Slide 1

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 2

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 3

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 4

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 5

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 6

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 7

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 8

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 9

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 10

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 11

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 12

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 13

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 14

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 15

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 16

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 17

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 18

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 19

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 20

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 21

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 22

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 23

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 24

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 25

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 26

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 27

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 28

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 29

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 30

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 31

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 32

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 33

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 34

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 35

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 36

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 37

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 38

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 39

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 40

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 41

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered


Slide 42

Caregiver Roles in the
Use of Marijuana
Division of Licensing and Regulatory
Services
July 2011

Conundrum
According to the U.S.
Attorney, “Nor does
this guidance preclude
investigation or
prosecution, even
when there is clear and
unambiguous
compliance with
existing state law….”

Federal Position
The federal government continues to be
concerned about the growers and
dispensers, not the patients. In July, the
Justice Department said that marijuana
dispensaries and licensed growers in states
with medical marijuana laws could face
prosecution for violating federal drug and
money-laundering laws.

Legally Prescribed Meds
• Marinol – It comes in the form of a pill and is being studied by
researchers for suitability via other delivery methods, such as an
inhaler or patch. The active ingredient is synthetic THC, which
has been found to relieve the nausea and vomiting associated
with chemotherapy for cancer patients and to assist with loss of
appetite with AIDS patients.
• Side effects – For some patients, it causes confusion; decreased
coordination; dizziness; drowsiness; elevated or relaxed mood;
headache; nausea; stomach pain; trouble concentrating; vomiting;
weakness.

Drugs Under Study
• Sativex - An oral spray approved outside the U.S. and
derived from the cannabis plant (THC and
cannabinoids) and not a synthetic. For use in treating
symptoms of MS. Trials underway for treating cancer
pain.
• Side Effects - Dizziness and tiredness. Some people
may also feel depressed or confused, may feel overexcited or lose touch with reality, may have difficulties
with memory or trouble concentrating and may feel
sleepy or giddy.

What is Marijuana Authorized For?
•
•
•
•
•
•
•
•
•

Cancer
Glaucoma
Positive Status for HIV
Hepatitis C
ALS
Chron’s
Agitation of Alzheimers
Nail-Patella Syndrome
A chronic or debilitating
disease/medical condition
or its treatment that
produces intractable pain.

• Cachexia or wasting
syndrome
• Severe nausea
• Seizures characteristic of
Epilepsy
• Severe and persistent
spasms characteristic of
MS
• Any other medical
condition or its treatment
approved by the
Commissioner of DHHS

What the literature says:
• Cancer – According to the
National Cancer Institute,
there has been much
interest in the use of
marijuana to treat
chemotherapy-induced
nausea and vomiting in
cancer patients. However,
there are no definitive
research results. Advocates
cite its effectiveness for
chemotherapy induced
nausea and vomiting.

• Glaucoma – Advocates cite
evidence that hemp products
can lower intraocular
pressure (IOP) in people
with glaucoma. The
Glaucoma Research
Foundation, however,
indicates a high dose of
marijuana is necessary to
produce a clinically relevant
effect on IOP in the short
term and requires constant
inhalation, as much as every
three hours.

The literature……
• Positive Status for HIV
– Some patients use
marijuana to stimulate
appetite and reduce
nausea. Some may use
it for the
accompanying
peripheral neuropathy.

• Hepatitis C - Published in
the October 2006

European Journal of
Gastroenterology and
Hepatology, a Northern
California study involving
71 participants
demonstrated that
moderate marijuana use
may relieve interferon’s
side effects, helping people
with Hepatitis C stick with
the full treatment regimen.

The literature……
• ALS – The Department of
Rehabilitation Medicine at
the University of
Washington conducted a
2004 survey. This study
was the first, anonymous
survey of persons with ALS
regarding the use of
cannabis. There were 131
respondents, 13 of whom
reported using cannabis in
the last 12 months.
Although the small

number of people with ALS
that reported using cannabis
limits the interpretation of
the survey findings, the
results indicate that cannabis
may be moderately effective
at reducing symptoms of
appetite loss, depression,
pain, spasticity, and drooling.

The literature……
• Crohn’s - anecdotal
evidence that
cannabis relieves
some of the
symptoms of
inflammatory bowel
disease

• Agitation of
Alzheimers –
Marinol has been
used for this, but
not everyone has
good results with
marinol.

The literature……
• Nail Patella
• Intractable Pain –
Syndrome The number one
Marijuana may help
reason why
relieve the
physicians
associated pain.
recommend
marijuana.
Anecdotally,
patients reduce the
use of narcotic pain
medicines.

American Nurses
Association
Position:

Pro to the question "Should marijuana be
a medical option?"

Reasoning:

"The American Nurses Association (ANA) recognizes that patients should have safe
access to therapeutic marijuana/cannabis. Cannabis or marijuana has been used
medicinally for centuries. It has been shown to be effective in treating a wide
range of symptoms and conditions." "Position Statement: Providing Patients
Safe Access to Therapeutic Marijuana/Cannabis," American Nurses Association
(ANA) website, Mar. 19, 2004

American Medical
Association
Adopted a resolution in November 2009, calling for
the government to review its classification of
marijuana, in order to ease the way for more
research into the use of medical marijuana.
While the AMA, the largest physician's organization
in the U.S., explicitly states it does not endorse any
current state-based medical marijuana programs or
the legalization of marijuana, the move is a
significant shift that continues a trend toward
support for easing restrictions against the drug.

Routes of Administration
• Progress has been made in recent years to reduce
the disadvantages of certain routes of cannabis
administration, notably the slow onset of action
with oral use and harm associated with the
inhalation of combustion products when smoking
cannabis.
• "Inhalation of carcinogenic combustion products
associated with smoking is generally regarded as
the major health hazard in connection with the
medical use of cannabis products.”

Consumers in NF’s

Norma Winkler, 82, uses cannabis oil mixed with applesauce to ease
pain from a back injury. She would not consider living in a nursing
home that did not permit her to use the oil. (from the NY Times)

Things Caregivers Need to Know
•Children and
incapacitated adults
have the same
opportunity to
participate in the
program, with the
permission of their
guardians, or the
assistance of a
caregiver.

•Licensing staff are not
responsible for
monitoring the
administration of
marijuana in nursing
homes or inpatient
hospice, the only
approved settings where
staff of facilities may
assist patients. There are
separate program staff.

No Assisted
Housing

Prohibitions
A person whose conduct is authorized under the
MMMP Act may not be denied any right or
privilege or be subjected to any penalty or
disciplinary action, including but not limited to a
civil penalty or disciplinary action by a business
or occupational or professional licensing board
or bureau, for lawfully engaging in conduct
involving the medical use of marijuana
authorized.

Protections
• A school, employer or landlord may not refuse to enroll or
employ or lease to or otherwise penalize a person solely for
that person's status as a registered patient or a registered
primary caregiver unless failing to do so would put the
school, employer or landlord in violation of federal law or
cause it to lose a federal contract or funding.
•This does not prohibit a restriction on the administration or
cultivation of marijuana on premises when that
administration or cultivation would be inconsistent with the
general use of the premises.

Permissions
• A landlord may prohibit the smoking of
marijuana for medical purposes on the
premises of the landlord if the landlord
prohibits all smoking on the premises and
posts notice to that effect on the premises.
• Bangor Daily News story on campus
students – reminding students it is a smoke
free campus.

DHHS Position
• MMMP rules provide guidelines for NF and
inpatient hospice to ensure the security and
non-diversion of marijuana.
• DHHS works closely with Maine DEA, the
federal government and other law
enforcement officers to validate participation
in the program, when necessary.

Patients, Caregivers and
Dispensaries
• On September 28, 2011, registration for patients
became voluntary. Patients may voluntarily
register and receive a registry identification card,
or may choose to simply carry their written
physician certification form.
• Lawful acts include possession of no more than
2.5 ounces of prepared marijuana and no more
than 6 mature flowering marijuana plants.

Unlawful Acts
• Undertake any task under the influence of marijuana
when doing so would constitute negligence or
professional malpractice or would otherwise violate any
professional standard
• Possess marijuana or otherwise engage in the medical
use of marijuana:
(1) In a school bus;
(2) On the grounds of any preschool or primary or secondary
school; or
(3) In any correctional facility;

More Unlawful Acts
• Smoke marijuana:
(1) On any form of public transportation; or
(2) In any public place;

• Operate, navigate or be in actual physical control
of any motor vehicle, aircraft, motorboat,
snowmobile or all-terrain vehicle while under the
influence of marijuana; or
• Use marijuana if that person does not have a
debilitating medical condition.

Confidentiality
• Information about patients, caregivers and
physicians is confidential.
• DHHS may verify to law enforcement
personnel whether an identification card is
valid.
• All existing medical information in DHHS
records will be expunged in 6 months.

Experience to Date
• Most patients who apply are very sick
and/or suffering individuals. Pain is the
number one condition.
• Most have tried other forms of treatment
and/or medication for their conditions
without success.
• Many favor marijuana over scheduled drugs
because of fewer side effects.

More Experience
• More physicians than were anticipated are
certifying patients and DHHS has given them
authority to recommend marijuana for less than 12
months.
• An ounce of prepared marijuana is enough for 70
joints. A patient may have 2.5 ounces every 15 days.
• The THC content in medical grade marijuana is
increasing 10% each year.
• Maine is seeing an increasing in treatment for
marijuana addiction.

Facility Participation
• Inpatient hospice providers and nursing facilities
may voluntarily participate in the MMMP to assist
registered patients. It is not required.
• MMMP documentation is not included in the
medical record, chart or medication administration
record that is required under facility licensing
and/or certification laws.
• A registered patient’s MMMP record must be
maintained at the facility as a separate record and
shall include but is not limited to the inventory
record, documentation of marijuana
administration and the relief provided.

Process
• Patients designate the nursing facility as a
primary caregiver.
• The physician certification of the patient’s
qualifying medical condition is required.
• The nursing facility or inpatient hospice
must register with DLRS and registry
identification cards will be issued to staff
who will help the resident.

More Process
• Sources of marijuana must be registered as
caregivers or dispensaries, unless it is a
family member, where no registration is
required.
• Facilities are not required to help in
marijuana administration.

More and More Process
• If the facility has a criminal background
record for an individual staff member within
the last 12 months, send it along to DLRS. If
not, DLRS will request a background check.
There is no charge.
• Staff are prohibited from assisting patients if
there are drug offenses within the last 10
years of more than a misdemeanor.

More and More
• No staff member should remove his or her
card from the facility unless transporting
marijuana from a dispensary or caregiver.
• Marijuana from a dispensary will be labeled
with a trip ticket indicating the amount.
• A facility may not cultivate marijuana for a
registered patient.

More and More
• Dispensary may deliver.
• A facility may not make marijuana into
products to be ingested. Edibles may be
purchased from a dispensary or caregiver.
• Edibles from a dispensary or a registered
caregiver will be labeled as food products
with ingredients and the amount of
marijuana in the dose. Family members are
not required to do this.

More and More
• Registered patients may not keep marijuana
in their room or on their person as it is a
danger to other residents. The facility must
store the marijuana in accordance with the
provisions for storing controlled substances.
Special storage consideration is required for
food that contains this controlled substance.

More and More
• When marijuana is removed from inventory,
it must be signed out by two licensed staff
persons who have MMMP registry
identification cards. In the event there is
only one licensed staff on duty, a CNA-M
may be substituted once rules are changed.
• Unless the dispensary or the cultivating
caregiver has provided the marijuana in unit
doses, the facility will need scales and other
necessary tools to monitor its marijuana
inventory.

More and More
• Prepared marijuana must be kept under double
lock and inventoried daily by two staff persons who
have MMMP registry identification cards, one of
whom must be a licensed professional.
• A medication technician or a nurse may administer
marijuana as long as he or she has a registry
identification card.
• The registered patient’s cultivating caregiver may
not administer marijuana medication in the
facility.

More and More
• The fact that a patient is participating in the
medical use of marijuana program is highly
confidential and each facility serving
MMMP patients must develop “need to
know” protocols.
• The registered patient will let the facility
know what dosage gives relief. The lowest
dosage possible that gives the registered
patient relief is optimal.

More and More
• Patients who smoke marijuana are subject to the
same facility policies as patients who smoke
tobacco. The facility may encourage registered
patients that the use of alternative forms of
marijuana administration may be preferable.
• Follow established protocols for monitoring
patient response to any treatment or medication
and observe the registered patient’s response to the
administration of marijuana.

More and More
• A resident may not be discharged solely because the patient
registers in the Maine Medical Use of Marijuana Program.
• Unused, unadulterated marijuana in the possession of the
registered patient, registered primary caregiver, a hospice
provider or a nursing facility named as a primary caregiver,
or a registered dispensary that is no longer needed for the
registered patient’s medical use may be disposed of by:
Donating it to a registered patient; or
Donating it to a registered primary caregiver; or
Donating it to a registered dispensary.

Unused marijuana may also be disposed of by transporting
the unused portion to a state or local law enforcement
office. Presentation of a valid registry identification card
and a Maine driver’s license or other state-issued photo
identification may be required.

Resources
www.maine.gov/dhhs/dlrs

Growing medical grade marijuana is an art to be
perfected in Maine.

Thank you!
Be open minded
Be patient centered