Written Certification and the Medical Use of Marijuana
Hawaii's Medical Use of Marijuana Law requires that in order to be authorized to engage in the Medical Use of Marijuana, patients must undergo a medical examination and be certified in writing by a Physician (MD, DO) or an Advanced Practice Registered Nurse (APRN) as having met certain eligibility criteria set by the State, as well as establish a Provider-Patient relationship with the Physician or APRN performing the Certification.
The Law says that patients are authorized to engage in the Medical Use of Marijuana only if (1) they have been diagnosed as having a debilitating medical condition, (2) a certifying provider has certified in writing that the potential benefits of the Medical Use of Marijuana likely outweigh the risks, and (3) the patient does not exceed their "adequate supply" of Marijuana for Medical Use.
One reasonable conclusion that can be drawn from this definition is that the instant Written Certification has taken place, patients are authorized to engage in the Medical Use of Marijuana for their own personal use under the supervision of a Physician or APRN, which entitles the patient to engage in the acquisition, possession, cultivation, use, distribution, and transportation of Marijuana for Medical Use, and which also provides the only way that an "uninterrupted availability" of Marijuana for Medical Use can be achieved.
Registration with DOH after being Certified is also required by state law, and should be completed either at the same time as Certification or shortly thereafter in order to obtain a Registration Card as soon as possible and to protect against possible harassment. However, patients may want to be aware of a conflict that exists between Hawaii's Medical Use of Marijuana Law, which says that Written Certification authorizes medical use, and DOH's policy that patients are not authorized to engage in the use of "Medical Marijuana" until their Registration Card arrives. The current wait time for receiving a Registration Card in the mail is 4 weeks from the time that an error-free online Registration Application is submitted, which does not allow for "uninterrupted availability".
Until this conflict can be resolved, patients who feel that they cannot wait for a Registration Card to arrive because of medical necessity, may want to take steps to document that Certification has taken place and that Registration is being processed. Such documentation can be accomplished by having Certifying Providers use the Physician Certification form that DOH created when it first took over the Registry Program. This form even includes a space at the top where the Registration Application number can be entered. This number is generated the second that the Online Registration process is started and is kept in DOH's records indefinitely.
A valid government-issued ID.
One page from your medical record that documents your qualifying medical condition.
An active email address.
A credit or debit card to pay the online state registration fee of $ 38.50.
FINDING A CERTIFYING PROVIDER
The problem with finding Certifying Provider in Hawaii is rooted in the fact that Medical Doctors receive practically zero education on Cannabinoids and the Endo-Cannabinoid System during medical school, and are therefore hesitant to get involved with something that they know very little about. Physicians also have an unfounded fear that being associated with the Medical Use of Marijuana could put their DEA controlled substance registration and state medical license at risk, and some have come to the false conclusion that the only way a substance can have medical use is if it has received FDA approval.
One way to approach this topic is to have a honest conversation with your Primary Care Provider about the Medical Use of Marijuana and its potential benefit for your condition. If your Provider does not feel comfortable performing a Written Certification, then ask if you can be referred to a Physician or APRN who provides this service. If your Provider is solidly against the Medical Use of Marijuana, and has a negative attitude towards the subject, then it might be time to find a new healthcare professional.
Recent updates to Hawaii's Medical Use of Marijuana Law (HB2707/Act230) now make it possible for APRNs, who have prescriptive authority and state and federal controlled substances registration in Hawaii, to perform Written Certifications. APRNs are also able to provide medical care in the State of Hawaii without Physician oversight, and therefore can create a Provider-Patient relationship with those requiring Certification, which is also a requirement of Hawaii's Medical Use of Marijuana Program. Hopefully, this will make it easier for patients to become Certified, since Nurses traditionally work more closely with patients and are generally more inclined to put Compassion before Convention.
Medical Cannabis Coalition of Hawaii (MCCHI) is one local advocacy group that maintains a list of Providers who perform Written Certifications. Beware of Written Certifications that are performed by any type of Provider other than a MD, DO or APRN. If a certification exam is performed by someone other than a MD, DO or APRN, or a Registration card is signed by a Provider with whom the patient has never met, then the patient may have been a victim of medical fraud, and may want to file a formal complaint with RICO.
PREPARING FOR THE CERTIFICATION EXAM
For many patients, the most difficult part of preparing for a Written Certification is gathering the necessary funds to cover the cost of the Certification Examination. Fees can range anywhere from a medical visit that is billed to the patient's Medical Insurance and includes a free Written Certification, to $300 in cash for a 10 minute evaluation in a busy "Blue Card clinic". There is no regulation over how much a Certification Examination can cost, so it's completely up to the Provider.
Some Certifying Providers require that patients bring copies of the relevant parts of their medical record that document the qualifying debilitating condition to the Certification Examination, others do not. This completely depends on the level of documentation that the Certifying Provider feels is necessary to justify Certification, and the availability of prior medical records. Most would probably agree that making a seriously ill patient with an obvious diagnosis go to great lengths to obtain historical medical documentation is neither required or appropriate.
Hawaii's Medical Use of Marijuana Law requires that Certifying Providers do more than just fill out their part of the online Registration Application. The law (HRS 329-126) requires that there be an informative discussion that covers the risks and benefits associated with the Medical Use of Marijuana, and a decision that the Medical Use of Marijuana is the safest and most potentially effective self-treatment available for the patient's debilitating medical condition.
In order to make the most of the Certifying Examination, patients may want to prepare specific questions regarding the application of the Medical Use of Marijuana for their particular condition. Cannabinoid receptor variability, type of debilitating illness, form of Marijuana preparation, and route of administration, will all contribute to the effectiveness of such medical use, and therefore, need to be discussed on an individual basis.
THE PROVIDER-PATIENT RELATIONSHIP
Hawaii's Medical Use of Marijuana Law (HRS 329-123) requires that Certifying Providers have a bona fide Provider-Patient relationship with the qualifying patient.
DOH's Medical Use of Marijuana Administrative Rules (HAR 11-160-2) define a bona fide Provider-Patient relationship as one in which the Provider is responsible for the "assessment, care and treatment of the qualifying patient's debilitating condition with respect to the medical use of Marijuana", which includes:
1) Performing an in-person assessment with physical examination.
2) Providing follow up care and treatment as medically appropriate.
3) Maintaining standard of care medical records.
SUBTLETIES OF THE PROVIDER-PATIENT RELATIONSHIP
While DOH's definition of the Provider-Patient Relationship states that treatment must be provided as medically appropriate, it should be noted that Providers who are certifying patients for the Medical Use of Marijuana are not treating these patients with Marijuana. The use of Marijuana to treat a medical condition would require a drug product that has been approved by the FDA for medical use. Certifying Providers are simply verifying that the qualifying patients meets certain eligibility criteria set by the State, and providing guidance on how to use Marijuana safely and effectively for their medical condition.
Treatment and Care are not the same thing. Medical Treatment involves a licensed Health Care Professional who is using of an FDA approved drug product or medical device for a specific medical purpose. Medical Care, in the case of the Medical Use of Marijuana in Hawaii, involves education on the safe and effective use of the Marijuana that patients are producing and using to treat themselves, along with appropriate follow up to assess whether patients are maximizing the benefits of such self-treatment that they have rightfully chosen to manage their own health.
DOH's rules on the Provider-Patient Relationship also require that an in-person examination be performed on all patients, or at least on all new patients. However, Hawaii's Telemedicine Law (HRS 453-1.3) clearly provides an alternative form of medical examination that may be the only option for bed-ridden patients on outer islands that are not able to travel for an in-office examination. Of course, the ideal situation is one where the Certification Examination is conducted in person, since this is the primary way that trust can be established within the Provider-Patient Relationship, although such trust can also be established via Telemedicine depending on how the encounter is conducted.
Finally, DOH's rules require that a Physical Examination be conducted in order to establish a Provider-Patient Relationship. However, it should be noted that Physical Examination is just one way of assessing the medical status of a patient. Verbal Examination is another. In fact, there are instances, especially with severe chronic pain patients, where a Physical Examination that is performed in order to elicit pain and justify eligibility is completely inappropriate and could actually aggravate or worsen the patient's debilitating condition.
Both the Certifying Provider and the Patient must maintain the utmost respect for the Provider-Patient Relationship, since this is the primary way that trust can be established and the patient can receive the best care possible. As long as the patient's medical needs are placed first and addressed appropriately by the Provider, then the patient will always benefit from the Provider-Patient Relationship.
DOH's Adminstrative Rules that define the Provider-Patient Relationship require that Certifying Physicians and APRNs provide ongoing follow up care as medically appropriate to assess patients' response to their own self-treatment during the course of the Medical Use of Marijuana. This could mean whatever form of follow up care is accessible and effective for the patient, including the use of the various electronic communication modalities that are currently available that allow for protection of confidential medical information.
The Medical Use of Marijuana requires a degree individual patient customization that is unprecedented in the medical profession. Individual physiologic make-up, type of debilitating illness, form of Marijuana preparation, and route of administration all contribute to the effectiveness of the medical use of this botanical substance. Therefore, patients should be able to obtain guidance from their Certifying Provider when needed on the appropriate use of this substance during the course of their Medical Use of Marijuana.
Disclaimer: The information on this webpage is for educational purposes only, and is not intended as legal advice. This webpage is an exercise in Freedom of Speech, and is afforded all the rights and protections of our Constitution. Please consult with a lawyer for professional legal advice on the Medical Use of Marijuana in Hawaii.