana in the event a patient leaves the medical marijuana behind or the patient becomes incapacitated or dies?
 
• Will the hospital permit practitioners to “opt out” and request that the patient be transferred to another practitioner if the patient demands to use medical marijuana and the practitioner does not believe in the use of medical marijuana? If so, what will be the procedure for transferring the patient and what should be documented?
 
Other Considerations
In addition to the above substantive medical marijuana use, storage, and delivery issues, the workgroup should create policies and procedures that describe how the hospital will ensure its staff and practitioners comply with the policies and procedures. The hospital should also consider implementing training requirements for its workforce with regard to these issues and support feedback from hospital stakeholders. Like other compliance policies, the hospital should regularly assess the policies and procedures to ensure it remains compliant with state law and closely work with legal counsel to minimize liability at the federal level.
 
Don’t wait for a problem to arise: be proactive and keep your workforce, decision-makers, and patients informed about the hospital’s position on medical marijuana from the get-go.10


On November 8, 2016, the Florida Medical Marijuana Legalization initiative went into effect, acknowledging medical cannabis as a treatment option for qualifying patients, under the care of a physician. Treatment plans should be specifically tailored with the patient’s illness, lifestyle and health history in mind, which may include administering less traditional forms of cannabis.

Our dispensary, Midwest Compassion Center, operates in Illinois but we believe that our government’s heavily regulated program is like that of Amendment 2, and our practices and information can act as a framework for Florida’s similar rules and regulations. A good understanding of how medical cannabis can be administered, and when each form is commonly used can better aid physicians in maximizing their patient’s quality of life.
 
The information presented is primarily for physicians who wish to incorporate cannabis into their patient’s treatment plan, and is meant for educational purposes only.
 
Flowers
Many of our patients choose to inhale cannabis for its convenient dosage method, which is why the flower is one of our bestselling products. Kief and hashish, also known as hash, are two cannabis products that come from the flower. Kief is a powder that is made from the resin glands of cannabis plants. Once compressed, kief makes hash, which has a texture that’s like paste. Both Kief and hash can be inhaled. The convenience of inhaling cannabis cannot be discounted, but by no means is it the primary benefit, which is its rapid relief. Smoking medical cannabis is a viable option for patients who suffer from chronic pain and need simple, fast relief that cannot be found in some other forms of administering cannabis.
 
Edibles
Medical cannabis can be added to many food and drink recipes because of its secreted chemical compound called cannabinoids. Heat is necessary in creating active THC and CBD, both responsible for marijuana’s medical benefits and psychological effects. Edibles are not as fast acting as smoking or vaping cannabis, but patients will experience stronger and longer lasting effects once ingested. For those who must take multiple pills a day, such as HIV/Aids patients, administering edible cannabis is a compassionate form of treatment in lieu of more pills. Edibles do not have to come in cakes, brownies or other foods that are attractive to children. It only needs to easily ingested by the patient.
 
Tinctures
Patients and physicians can turn to another form of ingesting medical cannabis via cannabis tinctures. Tinctures are cannabis liquids that are usually made by soaking the dried flower of a female hemp plant in ethanol. The process turns the plant into a concentrated cannabis liquid, which is very easy for patients to ingest. If HB 1397 goes into effect, it will restrict some patients from using edible products. For these suffering patients, tinctures can be a viable treatment option. Unlike edibles, cannabis tinctures take effect quickly, ranging between 5-30 minutes, depending on the patient. The fastest way patients can introduce cannabis into their system is by holding a few drops under the tongue for one minute before swallowing. Effects can last between 1-6 hours.
 
Topicals
The cannabis plant and its oil extracts can be used as topical treatments when added to lotions, salves, balms and oils. Topicals must be infused with active cannabinoids to be absorbed directly into the skin once applied to the affected area. This yields faster and more concentrated relief. Topical cannabis is non-psychoactive. It’s never absorbed into the blood stream, but instead, binds to the CB2 receptors near the skin. Ailments that can be treated with topicals include allergic skin reactions, inflammation, muscle strains, post-herpetic neuralgia and swelling. It is recommended that dose and coverage be very liberally when applying topicals onto the afflicted area because human skin has a low absorption rate for cannabinoids.
 
Vapor Pens
The cannabis plant has several cannabinoids secreted inside of the glands. Two primary cannabinoids are THC and CBD. Once extracted from mature cannabis foliage, THC and CBD is turned into an oil which patients can then vape. THC is responsible for most of marijuana’s psychological effects, whereas CBD is non-psychoactive. Patients who may benefit from vapor pens are those who need fast relief, such as a cancer patient enduring bouts of nausea from chemotherapy. CBD, while non-psychoactive, can be therapeutic for patients who suffer from chronic pain, arthritis and panic attacks.
 
Keep in mind that the rules and regulations of Amendment 2 are still being initiated, and physicians may not be allowed to prescribe all the forms of medical cannabis. It is strongly advised that caregivers and physicians stay up-to-date with Amendment 2, as more restrictive rules may be enacted down the road.


One of the problems facing the majority of patients that qualify for a medical cannabis recommendation is that many of them have debilitating conditions that often hinder or limit mobility and preclude them from driving—which makes it very difficult to get in to see a physician. 

To this end, www.myfloridagreen.com was created to remove the hurdles that these patients face. A virtual online clinic platform designed by industry experts and medical leaders, the app handles patient aggregation, vetting and qualification, and the establishment of a doctor/patient relationship.
“Through the use of telemedicine and virtual technology, a patient can even have an actual face-to-face consultation with a medical provider while remaining in the comfort of his or her own home,” explained myfloridagreen.com creator Nick Garulay.
 
The HIPAA-compliant platform streamlines patient flow for physicians and more importantly, assists sick patients with debilitative and terminal illnesses. Already, www. myfloridagreen.com has more than 3,500 patients registered with the application since the passing of Amendment 2, the Florida Medical Marijuana Legalization Initiative, on November 8.
 
As laws get implemented and doctors and patients start to navigate this emerging process, there are going to be large volumes of data that need to be inputted, archived, queried and protected, and Garulay and his team are already in the process of creating software to handle the patient data currently required by the state registry, the College of Pharmacy registry, and the medical cannabis card registration that was recently added to the regulations.
 
“These legislatively mandated reportable data sets, combined with the existing functionality of the current platform, will allow the medical cannabis recommendation process to be applied for, monitored, regulated, tracked, and enforced on one solid system,” he explained.
 
Despite the fact that this could provide a streamlined way for patients and doctors to communicate, a proposed ban on telemedicine being used to prescribe medical cannabis by caregivers in the state of Florida could derail the process.
 
“If passed, the ban would have a detrimental and negative impact on many non-ambulatory patients that could not obtain a recommendation via a traditional office visit,” explained Garulay, adding that the legislative language in the ban echoes the current telemedicine law that prohibits a controlled substance to be prescribed through telemedicine unless it is done by a psychiatrist.
 
“It is my ultimate goal to create a virtual process that facilitates and adheres to all of the legal requirements—from the initial consultation to the final dispensing of the medication for the qualifying patients in need,” he added. “By partnering with the state, together we can manage this immense undertaking in a way that meets the statutory requirements, as well as creates a unique way to help patients when a traditional office visit is not an option.”


As healthcare providers, we strive to continually improve upon our patient’s ability to live an involved and active life. With the advent of medical marijuana legislation in Florida, physicians now have the opportunity to help facilitate a better quality of life for those living with difficult to treat and chronic diseases such as Parkinson’s disease, Multiple sclerosis, Cancer and other chronic conditions requiring specialized care and a regimen of multiple medications. I live in Florida half the year, so while in Massachusetts, I work as a nurse practitioner with medical marijuana patients who benefit greatly using this alternative and safe solution. Unfortunately, patient care is limited by the lack of education and provider understanding of legal issues.

More than 200 people attended the second annual South Florida Physician’s Medical Marijuana Symposium to learn more about helping patients who qualify for this holistic treatment. The symposium was presented by Canna Holdings and is a labor of love for those involved in educating professionals with the hopes of expanding access to care for the hundreds of thousands of patients waiting for this opportunity. While Florida legislation is still deciding on the best way to implement Amendment 2, doctors need to be educated on how to use this evolving treatment.
 
Coming from a state that has a medical marijuana program in place and as a professional who works with patients and physicians, I was very pleased with the program presented on March 11th. Dr. Dustin Sulak, a leading expert in the field of cannabinoid medicine gave a compelling presentation to help us understand the endogenous cannabinoid system and how we can help patients improve its homeostatic abilities. His presentation offered a foundation for optimizing the therapeutic effects cannabis medicine offers often difficult to treat conditions. Dr. Gregory Smith, author and medical marijuana advocate, discussed current research suggesting microdoses of cannabinoids may act as a preventive measure in neurodegenerative diseases like Alzheimer’s and dementia. Dr. Gregory Gerdeman, neuroscientist and medical marijuana advocate has earned multiple awards of excellence for his research on medical cannabis including the physiological adaptation to pain and the synergistic effects of opioids and cannabis. Many patients being treated for chronic pain fear opioid addiction and overdose, while patients using cannabis report a decreased need or discontinuation of opioid use with few side effects and better quality sleep.
 
It is through educational symposiums like this that we expand our scope of treatment alternatives and access to care for those who need us most. Many patients have been through the conventional treatments with little to no improvement while antidotal evidence strongly supports the use of medical marijuana in helping to ease symptoms and improve quality of life for a variety of conditions. Florida’s patients are fortunate that Canna Holdings has committed to bringing quality education to the leaders in the medical field.


I recently had the opportunity to attend the South Florida Medical Cannabis Symposium for Physicians, presented by Canna Holding, along with physicians, attorneys, patient advocates and other healthcare practitioners around the state. The symposium was a great educational session designed to give an initial understanding, centered around education, of the endocannabinoid system, pain relief using cannabis, legal, and other physician concerns around cannabis. I spoke to several attendees who had an interest but did not know where to start.

Here are a few actions I would suggest to get started:
1. Florida Department of Health Compassionate Use Site – This is the starting point to understand the framework to get started. http://www.floridahealth.gov/programs-and-services/office-of-compassionate-use/index.html. There is a section specifically for physicians.
 
2. Active Physician License
a. Unrestricted License as a Physician- per Florida Statue Chapter 458 or
b. Osteopathic Physician per Florida Statue Chapter 459
 
3. Compassionate Medical Cannabis CME Course- This is a required prerequisite before getting authorized, and just because you take the class does not guarantee getting a license. You can access it at http://www.flcannabisce.com/. There is a fee to take the class and at the time of writing it was $995.
 
After you meet those basic guidelines and get approved then you have to follow several legal requirements, as stated on the Compassionate Use site:
• Physicians may only order low-THC or medical cannabis for a patient if he or she has treated that patient during the immediate preceding three months.
• Physicians must determine that the risks of treating the patient with low-THC or medical cannabis are reasonable in light of the potential benefit to the patient.
• If a patient is younger than 18 years of age, a second physician must concur with the low-THC or medical cannabis order, and such determination must be documented in the patient’s medical record.
• An ordering physician must maintain a patient treatment plan that includes the dose, route of administration, planned duration, and monitoring of the patient’s symptoms and other indicators of tolerance or reaction to the order for low-THC or medical cannabis. The physician must submit a patient treatment plan for each patient quarterly to the University of Florida College Of Pharmacy, or any time the plan changes.
• An ordering physician must enter an order of low-THC or medical cannabis for the named patient into the Compassionate Use Patient Registry, and update the registry to reflect the contents of the order. The physician must update the registry within days after any change is made to the original order and must deactivate the patient’s registration when treatment is discontinued.
• A physician may not order more than a 45-day supply of low-THC or medical cannabis for a patient.
 
Once you have considered all of this, you can’t forget to have written policy and procedures along with training for you and your team. It is important to ensure you have a compliance framework in place, just like you see for hospitals or other practices.
 
Document, document, document! Did I mention you should document what you are doing? The cannabis industry is heavily regulated and it is so important to have good document controls in place. When a risk event happens, you want to be able to provide any records or documents in minutes and not hours. If you are still keeping track of policies and procedures with paper and binders, it’s time to move towards the great digital divide.
 
To help make the move, consider an online document management platform. One that I use and recommend to clients is PowerDMS.com. It’s been successfully implemented by over 300 entities in Florida alone, over 200 of which are law enforcement who use it for their policy, procedure and training management. This is a solution that will give you peace of mind with its version control, audit capabilities, and overall control of your documents.