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By DAN REYNOLDS, senior editor of Risk & Insurance®

The fact that 14 states have passed legislation decriminalizing marijuana has only complicated what is already a nettlesome risk management burden for hospitals and healthcare providers.

What if you need to give a patient some pain medication and they've already cooked their morning eggs in a marijuana-infused butter? How is that patient going to react to something you might want to prescribe for them from your pharmacy?

"You don't want staff to operate in uncertainty," said Renee Bernard, the director of risk management at the Stanford University Medical Center. Bernard made her remarks on Oct. 15 at the annual conference of the American Society for Healthcare Risk Management (ASHRM) in Tampa, Fla. More than 150 risk managers attended her presentation.

HIGHER SEVERITY IN THE E.R.?

Where the profusion of medical-marijuana use might create the biggest problems is in hospital emergency rooms, an area of healthcare that is already high risk and the source of high-severity claims.

Emergency departments are going to see their job get a lot harder, according to Dr. Matthew Rice, the chief medical officer and senior vice president for Northwest Emergency Physicians of TeamHealth, which provides emergency-room personnel in Washington, Oregon, Montana, Wyoming and Idaho.

In the area of psychiatric care, Rice said, the United States has been underserved for decades. Hospital emergency rooms are already serving as the "safety net" for patients who don't have the money or the health coverage to have their mental health needs met elsewhere.

In many cases these patients could be self-medicating with marijuana or with something even stronger. A patient who uses a prescribed psychotropic drug could find that drug's effectiveness impacted by the use of marijuana. Rice said that formulated psychiatric medications have a specific neurological focus, and that a drug such as marijuana could interfere with that precision of medication.

"Certainly, we do lots of drug screens on patients that have impairments, and it is very, very common to find tetrahydrocannabinol (the active ingredient in pot) as being present in the person's screen," Dr. Rice said. "Whether the drug is causing a side effect that is related to the impairment or not, we can't always sort that out because sometimes you will have multiple drugs that will show up in the same test," he said.

That's just the beginning, said Dan Groszkruger, a Stanford University Medical Center risk manager who is also an ASHRM board member.

"How do you know what it is and where it comes from? What is the quality, what is the dose, what is the frequency? I mean, none of that is going to fit within our existing methods and structures," Groszkruger said.

MUM'S THE WORD?

States may make their own laws, Bernard said, but marijuana is still an illegal substance under the federal 1970 Controlled Substances Act; thus, the concern among healthcare risk managers in Tampa that, if they allowed their staff to knowingly condone marijuana consumption, they ran the risk of losing federal funding.

It's wise for healthcare risk managers to remind their physicians and nurses of one thing in the middle of all this uncertainty, Bernard said.

The right to recommend marijuana use is covered by the First Amendment. But so is the right not to touch the topic verbally if risk managers or physicians feel the risk is too great.

"Freedom of speech includes the freedom not to speak," Bernard said.

October 22, 2010

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