The Second Annual Report for the Arizona Medical Marijuana Program was released late last week. The report includes data about the demographics and kinds and qualifying conditions of Arizona’s cardholders, but according to ADHS Director Will Humble, “The most striking thing in the report is that 25 doctors have signed about 70%, about 25,000, of the 36,000 or so certifications this past year.”
Humble noted that a handful of doctors wrote more than 2,000 certifications. “That doesn’t necessarily mean that these doc’s aren’t acting in the best interests of their patients,” Humble wrote, “but it does give us some insight into which ones we should be focusing on to ensure that they’re meeting our certification expectations.”
Report findings:
Between July 1, 2012 until June 30, 2013, there were a total of 37,070 active cardholders, which included 36,416 qualifying patients and 654 caregivers. ADHS has been administering the program to support Arizona residents for whom medical marijuana may provide therapeutic and palliative benefit. The majority of the qualifying patients (82%) had one debilitating medical condition, with the remaining 18% reporting two or more conditions. Approximately 73% of the qualifying patients indicated “severe and chronic pain” as the only debilitating medical condition. Cancer was the second largest unique debilitating condition (2.0%), followed by Hepatitis C (1.6%). Ninety percent of all debilitating medical conditions had severe and chronic pain as a unique and/or multiple condition.
Given that “severe and chronic pain” accounts for the majority of the debilitating conditions either as unique and/or in combination, it is important to understand the etiology of how medical marijuana may influence pain management. One plausible way to capture a more nuanced classification of debilitating medical condition is standardizing the collection of debilitating medical conditions through International Classification of Diseases, Tenth Revision (ICD 10) codes, which would allow comparison of incidence of certain debilitating medical conditions through other available data sources at ADHS.
However, current Arizona Medical Marijuana Act (AMMA) provisions limit the scope for any such analysis. Conducting any epidemiological analyses to understand public health and safety implications are difficult unless AMMA statutory elements are amended (i.e., in furtherance of the act). Public health impacts to examine are the relationship of poisonings and the decrease in prescription drug use among qualifying medical marijuana patients prior to and post implementation of AMMA compared to the general population. For instance, recent evidence from Colorado suggests that the proportion of ingestion visits in patients younger than 12 years (age range, 8 months to 12 years) were related to marijuana exposure increased after decriminalization of medical marijuana in Colorado.
Since the passage of the law, in two instances (Laws 2011, Chapter 112 and Laws 2011, Chapter 336), modifications to AMMA were put in place to clarify ADHS’ authority to share doctor information with the various medical boards and required ADHS to allow employer access to the medical marijuana database to verify if employees were valid cardholders. Additionally, Laws 2011, Chapter 94 modified the controlled substances database to include medical marijuana to allow physicians to make more informed decisions about patient care. Without these modifications, it would have been difficult to assess the high frequency physician certifications noted in this report and/or to report them to their respective medical boards.
Year One Recommendations and Updates
Recommendation 1:
Develop intensive training for physicians who are high volume certifiers in conjunction with respective licensing medical boards for better patient provider coordination and adherence to AMMA statutory requirements. Leverage existing contracts with the Arizona Board of Pharmacy to more quickly identify physicians who may be making false attestations on physician certifications.
ADHS has contracted with the University of Arizona to develop and implement an online Continuing Medical Education (CME) Module regarding the physician’s role and expectations under the Arizona Medical Marijuana Program. To date, over 20 physicians have completed the module. ADHS has also continued the contract with the Arizona Board of Pharmacy to employ one dedicated, full-time pharmacist to assist with audit requests from ADHS. The contract has also provided for technical improvements to the Arizona Board of Pharmacy’s Controlled Substances Database.
Recommendation 2:
Given the overwhelming recommendations for patients with “severe and chronic pain”, explore the feasibility of further examining the nature of debilitating conditions. For instance, the current incident rates for cancer in Arizona (5-year average) was 390 per 100,000 (CI: 387.8-392.1) with an average annual count of 25,432 cases.10 However, in the medical marijuana database, there were only 467 patients with cancer as a unique debilitating condition.
Recommendation 3:
Explore the feasibility of temporary suspensions of cards. For revocations, the current AMMA statute provides only two possibilities with a cardholder status as either active and/or revoked. For instance, during the reporting period, there was one revocation for a QP and two revocations for designated CGs. In either case, there are a series of administrative actions that need to occur before a card is revoked, including the possibility of appeals through Administrative Hearing and Superior Court. During this time lag, a card remains in “active” status (i.e. the cardholders are protected by the AMMA) until a final decision is made; thus, providing immunity to potential misuse of AMMA provisions.
Currently, without a legislative change or amendment to the AMMA, a temporary suspension of cards is not feasible.
Recommendation 4:
Amend AMMA provisions to explore the feasibility of conducting epidemiological analysis of medical marijuana users to understand public health and safety concerns. For instance, epidemiological analyses can shed light on: a) whether use of medical marijuana has an effect on opiate dependency; b) whether use of medical marijuana has an impact on motor vehicle traffic injuries; and (c) whether use of medical marijuana has an impact on pregnancy outcomes or breastfeeding.
Currently, without a legislative change or amendment to the AMMA, conducting epidemiological analyses of medical marijuana users with other public health and safety data is not feasible.
Year Two Recommendations
Recommendation 1:
Given the continued overwhelming recommendations for patients with “severe and chronic pain”, explore the feasibility of collecting a more nuanced data through ICD10 codes.
Recommendation 2:
Propose Arizona Administrative Code rule changes to include the ability to appeal for dispensary certificate holders, eliminating the former “Year 2” selection criteria for dispensaries by focusing on vacant CHAAs rather than patient density, removing the lifetime disqualification for those applicants that receive a dispensary registration certificate but do not execute, and modifications to the current 25-mile radius rule.