When It Comes to Cannabis, Nurse Practitioners Make Perfect

Some nurse practitioners are being authorized to recommend cannabis.

Being treated with medical marijuana can mean anything from getting a “consultation” on the Santa Monica Boardwalk to sitting in an oncologist’s office discussing how to incorporate cannabis oil into a cancer treatment regimen. As medical cannabis laws expand, the tendency toward regulation is clear. Many states have a strict patient application review process, and mandate a bona fide doctor-patient relationship established over multiple appointments.

But what happens when one doctor ends up recommending cannabis to over 5,000 patients? Such was the case of Dr. John C. Nadolny of Canna Care Docs, in Massachusetts. When asked by regulators to explain how this was possible, Dr. Nadolny explained that nurse practitioners (NPs) often cared for patients in his practice, and signed certificates under his supervision. Although NPs are included under Massachusetts law as “licensed physician[s]” to certify qualifying patients, regulators have cracked down on the practice, and in May Dr. Nadolny’s medical license was suspended.

On Sept. 14, the Massachusetts Department of Public Health recommended to the state Public Health Council (PHC) that NPs be allowed to certify cannabis patients, as per the 2013 medical marijuana statute; ultimately, the PHC will have the final word. The Massachusetts Patient Advocacy Alliance (MPAA)  is confident that the decision will be approved, given the wording of the law. “It’s a statutory reason that nurse practitioners should be allowed to recommend,” says MPAA Development Director Michael Latulippe.

Allowing NPs to recommend cannabis makes it easier for patients to access state medical marijuana programs. Because cannabis is a federally illegal substance, doctors are often reluctant to recommend it, particularly in states like New York that have restrictive regulatory and liability laws. Most doctors in New York who recommend cannabis are in private practice, and in order to qualify under the state’s Compassionate Care Act (CCA), they must register with the Department of Health (DOH) and complete a four-hour cannabis class.

The DOH boldly recommended in its two-year review on Aug. 29 that “authorizing Nurse Practitioners to certify New Yorkers for medical marijuana [is] consistent with their current authority to prescribe controlled substances (including opioids) for patients diagnosed with qualifying conditions covered in the CCA.”

A month later, in a Sept. 30 memo to the DOH, Stephen Ferrara, Executive Director of the Nurse Practitioner Association New York State, stated: “It’s undisputed that New York continues to face a physician shortage, particularly in the area of primary care. NPs are able to bridge this gap and are meeting patient needs that would otherwise go unmet, particularly in rural areas. Qualified patients should not be denied the opportunity to have their healthcare needs addressed, simply because the patient opts to be treated by an NP….

“NPs have the necessary preparation and experience to diagnosis patients as suffering from a ‘serious condition,’ and determine whether a patient would benefit from using marijuana. The proposed regulatory changes are consistent with this skill, education and experience of the NP community. The proposed regulation is consistent with this authorization [that] a nurse practitioner shall be considered a ‘practitioner,’ who, in accordance with the rest of MMP [medical marijuana program] regulations, may register to issue medical marijuana patient certifications.”

Ferrara also addressed the question of who is a “practitioner” in his DOH letter: “The [CCA] that passed both houses and was signed by the governor [in 2014] provided an opportunity for [the DOH] to include NPs in the medical marijuana program…. As a result, the DOH is statutorily authorized to include NPs as ‘practitioners,’ subject to the same limitations as physicians in the MMP.”

On Nov. 22, the DOH made it official, authorizing NPs to register medical cannabis patients as of Nov. 30. According to Ferrara, “Over 100 of New York’s 19,000 NPs had already completed the Medical Use of Marijuana course.”

Maine and Washington State have longstanding medical programs that allow NPs to independently recommend cannabis without the supervision of an attending doctor. In 2014, Maine’s policy was updated and expanded to specifically permit NPs to certify patients independently.

Integr8 Health, a medical cannabis practice run by Dr. Dustin Sulak in Falmouth, Me., employs six nurse practitioners. Each NP has undergone extensive training with Dr. Sulak regarding the endocannabinoid system, and has independently researched cannabis medicine.

“Nurse practitioners have the mind of a physician and the heart of a nurse,” says Laurel Sheppard, a certified family nurse practitioner (FNP-C) who works closely with Dr. Sulak on childhood epilepsy cases. “Many patients prefer nurse practitioners because we can spend more time with them,” she says.

However, some states, including Colorado and California, specifically prohibit NPs from issuing medical cannabis recommendations. The same philosophy of states’ rights that has made it possible for 29 states to legalize medical cannabis has also allowed each state to impose different restrictions on NPs that ultimately impact the patients they serve.

Only 18 states allow NPs to practice independently, and some states restrict their ability to participate in surgeries and prescribe controlled substances. There are legitimate reasons for these regulations; doctors are required to complete twice the amount of classroom time as nurse practitioners, and spend years in residency and in clinical rotations through emergency medicine, neurology and surgery, while NPs must complete 500 hours of classroom training and 500–700 hours in clinics.

Dr. Dara Huang, a New York State nephrologist and DOH-registered doctor allowed to prescribe cannabis, is skeptical about allowing nurse practitioners to recommend cannabis independently of a supervising doctor, especially in New York, where the qualifying conditions only cover patients with life-threatening debilitating diseases (such as late-stage cancer and intractable epilepsy), and those using cannabis as a last resort. These patients usually have complicated medical histories, and intense drug regimens that need to be monitored closely for drug interactions, which requires a depth of knowledge only medical doctors can provide, Huang contends.

“For cannabis medicine, where there’s a lack of research, it requires the specialty of a doctor,” she tells Freedom Leaf. “You have to be able to identify complex situations, and to see the patient not only as a cannabis patient, but as part of a healthcare team. Nurse practitioners are very valuable in the healthcare system, but we’re talking about something completely new to the field. It’s in the best interest of the patient to receive comprehensive medical care. If I had a nurse 0practitioner in my practice, they would be under my license. At the end of the day, the doctor oversees everything.”

Ferrara disagrees with Huang. «It’s just not true in New York State that ‘doctors oversee everything,'» he says. «Nurse practitioners are considered independent providers and are accountable for the care they deliver—not to a collaborating physician.»

Patients looking for an alternative to pharmaceutical treatments are challenging what was once medicine’s greatest sales pitch: Doctor knows best. A 2013 survey indicated that only 13% of medical schools even discuss the endocannabinoid system. Due to the current lack of availability of formal medical cannabis training, any healthcare practitioner who enters into cannabis medicine needs to do substantial independent research into the healing properties of THC, CBD and other cannabinoids.

By permitting nurse practitioners to recommend cannabis, states like New York, Maine, Massachusetts and Washington are opening a window to patients to choose the practitioner that’s right for them.

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