PACProvider Posted September 14, 2014 Share Posted September 14, 2014 I have worked in sites where patients who are treated for chronic pain are tested randomly. If the patient tests positive for Marijuana, they could have the narcotics stopped and offered non-narcotic medication. I haven't had patients repeatedly test positive so I haven't stopped narcotics but I know other practitioners who eventually did stop prescribing narcotics because of simultaneous Marijuana use. I have questions if practice patterns are the same in the two states where Marijuana use is legal for non-medical use (recreational). Also, how do you respond to a patient who has a Medical Marijuana certificate (in a state where that is legal) and wants narcotics. I believe that there is no place for Marijuana in the treatment of pain and the practitioner (not the patient) should manage the patient's pain concerns. Obviously, I have not seen a lot of pain management problems so I would like to hear some other views. How do you manage the following situations? 1. Marijuana illegal in your state and patient tests positive while prescribed narcotic 2. Medical Marijuana is legal in your state and patient uses marijuana for pain and comes seeking narcotic 3. Recreational Marijuana is legal in your state and patient uses marijuana non-medically and seeks narcotics for pain. Link to comment Share on other sites More sharing options...
wilso2ar Posted September 14, 2014 Share Posted September 14, 2014 It's opioids not narcotics. When speaking about that class anyway. Sorry that's a pet peeve of mine. Our policy is no tolerance with positive THC on urine drug screen when prescribed any controlled medication (except Lyrica). I tell them it does not matter if it is medicinally or recreationally, legal use or illegal use. Marijuana is legal for medicinal use in my state. When it is legal for non-medical use and I think it will be in the not so distant future, our policy will be the same. I think we are going to see major changes in the future about opioid prescribing. I hope it is going to be a lot less common and at much smaller doses. which are both good things. Link to comment Share on other sites More sharing options...
bradtPA Posted September 14, 2014 Share Posted September 14, 2014 It comes down to trust. If they are willing to break the law to buy marijuana, can you trust them not to break the law and sell the pain meds? Also, IMHO repeated use could indicate a dependence issue, which is a big red flag for developing a dependence to opioids. Link to comment Share on other sites More sharing options...
G. Davenport Posted September 14, 2014 Share Posted September 14, 2014 It's really about management. If they use drugs that potentials opiate treatment, how can you manage it? I would terminate treatment for any threat to include benzodiazepine, amphetamines, other opiates, street drugs, etc. But that's just me. Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
gbrothers98 Posted September 14, 2014 Share Posted September 14, 2014 All of your questions should be answered in one place. That is a narcotics or opiate agreement that is discussed with the patient and signed prior to any prescription. There should be a clinic or hospital policy about prescribing opiates. That way there is no manipulative behavior on the part of patients concerning providers they will and won't see. Both should be in place if you are prescribing opiates. They protect you from making bad decisions even though those decisions may have good intent and serve as a backstop for your actions if questioned. The use of all other drugs should be outlined, whether it is marijuana, etoh, nicotine, other opiates. The end result should be that regardless of what is legal and illegal, concurrent other drug use with long term opiates (and other controlled substances) is not tolerable and would result in discontinuation of these prescribed medications. I would say no to the marijuana smoker with chronic abdominal pain, the alcoholic with chronic back pain and the anxiety disorder on benzos with fibromyalgia. We should get comfortable with the fact that for some patients we cant make them better and that adding opiates will likely make the overall picture worse. There is also zero consideration for the 50 year old patient we place on opiates and what that effect will be in their 70s and 80s. Opiate prescribing is undergoing a significant focus right now. This focus will only increase. There is now an established perception that long term opiates AND the ready availability of prescribed opiates have a significant downside not only for patients but for society and communities in general. I always thought it was intuitive that when pts where precribed opiates for nonacute, nontraumatic, nonmalignant pain that we as healthcare providers and prescribers were not truly relieving suffering but instead were playing into the overemphasized attention to pain and the overmarketing of pharmaceutical companies. We in turn created societal problems that will play out for generations both in poor health and fostering attitudes regarding the acceptance of opiates in general. We lost our way as stewards of health and became pill dispensing middle men. I am waiting for the first successful legal action re my doctor turned me into a drug addict. We know better, practice that way. Until then we are no better than opium dens and crack houses, just much cleaner and better staffed. Regards G Brothers PA-C Link to comment Share on other sites More sharing options...
winterallsummer Posted September 15, 2014 Share Posted September 15, 2014 Just to play devil's advocate here... Does anyone care to acknowledge the fact that the abuse and damage and OD potential is substantially higher for opiods than marijuana? Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted September 15, 2014 Administrator Share Posted September 15, 2014 Just to play devil's advocate here... Does anyone care to acknowledge the fact that the abuse and damage and OD potential is substantially higher for opiods than marijuana? On what basis are we going to say that? The feds have effectively put the kibosh on any MJ research with its' Schedule 1 status, so even though it's legal for recreational use in my state, I can provide zero evidence-based guidance about its use. Sure, no one goes into respiratory arrest from a THC overdose, but that doesn't mean that the long term morbidity of chronic MJ use is less than that of well-managed opioid use. You may well be right, but I was taught to practice evidence-based medicine and do no harm. Really hard to do that when the only 'evidence' is old, observational, and collected and disseminated with the specific goal of discouraging MJ use. Link to comment Share on other sites More sharing options...
PACdan Posted September 15, 2014 Share Posted September 15, 2014 There are some rather recent NIH subsidiary studies about the use of Cannabis in pain mitigation and specifically as an adjunct to opiate prescriptions with the goal of reducing the use/dose of the opioid. Also, more studies have been conducted at large, well equipped academic research institutions in highly developed countries that are not the US. Pretty sure we can get EBM from them too. We should probably refer to it as Cannabis as well. Link to comment Share on other sites More sharing options...
Contrarian Posted September 16, 2014 Share Posted September 16, 2014 Meh... In the program I'm the prescriber for: 1.) It is a "Abstinence Based" program so... no tolerance for any NON-prescribed substance. 2.) Its in a "Medicinal Cannabis" state so if they have a valid, on file medicinal cannabis authorization, we don't consider THC in the urine a positive U/A. 3.) Its also in a recreational cannabis state but no card means dirty U/A just like if we find Etoh its a dirty U/A. Cannabis HAS been shown to significantly reduce the use of opiods. Lastly... lots of folks really do need to get off the judgmental high-horse. Especially when one considers that each of these folks likely imbibe etoh. I believe that there is no place for Marijuana in the treatment of pain and the practitioner (not the patient) should manage the patient's pain concerns. Obviously, I have not seen a lot of pain management problems Curious as to how someone "believe" the former... knowing the latter... Do tell... Link to comment Share on other sites More sharing options...
winterallsummer Posted September 16, 2014 Share Posted September 16, 2014 As mentioned above, there are many studies showing the efficacy of cannabis for several disease states and illustrating the relatively low ADRs a/w it. Honestly, if cannabis was not so tabboo, would you have a problem? Would you refuse to treat a patient who has a gambling addiction? ETOH - do you turn them away? Cigarettes? Link to comment Share on other sites More sharing options...
PACdan Posted September 16, 2014 Share Posted September 16, 2014 Would you refuse to treat a patient who has a gambling addiction? ETOH - do you turn them away? Cigarettes? And in all likelihood, cannabis has the least deleterious effects on health when compared with the above. Link to comment Share on other sites More sharing options...
bradtPA Posted September 16, 2014 Share Posted September 16, 2014 And in all likelihood, cannabis has the least deleterious effects on health when compared with the above. But it's not risk free. And it definitely needs more study before I am willing to recommend it. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2797098/ Link to comment Share on other sites More sharing options...
wilso2ar Posted September 16, 2014 Share Posted September 16, 2014 I don't think It's about being on a high horse. I think it is more about current standard of care. Current standard of care in chronic opioid use for non-cancer pain it is either one or the other. I attribute this to lack of evidence of efficacy, lack of knowledge of adverse reaction especially in conjunction with opioids and lack of control over dosing. There are standards for how much and how frequent ETOH is a problem. How much cannabis is too much and what is the potency of said cannabis. I personally do not think that there is going to be much research available because once it is legalized for recreational use no one will care. Until it becomes apparent that heavy users have serious health problems . Just like any chronic overuse of any substance of abuse. Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted September 16, 2014 Moderator Share Posted September 16, 2014 I always thought it was intuitive that when pts where precribed opiates for nonacute, nontraumatic, nonmalignant pain that we as healthcare providers and prescribers were not truly relieving suffering but instead were playing into the overemphasized attention to pain and the overmarketing of pharmaceutical companies. We in turn created societal problems that will play out for generations both in poor health and fostering attitudes regarding the acceptance of opiates in general. We lost our way as stewards of health and became pill dispensing middle men. I am waiting for the first successful legal action re my doctor turned me into a drug addict. We know better, practice that way. Until then we are no better than opium dens and crack houses, just much cleaner and better staffed. Regards G Brothers PA-C Could not have said it better. And given the choice between handing out marijuana and writing for opiates...my gut tells me I'd choose the former 100% of the time Link to comment Share on other sites More sharing options...
Acebecker Posted September 16, 2014 Share Posted September 16, 2014 I don't think It's about being on a high horse. I think it is more about current standard of care. Current standard of care in chronic opioid use for non-cancer pain it is either one or the other. I attribute this to lack of evidence of efficacy, lack of knowledge of adverse reaction especially in conjunction with opioids and lack of control over dosing. There are standards for how much and how frequent ETOH is a problem. How much cannabis is too much and what is the potency of said cannabis. I personally do not think that there is going to be much research available because once it is legalized for recreational use no one will care. Until it becomes apparent that heavy users have serious health problems . Just like any chronic overuse of any substance of abuse. Cigarettes once fell into the same category as cannabis does now; legal for recreational use, but with unknown effects at that time. Since then, the surgeon general has issues a warning stating that cigarette smoking is known to cause cancer and increased of fetal death and birth defects. Same has occured with EtOH. Every substance that the public or you and I use to change our mood or alter body chemistry in some way has been shown to have deleterious effects. Cannabis is so young as a drug for recreation (and in the grand scheme of things) that we don't know yet what it will do. I read a study performed in Sweden on military conscripts that correlated lung cancer with inhalation of cannabis at a much higher rate than that of cigarette smoking. This was with just 50 cannabis use episodes in a lifetime, if I remember correctly. I'll work to find that study. Not to mention the exacerbation or uncovering of underlying psychosis which can occur with cannabis use. Or the cannabanoid induced hyperemesis syndrome. All drugs have side effects. The fact is that we don't know what cannabis will do with long term heavy use, which is quickly becoming a reality. I work in a state where it is legal for recreational use; my current recommendation to all patients who use it is that they ingest it rather than smoking it. This is unpopular as it takes longer prep time and has a slower onset. I also will not give opiates to patients who are using cannabis recreationally and I generally try to avoid opiates even if they have a medical marijuana card. As far as I have seen, there is no FDA indication for cannabis in the treatment of chronic pain. As a result, our licenses are in jeopardy if we do give opiates to folks using cannabis on a regular basis. This comes from an attorney who gave a presentation at a CME I attended. Hope this helps. The cannabis + opiates question will come up repeatedly for quite some time; we need to have a solid plan in place to deal with it. Link to comment Share on other sites More sharing options...
winterallsummer Posted September 18, 2014 Share Posted September 18, 2014 My question for those who would rather start a pt on long term opioids instead of cannabis: if your mother/spouse/sibling had to be started on one or the other - not by you but by some other PA - what would you want them on? There are studies showing no link between cannabis and lung CA however as others have pointed out this may or may not change. I worked in psych before becoming a PA and while I have seen a handful of lives significantly corrupted by cannabis (either 1. Teen smokes parents want him or her to quit or 2. Someone was arrested for cannabis possession and can't get a good job now). However this pales in comparison to the vast number of patients and individuals I've met who's lives have been ruined because of opiates. And many of them were not started on opiated by some neighborhood drug dealer in a bad part of town. They were started on them in our offices and hospitals. I by no means am trying to suggest cannabis is a solution to America's pain pill addiction. And I don't think I'd want prescribing authority for it anyway outside of oncology perhaps, because I wouldn't want people coming to me for cannabis. However I do think we as providers should open our minds a little bit - and I am speaking in general here, not directing this toward anyone on this forum. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted September 18, 2014 Administrator Share Posted September 18, 2014 With all due respect, Winterallsummer, personal experience and anecdote are no substitute for appropriately constructed and controlled studies. THAT is what we need to be arguing for: that marijuana be reclassified from schedule I to schedule II YESTERDAY so that appropriate experimentation and study can take place. No one can argue with a straight face that marijuana belongs on schedule I when opium, cocaine, and amphetamines are all schedule II.... yet there it sits. Link to comment Share on other sites More sharing options...
wilso2ar Posted September 18, 2014 Share Posted September 18, 2014 An article just published in pain medicine news stated the same, saying that there is VERY limited research. apparently pharmacologic preparations are more desirable for treatment than herbal forms. So I guess you will be able to go to the pharmacy and get your cannabis in a known quantity from a licensed pharmacist in the future instead of the local head shop that has a smoke room like the one down the road. Link to comment Share on other sites More sharing options...
winterallsummer Posted September 18, 2014 Share Posted September 18, 2014 Rev I agree with your point. Research needs to be done not only the sake of medicinal use but also how to combat ADRs for those using it recreationally. I would not be surprised if the ADRs are significant perhaps. But I still would be surprise if it compared to opiates. Link to comment Share on other sites More sharing options...
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