To: Alabama Medical Board of Examiners

From: Christine C Carr, CRNA, MNA

Re: Public Comment on Proposed Ala.Adm. code r. 540-y-25-01, et seq

For nearly thirty years my entire adult life has been personally and professionally dedicated to excellent, and
safe, patient care. Inspired by ICU nurses’ sacrificial care for my brother, I accepted the call to pour out my
heart, soul, and mind for my patients. Whether in nursing or medicine, hospital or outpatient care, modern or
developing health systems, we are all bound by core principles that define compassionate and excellent patient
care: a commitment to patient safety, well tested evidence-based therapies, informed consent, and the highest
standards of scientific education and inquiry.
By allowing the Alabama State Legislature, Lt. Governor, and Governor to redefine and legislate medicine,
without a commitment to the above standards and barely a word of concern from this august Board of Medical
Examiners, have we been made complicit in the most egregious example of negligence for both the patient and
future of medical standards? For what purpose? A better income-stream? Research grants? Political favor?
Whatever the reasons behind the Board’s acquiescence, let us not confuse it with words such as compassion,
science, evidence, or safe patient care. In the following, I will honor my duty as a patient advocate and remind
the Board of its duty to all patients and the future of medicine in Alabama. Before it is too late, let us correct
past errors today.
1. The ALBME has the ability to recommend legislation and advise on all matters considered medical.
First and foremost, call for a full repeal of the current “medical” marijuana act. It is so full of errors,
loose ends, poorly thought-out constructs, scientifically unfounded conditions list, etc., the entire law
should be sent to the scrap yard. The ALBME should be the first to call for its repeal.

2. The ALBME should demand that the use of the term “medical” only be applied to FDA-approved
cannabis-based medications such as Epidiolex, Marinol, etc. The other substances currently bearing the
euphemism of “medical” marijuana should be labeled “regulated cannabis products.”

3. The ALBME should increase standards for physician education and testing. Though, by law, you cannot
remove the four hour video with exam, you do have the power to increase educational standards. Any
physician applying for a cannabis certification should undergo a minimum 40-hour/5 day course that
thoroughly covers the following: review and update for every condition allowed, all known drug and
chemical reactions, pharmacology and pharmacokinetics for every FDA cannabis drug and various
dispensary formulations, a thorough study of evidence behind dosing recommendations, risk
management and mitigation of adverse events, a thorough review of systemic effects and impact on
disease states, and processes for communicating and documenting informed consent. The educational
materials should not have primary sourcing from the marijuana industry.

4. The ALBME must establish guidelines for ensuring every female patient of child-bearing years confirms
a negative UCG before purchasing cannabis from a dispensary.
 5. The ALBME should establish requirements that involve the patient’s board-certified specialist. No
cannabis-certified physician may examine or consult with a patient unless that patient has been followed
by their specialist for one year (excepting those with life expectancy less than one year), declared
treatment resistant, given a 90-day trial of current FDA cannabis medications, and consulted with the
specialist first.

6. The ALBME must address the nebulous caregiver industry. Should the Board of Nursing be involved?
Should the cannabis commission only decide how many patients a professional caregiver can manage?
Should we not insist on medical training? Drug counts? Guidelines for reporting abuse or missing
drugs? Should we not refuse a caregiver (family or professional) use of marijuana while caring for
another? What other patient care professionals are allowed to use Schedule I drugs?

7. The ALBME must demand an adverse-events reporting system, as basic patient safety requires, and a
system established to address patient injury and physician discipline.

8. The ALBME must insist on valid and reliable evidence for dosing guidelines. Even though the law
allows THC up to 50mg, or even 75mg, per day, this does not mean the ALBME can allow doses that
high. Licensed physicians must answer to the Board for dosing THC above 20mg (known limit for
Marinol). Pediatric dosing should be based on weight and data that establishes known parameters of
pediatric safety.

9. The ALBME must set the standard for addressing and exposing conflicts of interest. The Alabama
cannabis commission currently tolerates doctors that should not be involved. The ALBME should use its
powers of advisement and recommend the removal of physicians that currently profit from the marijuana
industry, whether through research grants, clinics, lobbying activity, or any other personal gain.

10. The ALBME and Alabama Law Enforcement Agency, together with the Alabama Board of Nursing and
Alabama Department of Public Health, must call for a robust toxicology data network. In order to assess
patient and community impact of drugs, consistent toxicology screening should occur for every
ER/Hospital managed trauma, county coroner examination, motor vehicle accident, and acts of
public/domestic violence.

I implore you to rethink this terrible legislation and its future impact on patients, public safety, and the quality
of medical research. There is no clear path forward, except for a full repeal. The ALBME cannot regulate this
statute to safety. The Alabama Legislature of tomorrow cannot adequately repair the statute through piecemeal
legislation. Very soon, financial and legal entanglements will cement the marijuana industry’s grip on
Alabama’s healthcare system. This time is your time. This task is your task. This burden is your burden.
Call for full repeal. Re-establish the honor of the ALBME. Save the future of medicine in Alabama today.

Sincerely,
Christine C Carr, CRNA, MNA