medical marijuana

[kittryn]

The majority of the states have chronic or severe pain on the list.  My guess is that will be the majority  of patients you will see and need to evaluate.  How will you decide the pain is chronic and severe?  Does the practice require the past medical records of the patients, including surgery notes, pain clinic notes, primary care notes, psychiatric notes, specialty notes etc. before you see the patient? That in itself will take lots of time to sort out the patients and you will spend plenty of time with the patient discussing their results.  Does the clinic review disability documents to review why a patient is medically disabled?  Do you verify?

 

If this method is used you will probably see 4 patients a day while you call for records, wait for faxes, etc., etc., etc.  

 

Are you paid on production?

 

Are the physicians who write the certification paid on production or volume?

 

Do patients pay cash?

 

if you read my posts, you would see the answer to these and other questions.

 

yes, they must bring complete medical records documenting qualifying conditions.

 

it is not a given that the majority have pain issues, or at least not chronic pain as the primary condition. many come with pain 2/2 cancer, devastating neurological conditions, etc.

 

since it is a practice that does not take insurance, only cash (check, etc), we can spend as much time as we want/need talking to/evaluating the patient and going through med recs with them.

 

no one is paid on production. we are simply treating patients.

 

we follow up with these patients as well, to see how they are progressing.

[kittryn]

Bully for you. But you bet wrong so you lose.

 

Do you always discount the opinions of those who disagree with you?

 

With regards to the hammer, case of mistaken identity. I didn't touch you. I swear.

 

Be careful though, a fall from such a high horse can really hurt.

 

Sent from my SM-G900V using Tapatalk

 

I read all your posts and you sound like a hard-headed and hard-hearted person, even a bully, not just with me but with others.

 

I won't take anything to heart coming from such a person, so you might as well save your energy.

 

and yes, I have always enjoyed the ride from the back of a tall horse, it's just how I am. if you're a good rider, it's not dangerous. but you sound like someone who would enjoy watching someone fall from a height. wonderful quality in a medical provider.

 

good luck to you.

[JohnnyM2]

wtf are you talking about?

 

and yes, I have always enjoyed riding a tall horse, nothing wrong with that.

I was wondering how long it would take you to get all emotional. You have a lot of hot buttons that are fun to push. I find this to be true of many know-it-all liberals. Are you one of them? You seem to be so totally sure you are always right. Feel free to launch a final tirade. I will give you the last word and cease taunting you before the moderators get upset.

[rev ronin]

How about not taunting each other because it's the right thing to do (or not do) on a professional forum, rather than waiting for one of us to close the thread as having devolved too far?

 

I don't think any medical professional should ever use the phrase "big pharma", and it's unprofessional to do so, but I fear I set the thread on an entirely wrong track by highlighting that unprofessional language.

[kittryn]

so much for open discussion. I expected better of my profession.

 

I actually would welcome you closing the thread, rev. be my guest. I prefer not to throw my pearls before swine.

[Guest Paula]

Well, G. K. Chesterton had it right.   Most of us are wicked and naturally prefer mercy.  

 

Perhaps we can all extend each other some grace.  

[cbrsmurf]

MJ may have some use in some neurologic disease/symptoms and chronic pain

 

JAMA

http://jama.jamanetwork.com/article.aspx?articleID=2338251

 

Cochrane Review

http://www.neurology.org/content/82/17/1556.short

 

Mods shouldn't have to close a thread on an important medical topic, but they should ban/temp ban users who disrespect/attack others

[kittryn]

MJ may have some use in some neurologic disease/symptoms and chronic pain

 

JAMA

http://jama.jamanetwork.com/article.aspx?articleID=2338251

 

Cochrane Review

http://www.neurology.org/content/82/17/1556.short

 

Mods shouldn't have to close a thread on an important medical topic, but they should ban/temp ban users who disrespect/attack others

 

 

thank you for the citations and the support of an important topic.

[problem child]

MJ may have some use in some neurologic disease/symptoms and chronic pain

 

JAMA

http://jama.jamanetwork.com/article.aspx?articleID=2338251

 

Cochrane Review

http://www.neurology.org/content/82/17/1556.short

 

Mods shouldn't have to close a thread on an important medical topic, but they should ban/temp ban users who disrespect/attack others

 

Thank you for the links and for bringing this back to reasonable discussion! It's an important topic and should not be denigrated to valueless status!

[cbrsmurf]

One effect that I thought was interesting, that I didn't before reading those reviews, was that mj frequently causes nausea.  I had sometimes tried it as an anti-nausea med when I couldn't use my 1st, 2nd or 3rd lines in oncology.  I had also written marinol and mj as an appetite stimulant in my chemo pts.

[cinntsp]

so much for open discussion. I expected better of my profession.

 

 

 

You are arguing with someone that isn't a PA, just fyi.  Please continue to post your thoughts.

[winterallsummer]

Those saying cannabis has many side effects and many people are going to use it "medically" just to get high rather than treat their pain responsibly are accurate.  However, the exact same can be said for opiates.  But I think we all know this.

 

Those expecting cannabis to be a magic bullet are in for a grand disappointment (implying nothing here regarding the petty argument between members which reflects poorly on our profession, could care less and am not taking sides.)  In my opinion, providers will probably run into the same frustrations with cannabis as they do with opiates.  Patients will demand them.  Patients will abuse them.  Patients will, after using them for a while, want something stronger.  And yes patients will want cannabis AND opiates - thinking otherwise is simply inaccurate.  I saw a local news spot a week ago with a guy talking about how awful it is that cannabis is illegal and he is "addicted to opiates."  Not to be insensitive, but give me a break - reality is this guy looked stoned during the interview and is very likely on both.  Are there a few patients that it will be the "miracle drug" for and they will get off opiates and turn their life around?  Probably so yes, but very few.  But are there going to be patients who become addicted to cannabis, whom cannot "enjoy anything" without cannabis in their system, whom become alienated from their families and emotionally addicted to the drug?  Yes, absolutely.  And of course there will be plenty of patients using both.

 

There is a role for cannabis in medicine.  I think the most well defined role is in terminal cancer patients with pain and nausea.  I don't mind chronic pain patients taking it if they are doing it responsibly - that is their choice in this country - but I don't want that coming from me.

 

Unfortunately, medicalizing and/or legalizing cannabis and expecting it to revolutionize medicine - it is just not realistic.  We are going to now have patients who used to deal with drug dealers now coming to us for the drug.  We are going to have addicts faking conditions to get "medical grade" cannabis.  And what will happen when the patient on cannabis is hospitalized and it's the only thing that works for them?  Are they supposed to go outside and light up out front with the IV pole connected (granted they do this with TOB anyway.)

 

We all know the real answer to chronic pain.  Counseling, better diet, exercise, getting involved in the community and having better support, etc etc.  However still people are wanting the magic bullet, be it opiates or cannabis or whatever, instead of actually addressing this.  I am speaking more about patients than providers here.

 

I personally do not even care to be in the position to perscribe this stuff.  I don't take issue with other PAs writing for it.  If you want to deal with it, fine.  I have no problem with that.  It just seems like a giant headache to me.

 

ALL of that being said, I have absolutely no problem with cannabis being legalized across the board.  In a society where gambling, alcohol, tobacco, firearms and even in some states prostitution is legal, it is pretty funny that cannabis is not.  And just like with TOB, states can be taxing this stuff to help with education, etc.  Also if it were legal across the board, then we as providers don't even have to deal with this.  Yes there are side effects.  Yes it may cause cancer, we just don't have the data to know all of these things yet.  If you are an adult in America, you have the right to do many things, and as long as you accept whatever consequences unfold, it is not my place as a PA to become your conscious or parent.

 

My issue is not with cannabis.  Lots of my patients use cannabis.  Can't say I am thrilled about it but I treat them just the same.  In COPD, etc, obviously I take greater issue with this.  But when patients press me if it's better for them to stop smoking TOB vs cannabis, it would labor me to answer the latter.  

 

Anyway, those are my thoughts on this issue.  Saying it is a miracle drug is unrealistic.  Saying it is the worst thing ever while not advocating for banning alcohol and gambling is a bit confusing, however I do see your all points on this.  Bottom line is cannabis is probably going to be medicinalized and legalized fairly soon and we are going to have to answer patients' questions about it.  So we all need to keep up with the emerging literature on this topic, and as with all situations in medicine, be able to talk openly and honestly with our patients about it.

[problem child]

You are arguing with someone that isn't a PA, just fyi.  Please continue to post your thoughts.

 

 

???? c'est que c'est ???? c'est vrai????

 

I've been following this thread...the turnip isn't a PA? I didn't look so closely.

 

what is he???

[JohnnyM2]

You are arguing with someone that isn't a PA, just fyi. Please continue to post your thoughts.

...and whatever you do, DO NOT PAY ANY ATTENTION TO SOMEONE WHO ISN'T A PA. Even if they have a PhD in chemistry and spent their entire career in the medical industry. Without that PA-C, what, of value, could they possibly have to contribute? And how dare they interlope on a forum designed for PAs? The nerve....

[cbrsmurf]

Those saying cannabis has many side effects and many people are going to use it "medically" just to get high rather than treat their pain responsibly are accurate.  However, the exact same can be said for opiates.  But I think we all know this.

 

Those expecting cannabis to be a magic bullet are in for a grand disappointment (implying nothing here regarding the petty argument between members which reflects poorly on our profession, could care less and am not taking sides.)  In my opinion, providers will probably run into the same frustrations with cannabis as they do with opiates.  Patients will demand them.  Patients will abuse them.  Patients will, after using them for a while, want something stronger.  And yes patients will want cannabis AND opiates - thinking otherwise is simply inaccurate.  I saw a local news spot a week ago with a guy talking about how awful it is that cannabis is illegal and he is "addicted to opiates."  Not to be insensitive, but give me a break - reality is this guy looked stoned during the interview and is very likely on both.  Are there a few patients that it will be the "miracle drug" for and they will get off opiates and turn their life around?  Probably so yes, but very few.  But are there going to be patients who become addicted to cannabis, whom cannot "enjoy anything" without cannabis in their system, whom become alienated from their families and emotionally addicted to the drug?  Yes, absolutely.  And of course there will be plenty of patients using both.

 

There is a role for cannabis in medicine.  I think the most well defined role is in terminal cancer patients with pain and nausea.  I don't mind chronic pain patients taking it if they are doing it responsibly - that is their choice in this country - but I don't want that coming from me.

 

Unfortunately, medicalizing and/or legalizing cannabis and expecting it to revolutionize medicine - it is just not realistic.  We are going to now have patients who used to deal with drug dealers now coming to us for the drug.  We are going to have addicts faking conditions to get "medical grade" cannabis.  And what will happen when the patient on cannabis is hospitalized and it's the only thing that works for them?  Are they supposed to go outside and light up out front with the IV pole connected (granted they do this with TOB anyway.)

 

We all know the real answer to chronic pain.  Counseling, better diet, exercise, getting involved in the community and having better support, etc etc.  However still people are wanting the magic bullet, be it opiates or cannabis or whatever, instead of actually addressing this.  I am speaking more about patients than providers here.

 

I personally do not even care to be in the position to perscribe this stuff.  I don't take issue with other PAs writing for it.  If you want to deal with it, fine.  I have no problem with that.  It just seems like a giant headache to me.

 

ALL of that being said, I have absolutely no problem with cannabis being legalized across the board.  In a society where gambling, alcohol, tobacco, firearms and even in some states prostitution is legal, it is pretty funny that cannabis is not.  And just like with TOB, states can be taxing this stuff to help with education, etc.  Also if it were legal across the board, then we as providers don't even have to deal with this.  Yes there are side effects.  Yes it may cause cancer, we just don't have the data to know all of these things yet.  If you are an adult in America, you have the right to do many things, and as long as you accept whatever consequences unfold, it is not my place as a PA to become your conscious or parent.

 

My issue is not with cannabis.  Lots of my patients use cannabis.  Can't say I am thrilled about it but I treat them just the same.  In COPD, etc, obviously I take greater issue with this.  But when patients press me if it's better for them to stop smoking TOB vs cannabis, it would labor me to answer the latter.  

 

Anyway, those are my thoughts on this issue.  Saying it is a miracle drug is unrealistic.  Saying it is the worst thing ever while not advocating for banning alcohol and gambling is a bit confusing, however I do see your all points on this.  Bottom line is cannabis is probably going to be medicinalized and legalized fairly soon and we are going to have to answer patients' questions about it.  So we all need to keep up with the emerging literature on this topic, and as with all situations in medicine, be able to talk openly and honestly with our patients about it.

 

I think your argument is well put, and I think providers who have worked in emergency med, FP, or other specialties can agree having drug seekers asking for opiates is one of the most unpleasant parts about practicing medicine.

 

However, opiates work and they work well for pain control.  Benzos work well for anxiety and panic problems.  And according to the data, MJ appears that it might work well for neurologic spasticity and chronic pain.  It can be difficult to separate the drug seekers from the people with real problems AND to find a way to manage those patients that fall in between those two sides.  Our job as practitioners isn't to love our job, is to treat our patients and improve their lives if we can.  I don't have all the answers, but I don't think the answer is to ban a substance that could help some people.

[cinntsp]

...and whatever you do, DO NOT PAY ANY ATTENTION TO SOMEONE WHO ISN'T A PA. Even if they have a PhD in chemistry and spent their entire career in the medical industry. Without that PA-C, what, of value, could they possibly have to contribute? And how dare they interlope on a forum designed for PAs? The nerve....

 

You missed the point.  She said "I expected better from my profession" when talking about open discussion so I was pointing out that you're not in the profession.

[JohnnyM2]

You can try walking it back but the intent was clear. You want to discount the same opinions Kitty wants to discount, as I am also a professional. Otherwise, why would you bother to draw attention to it? Is there something that makes PAs superior to other professionals?

 

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[swooshie1]

Back on topic: I agree that there is benefit for serious illnesses within very specific framework.  I don't prescribe, but my SP will under very specific circumstances (e.g., cancer related pain);  what I am finding very important is, like all things when counseling patients, is educating patients when their request for medical marijuana is not legit and the few circumstances where prescription *might* be more legitimate. I've had several patients inquire not because they were "seeking" but truly thought this could be an alternative to other medical solutions to their issues. That being said, I recall a recommendation that my family practice clinical preceptor made to a patient who was "stressed out" about work (paraphrasing):  "have a couple drinks when you get home and try to relax" .....

[JohnnyM2]

Winter all summer has one of the most balanced posts on this topic. One doesn't have to be a PA, MD or whatever to have a valid opinion on a subject for which evidence in favor is mostly anecdotal and inadequate research has been done to characterize patient benefits for various symptoms and medical conditions. Winterallsummer correctly points out that laws and societal values regarding substances that can be abused are often conflicting. Throughout society there are conflicting views and laws on sexual conduct, free speach, human rights and any number of subjects. It isn't surprising that these same conflicts would exist regarding MJ, various opiates, alcohol and other substances subject to abuse. I don't agree, however, that because these conflicts exist, we should legalize everything (or restricted everything.) Attempting to control people's lives is rarely successful, though our society seems hell bent on trying to do that.

Most of you are providers claiming to just want to do the best you can for your patients. I am a patient living every day with unpleasant effects of an illness that would make me an easy candidate for medical cannibis. But I am not interested in that or opiates because what I value most in my life, such as it is, is having a clear mind and the ability to stay busy doing productive things. Don't think you would be doing me a favor by prescribing anything that clouds my mind. I would rather do the best I can with Zofran, Tylenol and ibuprofen and just deal with the rest of it. Unfortunately, many people don't understand or don't care about the problems, including lack of independence they may face with controlled sustances. They just want to feel good, regardless of the consequences. I have a deeply ingrained sense of responsibility (not the bleeding heart kind) towards other people, and expecially my family and my customers. Frankly, I have little sympathy with the vast majority of folks who just want their stuff. Having said that, I realize that some people, nearing the end of their lives after a long fatal illness, need to be made comfortable, regardless of the side effects, so they can die without extreme pain. The majority of those seeking MJ aren't those people. As such, until there is a body of research to determine efficacy, safety and various side effects, I am not in favor of pseudo legalizing maijuana on a state-by-state or county-by-county basis. I believe that the potential for abuse is too high.

 

Regarding states making money from mj, I realize they do it with alcohol and tobacco but it is a shameless practice and yet another conflict of ideals.

 

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[cbrsmurf]

Winter all summer has one of the most balanced posts on this topic. One doesn't have to be a PA, MD or whatever to have a valid opinion on a subject for which evidence in favor is mostly anecdotal and inadequate research has been done to characterize patient benefits for various symptoms and medical conditions. Winterallsummer correctly points out that laws and societal values regarding substances that can be abused are often conflicting. Throughout society there are conflicting views and laws on sexual conduct, free speach, human rights and any number of subjects. It isn't surprising that these same conflicts would exist regarding MJ, various opiates, alcohol and other substances subject to abuse. I don't agree, however, that because these conflicts exist, we should legalize everything (or restricted everything.) Attempting to control people's lives is rarely successful, though our society seems hell bent on trying to do that. Most of you are providers claiming to just want to do the best you can for your patients. I am a patient living every day with unpleasant effects of an illness that would make me an easy candidate for medical cannibis. But I am not interested in that or opiates because what I value most in my life, such as it is, is having a clear mind and the ability to stay busy doing productive things. Don't think you would be doing me a favor by prescribing anything that clouds my mind. I would rather do the best I can with Zofran, Tylenol and ibuprofen and just deal with the rest of it. Unfortunately, many people don't understand or don't care about the problems, including lack of independence they may face with controlled sustances. They just want to feel good, regardless of the consequences. I have a deeply ingrained sense of responsibility (not the bleeding heart kind) towards other people, and expecially my family and my customers. Frankly, I have little sympathy with the vast majority of folks who just want their stuff. Having said that, I realize that some people, nearing the end of their lives after a long fatal illness, need to be made comfortable, regardless of the side effects, so they can die without extreme pain. The majority of those seeking MJ aren't those people. As such, until there is a body of research to determine efficacy, safety and various side effects, I am not in favor of pseudo legalizing maijuana on a state-by-state or county-by-county basis. I believe that the potential for abuse is too high. Regarding states making money from mj, I realize they do it with alcohol and tobacco but it is a shameless practice and yet another conflict of ideals. Sent from my SM-G900V using Tapatalk

 

I just posted two meta-analysis from respected journals.  

 

You dismiss MJ research as anecdotal, then immediately follow it up with your own anecdote. 

[JohnnyM2]

I just posted two meta-analysis from respected journals.

 

You dismiss MJ research as anecdotal, then immediately follow it up with your own anecdote.

Not the same thing. My anecdote would ordinarily make me a proponent and I'm not. I also didn't attempt to use the story to prove anything. Just to help explain an opinion.

 

Regarding your references, they are well and good but don't constitute a body of evidence. I can find you research papers published in respected journals to "prove" just about anything. Unfortunately, being published, doesn't make it correct, often because the data is too narrow or the interpretations are wrong. Show me 50 papers that say the same thing and I will pay more attention. I have personally published parts of my dissertation in respected journals. I recognize that our conclusions were just our interpretation of my data. Those papers are now part of a body of scientific knowledge, and our conclusions still stand, but they have to be taken as part of the scientific compendium, not as gospel. That is true of most published research. Very little of it is definitive until there is a large enough body of evidence. Many papers have been published on the origins and eventual fate of the universe. But there is a lot of disagreement. Even Einstein got some things wrong because he didn't know about dark matter and dark energy. It is easier than you think to get published. And a lot of what gets published is later shown to be wong. But Francisco Franco is still dead!

 

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[cinntsp]

You can try walking it back but the intent was clear. You want to discount the same opinions Kitty wants to discount, as I am also a professional. Otherwise, why would you bother to draw attention to it? Is there something that makes PAs superior to other professionals?

 

Sent from my SM-G900V using Tapatalk

 

I didn't comment on your opinion or even give my own.  A fellow PA felt she was being let down by her PA colleagues so I pointed out that you aren't a PA, since you are who she was referring to.

[True Anomaly]

Not the same thing. My anecdote would ordinarily make me a proponent and I'm not. I also didn't attempt to use the story to prove anything. Just to help explain an opinion.

 

Regarding your references, they are well and good but don't constitute a body of evidence. I can find you research papers published in respected journals to "prove" just about anything. Unfortunately, being published, doesn't make it correct, often because the data is too narrow or the interpretations are wrong. Show me 50 papers that say the same thing and I will pay more attention. I have personally published parts of my dissertation in respected journals. I recognize that our conclusions were just our interpretation of my data. Those papers are now part of a body of scientific knowledge, and our conclusions still stand, but they have to be taken as part of the scientific compendium, not as gospel. That is true of most published research. Very little of it is definitive until there is a large enough body of evidence. Many papers have been published on the origins and eventual fate of the universe. But there is a lot of disagreement. Even Einstein got some things wrong because he didn't know about dark matter and dark energy. It is easier than you think to get published. And a lot of what gets published is later shown to be wong. But Francisco Franco is still dead!

 

Sent from my SM-G900V using Tapatalk

 

Usually a meta-analysis does refer to a "body of evidence", and in this case the two meta-analyses cited involve 34 from the Cochrane Review and 28 from the JAMA review...totaling 62.  Some of those may have been used in both studies, but the way to counter-act the argument is by citing a meta-analysis that shows something that counter-acts the findings of the two cited meta-analyses....not moving the goalposts to discredit any study that may be cited to support someone's argument.

[JohnnyM2]

I don't think a meta-analysis refers to a body of evidence, particularly given the conclusions of both publications which suggest thc or derivatives may be helpful in certain instances. Neither paper, however, seems to constitute a ringing endorsement. Additionally, I am relatively sure you must be aware that meta data analysis is subject to errors due to adverse data selection and omissions. The authors do appear to have made efforts to avoid that and their conclusions don't appear to be politically motivated. But even if you take the conclusions at face value, they don't offer tremendous support for the use of cannabis. The risk of adverse events, in my mind, is of greater significance when the potential benefits are marginal or questionable, as seems to be the case here. Meta analysis has been popularized in medicine, in part, because patient data is difficult and expensive to gather. Generally, though, it constitutes doing retrospective research on someone else's research data. The conclusions, though interesting, hardly constitute a body of evidence in favor of the use of cannibis and I don't know that the authors intended their conclusions to be definitive. Are you sure you aren't reading what you want into the conclusions?

[JohnnyM2]

I didn't comment on your opinion or even give my own. A fellow PA felt she was being let down by her PA colleagues so I pointed out that you aren't a PA, since you are who she was referring to.

It's nice that you want to close ranks with kitty against a common, should I say enemy? Should I suppose you think there aren't any PAs that share my views? That seems unlikely, through I wouldn't expect any support from those of like mind, at this point, since the lines have been clearly drawn and you may have successfully marginalized my position with your gratuitous but irrelevant revelation. After reading this forum for several years I don't think it's unheard of for PAs to let other PAs down. What do you reveal then? He's just a PA-S? What would you expect from a psyche PA? Or maybe; She's just a nurse practioner. (Come to think of it, I've seen that one.) It's interesting how often PAs on this forum disrespect each other as well as anyone who is not in the club. It's especially interesting to see that disrespect directed at someone who is an unwavering supporter of the profession. Fortunately, I have developed a thick skin.