By BRETT PUFFENBARGER
Let's cut straight to the point...Cannabis is the next "dot com" boom, or gold rush. The Orange County Commissioners just voted unanimously to allow dispensaries, and a similar story is playing out across the state as cities and counties discuss medical marijuana.
Over half the country now has either a legal medical or recreational market, and recent polls suggest as much as 64 percent support for nationwide legalization. Here in Florida, 71.3 percent of voters supported the constitutional amendment that passed last November, and the patient count is the fastest growing registry in the country. Basically, Cannabis is big business, and it's easier to get involved than you may think.
For a medical provider to recommend "Medical Marijuana" here in the Sunshine State requires a two-hour course. That's about it. Any unrestricted license as a medical doctor or osteopathic physician qualifies you to take the course through the Florida Medical Association or Florida Osteopathic Medical Association depending on your license type. The course costs $250.00, and a passing grade of 80 percent on the final exam is required.
The only other restriction is that you can't work for any of the Medical Marijuana Treatment Centers (MMTCs, Dispensaries), or have any direct or indirect financial ties to them. This state required course is a very basic overview of the law and how to ensure you are following it as doctors, but it really doesn't cover any of the hows, whys, and whats of being a medical cannabis qualified ordering physician.
The how is pretty simple: either begin offering cannabis recommendations at your current practice, start a second cannabis specific practice, or join one of the many "referral agencies" that allow providers to moonlight with them, separately from any of their other medical business. Each one of these has their own pros and cons. Cannabis specific practices, and doctor groups seem to be the most popular options, though most advocates and patients are pushing for family practices and primary care clinics to start offering medical marijuana.
When it comes to cannabis patients in Florida, the average age is 57 and most are suffering from terminal or incurable conditions. They don't want to be associated with any of the false or negative stigmas attached to "weed" or "dope" any more than some doctors and politicians do, and being able to talk to their normal doctor about this option is much more comfortable for them.
For the why of medical marijuana, the most obvious is economic. The average cost of an appointment for a cannabis referral is between $120-$250, with bi-annual follow ups usually costing patients $75-$100. With the current patient count being just over
60,000 and a doctor count at under 500, the potential income is substantial to say the least. A less obvious, but more important why is part of your Hippocratic Oath, where all known measures are required for the benefit of the sick. Here in Florida there is a list of 10 qualifying conditions: Cancer, Epilepsy, Glaucoma, HIV, AIDS, PTSD, ALS, Crohn's disease. Parkinson's, and Multiple Sclerosis. Similarly debilitating conditions are also qualifiers. The major take-away here is that these are sick people who are tired of the pills, and treatments. They are looking for a more natural relief, and with cannabis being the most talked about subject of 2017, they will be coming to you for information. No business, least of all medical practices, want to leave their customers/patients high and dry when they come looking for the most popular single medical product in America.
Last but not least is the what of medical marijuana. Most importantly, here in the land of Mickey, Cannabis is a constitutional right. Medical Marijuana is also a lot more than a right though; it's the only medicine you can talk about without a list of side effects longer than the symptoms it relieves. Marijuana is actually a negative term coined in the 1930's to make a harmless and wild growing plant seem alien or foreign. The plant is actually Cannabis Sativa, and it's related to Hops, Dogwood trees, and most other flowering trees and bushes. Ancient Greek, Chinese, Middle Eastern, and Native American cultures all recognized the industrial and medical uses of Cannabis. Even the founding fathers have referenced the plant. Here in Florida, you are limited to only extracts, tinctures, and concentrates. There is no "whole flower" cannabis, and patients can't smoke any of the products. There are currently only 9 licensed MMTCs, with 5 currently dispensing products. Products are limited to two categories, and two general delivery methods.
The categories are:
THC/Medical Marijuana with any amount of the psychoactive agent TetraHydraCannabinol (THC) above 0.8 percent, and Low Strength/CBD with under 0.8 percent THC and comprised mostly of the other major agent in cannabis, Cannabidiol (CBD). Delivery Methods are split into inhalation and oral. The former is for any of the vape pens, inhalers, or other ingestion methods where the lungs are the major processing method. The latter is for any number of drops, tinctures, capsules, and sprays where the stomach or mouth is the intake method. There is also a third method that covers balms, salves, suppositories, and other methods that are much less common given the current qualifying condition list. Now that you know the basics of how to become a qualified physician, why you should consider it, and what is happening, the rest is on you. Whether it's the economic incentive, a true love for your patients, or peer pressure, the time to jump on board is now. This article is just a start, just like the state course is only the very basics. Cannabis is only in it's infancy as a medicine in the modern world, and the more qualified medical professionals who take the time to understand this phenomenon the better. Check with the Florida Department of Health and The Office of Medical Marijuana Use for more information on how, and get involved with any of the non-profits, groups, or consulting firms to really dig into why and what.
Steps After Qualifying as an MMJ Physician
You've taken the two-hour course, and can now recommend medical cannabis here in Florida. That's an important first step, but to really be a knowledgeable provider in the medical marijuana field, you must understand exactly what you're dealing with. Over the next few paragraphs, we're going to go over the delivery methods, the recommendation types, and some of the strains and varieties available here.
Let's start at the very beginning, the recommendation. When you decide to offer cannabis as a medicine to a patient it isn't a prescription. Most of you probably already know this, but just in case you don't, I'll repeat: It's a recommendation, not a prescription. Prescriptions are federally regulated, and as we all know cannabis is illegal at a federal level, so a script for cannabis would cause a loss of license, and probably some hefty fines.
As far as what a recommendation entails, it is fairly simple. Recommendations come in two forms, CBD/LOW DOSE and THC/FULL STRENGTH. The two are not interchangeable, and will be displayed as grey for CBD, and green for THC in the state registry. The DOH has currently set the maximum daily dose at 400 mg, though very few patients will ever use more than 200 mg a day.
When discussing these dosages, you are referring to the actual amount of the active ingredient, not the total amount of the container your patient purchases. For THC recommendations, patients can try either variety (Indica or Sativa), though most doctors recommend them one or the other depending on the individual patient's situation. Very generally speaking Indica will produce a tired, relaxed feeling, whereas Sativas produce an energetic or creative feeling. Products also come in hybrids that share both characteristics. Once you have made this recommendation, the patient will be able to purchase products that fall under this category, so there will be some trial and error for both of you as you set dosages, and recommended strains.
The second component of the recommendation is delivery method, and comes in three varieties: Inhalation, Oral, or Other.
• Inhalation comprises vape pens and inhalers, works nearly instantly, and lasts for as long as four hours. Inhalation is the most common method, but most specifically is for breakthrough pain/anxiety, or for conditions that are sudden onset (seizure, panic attack).
• Oral can be sublingual drops, tinctures, capsules, or throat sprays, and takes as much as two hours to feel affects, but lasts as long as 8 or 10 hours. Oral is the second most common, and is for chronic conditions, or long-term relief. Oral is also considered "stronger" since it doesn't process through the lungs and liver, causing the active ingredients to change slightly.
• The final method is the Other category, and comprises salves, balms, oils, lotions, suppositories, and any number of creative methods the dispensaries develop. These methods are usually non-psychoactive, and are for localized pain or other conditions with the exception of the suppository, which works similarly to Oral as far as effects.
While on the subject of delivery methods, let's touch on the final component of recommendations - maximum and recommended doses. As it currently stands, most patients use a maximum dose of 200 mg a day, but this can be as low as you want or as high as 400 mg a day. Some patients may only need 10mg, whereas experienced patients may need over 200mg. A prudent method is to follow averages, and allow your patient to work themselves up cautiously to an effective dosage.
There has been much discussion in activist circles about when a recommendation should go active - with some doctors seeing their patient and once the card is approved the recommendation is there, while other doctors require a second visit between the patient obtaining the card and making their first purchase. The second method is generally not preferred, and really doesn't make sense.
The follow up schedule is currently set at 7-month intervals, though some doctors require patients come in every 60-90 days for the first 7-month cycle so they can help patients adjust with the trial and error process.
I offer one last bit of advice learned from my time as a dispensary manager; please ALWAYS click the "Patient may purchase delivery device" when adding your patient's recommendations. Here in the Sunshine State, a registered patient can only use dispensed medicine in a dispensed delivery method - otherwise the medicine is invalidated and becomes a felony to possess. If you don't click this little button, patients can't use the meds they buy legally.
So, now you have taken your two-hour course, and spent the last 5 minutes or less reading this brief explanation to what the next steps are. So where do you go from here? I would start by either pursuing a consultant, doing your own independent research, or going to one of the many CME courses offered throughout the state for providers on this subject. If none of these options work, all of the current active dispensaries have education departments and would be happy to send you an educator if you are willing to listen to the product sales pitch as well. Go out and start learning, because the registry is growing every day, and patients are begging for educated physicians to visit.
Brett Puffenbarger is a cannabis educator, activist, and consultant with Key & Support badges for the cannabis industry nationwide. He was the general manager for the first dispensary in Florida, and is currently serving as the Director for Public Relations for the charity: Buds for Vets. He's a full-time consultant to physicians, their staff, and secondary markets through his business page: Professor Cannabis. You can find him
on Twitter @ProfCannabis and FB @ProfCannabiz or online at professorcannabis.ml. Inquiries can be directed to Brett.ProfessorCannabis@gmail.com & for my charity work Brett@budsforvets.org