11/26/2024

The purpose of this Special General Memorandum (SGM) is to provide guidance regarding access to Indian Health Service (IHS) clinical program providers for patients participating in state-approved medical cannabis programs.

Background

The IHS has demonstrated a commitment to ensure that comprehensive, culturally appropriate services are available and accessible to American Indian and Alaska Native people and has encouraged optimal provider-patient relationships and comprehensive provider assessment and care planning. Current Federal law specifically prohibits the use of cannabis under all but very controlled research protocols. In accordance with these laws, the IHS providers cannot prescribe, administer, or dispense cannabis for medical use. Additionally, IHS providers are prohibited from completing forms or registering IHS patients for participation in a state-approved medical cannabis program.

Definition

Cannabis:All parts of the plant Cannabis sativa L., whether growing or not; the seeds thereof; the resin extracted from any part of such plant; and every compound, manufacture, salt, derivative, mixture, or preparation of such plant, its seeds or resin. Such term does not include the mature stalks of such plant, fiber produced from such stalks, oil, or cake made from the seeds of such plant, any other compound, manufacture, salt, derivative, mixture, or preparation of such mature stalks (except the resin extracted therefrom), or the sterilized seed of such plant which is incapable of germination.

Applicable IHS Policies

Participation in state cannabis programs does not affect eligibility for IHS care and services. Indian Health Service providers may discuss cannabis use with patients when clinically relevant to patient care. Providers need to make decisions to modify treatment plans based on cannabis use on a case-by-case basis. Such decisions need to be made in partnership with the patient and must be based on concerns regarding patient health and safety. These decisions should be documented in the patient’s IHS electronic health record (EHR).

Indian Health Service providers and/or pharmacists should discuss with patients how their use of state-approved medical cannabis to treat medical or psychiatric symptoms or conditions may relate to the participation in other clinical activities, (e.g., discuss how medical cannabis may interact with other patient medications, pain management, Post-Traumatic Stress Disorder, or substance use disorder treatment). If a provider discusses cannabis with a patient, relevant information should be documented in progress notes, and considered in the development or modification of the treatment plan.

Furthermore, for patients with chronic pain syndromes and/or substance use disorders, rapid discontinuation of prescription opioids puts patients at risk for opioid withdrawal and may have other adverse consequences on patient safety, including the patient obtaining opioids or other drugs from alternative sources. According to the 2016 Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain, it is recommended that clinicians do not test for substances for which implications for patient management are unclear.[1] The updated 2022 CDC guidelines recommended that toxicology testing should not be used in a punitive manner but should be used in the context of other clinical information to inform and improve patient care, and that clinicians should not use toxicology results as the sole basis to dismiss patients from care.[2] It is recommended to discuss any potential interactions with medications or disease states with the patient, and document in the patient’s EHR accordingly.

Effective Date

This SGM becomes effective on the date signed.

/Roselyn Tso/
Roselyn Tso
Director
Indian Health Service

[1]Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1 .

[2]Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep 2022;71(No. RR-3):1–95. DOI: http://dx.doi.org/10.15585/mmwr.rr7103a1