jdenning Posted August 12, 2015 Share Posted August 12, 2015 It's causing me many. Our patients want MJ for everything now - headaches, tremor, Parkinson's disease, sleep, seizures, tics - you name it. In the past I was quite happy to say "discuss with your physician because as a PA I can't sign your card application." But now MJ is legal in Oregon... So what are those of you in other "marijuana states" doing? Forgive me for now knowing but I really don't know - do you still apply for a card? Just today I had a guy call asking me for a letter to the administrator of his assisted living facility that he plans to use MJ via an inhaler and that he won't have hallucinations because he's going to get MJ without any THC. I'm thinking I'm not writing any letter stating these things, but this guy's physician is on vacation and I'm covering. The whole "sending orders to the facility" is what bothers me. Any insights? Thanks Link to comment Share on other sites More sharing options...
LKPAC Posted August 12, 2015 Share Posted August 12, 2015 Just take a few tokes. You'll be fine! Link to comment Share on other sites More sharing options...
RealityCheck Posted August 12, 2015 Share Posted August 12, 2015 Some might see this as a cop out but this is how I have chosen to handle any questions about marijuana. No matter what is legal at the state level, my DEA is federal and federal law still says marijuana is illegal. I will not prescribe it or really condone its use. I haven't had time to go through all the studies to see what THC really does and there are no FDA recommendations for it outside of chemo and glaucoma if you stretch it. If a patient has a pain contract, I still treat marijuana as a potentially harmful substance like alcohol. You wouldn't let a patient take narcotics and drink alcohol. Chances of waking up dead go up exponentially. I also would not want a patient ingesting marijuana while taking narcotics or xanax or anything else controlled. Marijuana is often not pure and can be mixed with other substances and cause interactions and even death. So, I have chosen to stay out of the marijuana arena with the federal out. And I am in Washington where it is recreationally legal. The number of DUIs for pot have gone up ten fold and it makes people just as stupid and impaired as alcohol. Again, my two cents. Link to comment Share on other sites More sharing options...
jdenning Posted August 12, 2015 Author Share Posted August 12, 2015 Thanks. The concerning thing about this particular patient is that he's cognitively impaired - which is why he's in assisted living in the first place. Personally I don't like the idea of him using something that could make his cognitive impairment worse. I usually tell patients that the word "pot head" exists for a reason. As far as the letter goes I'm going to punt to the MD who's back from vacation next week Link to comment Share on other sites More sharing options...
RealityCheck Posted August 12, 2015 Share Posted August 12, 2015 I agree with your concerns. I would never want a patient to hurt themselves or others due to a prescription. Good Luck - Stick to your gut feelings - They will serve you well! Link to comment Share on other sites More sharing options...
cinntsp Posted August 12, 2015 Share Posted August 12, 2015 The number of DUIs for pot have gone up ten fold and it makes people just as stupid and impaired as alcohol. The number of DUIs due to marijuana have gone up, but it's probably because it's being tested for more often. The data so far doesn't seem to support your opinion that marijuana makes someone impaired to the same degree as alcohol. http://www.washingtonpost.com/news/wonkblog/wp/2015/02/09/stoned-drivers-are-a-lot-safer-than-drunk-ones-new-federal-data-show/ It's important to approach this topic objectively and rationally. Sent from my SHIELD Tablet using Tapatalk Link to comment Share on other sites More sharing options...
BruceBanner Posted August 12, 2015 Share Posted August 12, 2015 It's "legal" here but PAs cannot prescribe MMJ. Once in a while I get a pt asking me for a card but it's really rare because the legal market is booming, as is the grey market so there is really no reason to go through the hassle of having a MMJ card anymore. I had a pt yesterday who works as a grow consultant for dispensaries and easily makes more money than any of us. Link to comment Share on other sites More sharing options...
Acebecker Posted August 12, 2015 Share Posted August 12, 2015 My take on MJ is the same as tobacco and alcohol. We have legalized these things and my patients have the autonomy to make their own decisions. Doesn't mean I have to like it and doesn't mean I have to keep them as a patient if they're making stupid decisions contrary to my advice that affects their health. While in urgent care, I get a lot of people who tell me about how often/how much they're smoking (I work in a MJ legal state) and I tell them that the research is fairly conclusive that there is increased risk of lung cancer if you smoke pot, worse than with cigarettes. The National Cancer Institute website doesn't mention it at all (I find that odd) but the research is out there (it's out of Sweden and the title of the article is "Marijuana use and risk of lung cancer: a 40-year cohort study"). So I tell them that it is their risk and that if they're going to use it they should eat it instead of smoke or inhale it. I also make note that it is so poorly studied with regard to the long term effects that they need to be cautious. I do not write for it, nor will I at this point. I would not write any notes for a patient if they are not my patient. They need to await their PCP's return because the PCP knows that patient and knows what the risk is (if there is a risk). Good luck. Touchy subject and until I see long term data, I'm not buying in totally. That said, there are case reports of good things happening with MJ. But we used to think that cigarettes didn't cause cancer or birth defects. So.... Link to comment Share on other sites More sharing options...
jdenning Posted August 12, 2015 Author Share Posted August 12, 2015 Do people need a card then if MJ is legal? Link to comment Share on other sites More sharing options...
Acebecker Posted August 12, 2015 Share Posted August 12, 2015 The MJ card can be a "get out of jail free" card in some cases. It's legal, but employers can still fire you for testing positive for it (same as coming to work drunk), unless you have a MJ card. Link to comment Share on other sites More sharing options...
Sam I Am Posted August 12, 2015 Share Posted August 12, 2015 I believe, as a recreational marijuana user, you can just buy the product from a rec store without a card - not sure as I don't do it. As a medical marijuana user, you must have a card. This card is given once you are seen and evaluated by a medical provider - this I do know as several friends have this card. I've only prescribed Marinol to a patient once. Link to comment Share on other sites More sharing options...
RealityCheck Posted August 12, 2015 Share Posted August 12, 2015 cinntsp - I work directly with the State Patrol and the impairment is VERY REAL and very dangerous. The testing is at best cumbersome and requires a blood draw to determine the ng percentage which has been agreed upon as a level but is highly difficult to interpret. The troopers or sheriff or whomever has to detain the person if possible and then call for an EMT who can draw blood or get the person to a hospital to have blood drawn. It is not an easy process and the time between being pulled over and the time to blood draw can be 6 hours or more in some cases. Law enforcement is struggling with the whole federal/state/local issues. Impaired driving is impaired driving whether it is xanax, alcohol, pot, meth or whatever. If you drive stupid - you can and will get arrested for driving impaired and dangerously. I am not sure what your point is but my practice ethics do not endorse patients using impairing drugs in the workplace, around children or driving a vehicle. I AM approaching this logically. Thank you for your input. Link to comment Share on other sites More sharing options...
RealityCheck Posted August 12, 2015 Share Posted August 12, 2015 In Washington, some Oregon doctors are still coming over the border, renting a hotel room and then thru Twitter and social media - the word goes out that there is a Medical Marijuana doctor in Room X of Hotel Y and come on down. It is very unscrupulous. You limp in, claim back pain and get a green card. Law enforcement finds out about the hotel operation and swoops in. The doctor disappears because someone alerts them and they vanish. Most employers are confused my medical marijuana cards. If you are operating a drill press or welder or smelting metal - they don't want you on pot - medical, recreational or otherwise - just like they don't want you on alcohol at work. There are breath tests being tested for law enforcement use but the absorption and results are much more difficult to evaluate than alcohol. It is a tricky subject. From a medical care standpoint - I don't we have enough solid data and zero federal support to say one way or another. Link to comment Share on other sites More sharing options...
cbrsmurf Posted August 12, 2015 Share Posted August 12, 2015 I think I signed a couple when I worked in heme/onc Link to comment Share on other sites More sharing options...
BruceBanner Posted August 12, 2015 Share Posted August 12, 2015 Do people need a card then if MJ is legal? No. Here in Colorado it only gets you a lower retail cost (not taxed as heavily), and MJ card holders can legally have a higher quantity. But retail prices vary, and the gray/black market are both alive and well. Many people grow and sell small quantities. TBH I wouldn't prescribe it even if I could (It has some palliative benefits but it's ubiquitous and I'm not a dispensary), but I have no qualms whatsoever with patients using it. I just tell them if they are going to use it regularly they should vaporize or eat it. In the big scheme of health risk I think people's sh!t diets, tobacco use, and drinking are much more of an issue. Link to comment Share on other sites More sharing options...
cinntsp Posted August 12, 2015 Share Posted August 12, 2015 Impaired driving is impaired driving whether it is xanax, alcohol, pot, meth or whatever. If you drive stupid - you can and will get arrested for driving impaired and dangerously. This is true and I totally agree. But to say that marijuana impairs one to the same degree as alcohol is false. Sent from my Nexus 5 using Tapatalk Link to comment Share on other sites More sharing options...
Evolute Posted August 12, 2015 Share Posted August 12, 2015 RealityCheck, this same thing happened in MT. Docs would come in from out of state, set up in a hotel, see 75-100 pt's/day for a few days. issue med MJ cards then leave the state. Interestedly, One requirement in MT is/was that all pt's with a MMJ card be registered with the state. Well, after a few years someone/some entity published a paper with demographics that showed the highest percentage of people with a med MJ card were males between the age of 21-35..... I know right? then in 2012/2013 the overwhelming public/professional opinion that the MMJ laws were to lax finally reached the state law makers. the best part of all this is that some legislators were completely dumb founded, and couldn't believe that people would abuse the system. Are your F@$king kidding me? Surprised that people are abusing the system. Thank goodness our state legislation only meets once every two years. EDIT: clarification. the "highest percentage of people with med MJ cards" is for Montana residents only, not nationally. Link to comment Share on other sites More sharing options...
RealityCheck Posted August 12, 2015 Share Posted August 12, 2015 I am chuckling, Evolute. When Washington legalized recreational marijuana there was no connect to federal agencies or consideration of how it would affect other legal aspects or employment. I don't think it was well thought out and it was a field day for voters who have probably never cast a ballot before in their lives. I have driven down the main streets in our town and seen a huge variety of bongs in the creepy little car next door and a huge Cheech and Chong smoke cloud wafting from the car. It bothers me as much as it would to see someone drinking from a brown paper bag while driving. Medical marijuana might keep you out of jail but it will keep you unemployed in many fields as will recreational marijuana. If you test positive at the time of seeking employment or after an injury - then you are SOL and bye bye. Folks are mystified and ask me how this could happen to them. A lot of folks just don't get it and don't equate marijuana use with similarities to alcohol use. I ask them "you wouldn't show up drunk to work, would you", "ok, don't show up stoned.............." If it is in the employment guidelines and you signed the paper - you agreed to not be under the influence of marijuana while at work. Same with injuries and chronic narcotic use. Some of my DOT drivers don't understand why I won't certify them when they are "stable" on oxycontin 10 mg tid for the past 3 years. Well, the federal guidelines say it isn't ok and I am bound by federal and I don't want that person driving next to my teenager on the highway. Metabolic and physical conditions change and 30 mg of oxy might just be lethal one day. Some days I just shake my head and am more grateful and feel a bit more sane than most........................ Link to comment Share on other sites More sharing options...
Evolute Posted August 12, 2015 Share Posted August 12, 2015 cinntsp, based on your quote of RealityCheck. He/She did not say MJ impairs one to the same degree as ETOH. Realitycheck just said MJ impairs ones judgment and they should not be driving when impared..... on any drug/medication..... And quite honesty, I agree. I don't want someone in control of a vehicle after they smoked a bowel or two....or three. no more so then I do after they drank ETOH...took benzos... etc.... Link to comment Share on other sites More sharing options...
cinntsp Posted August 13, 2015 Share Posted August 13, 2015 cinntsp, based on your quote of RealityCheck. He/She did not say MJ impairs one to the same degree as ETOH. Realitycheck just said MJ impairs ones judgment and they should not be driving when impared..... on any drug/medication..... And quite honesty, I agree. I don't want someone in control of a vehicle after they smoked a bowel or two....or three. no more so then I do after they drank ETOH...took benzos... etc.... Actually, he did say that. The exact statement was "it makes people just as stupid and impaired as alcohol." I linked an article discussing stats that show marijuana is not associated with increased likelihood of a car wreck, though it is greatly increased with alcohol. I certainly don't support driving under the influence of anything but I think it's important that we are objective and not join in fear mongering. Sent from my SHIELD Tablet using Tapatalk Link to comment Share on other sites More sharing options...
ItRainsItPours Posted August 13, 2015 Share Posted August 13, 2015 While in urgent care, I get a lot of people who tell me about how often/how much they're smoking (I work in a MJ legal state) and I tell them that the research is fairly conclusive that there is increased risk of lung cancer if you smoke pot, worse than with cigarettes. No it's not. That study suggests heavy marijuana use might increase the likeliness of developing lung cancer but to say it's conclusive that it's more dangerous than smoking tobacco is simply not true. Link to comment Share on other sites More sharing options...
Evolute Posted August 13, 2015 Share Posted August 13, 2015 cinntsp, after reviewing this thread. I see that you are correct. RealityCheck did indeed make the statement that "it makes people as stupid as alcohol". My apologies. In the future I would suggest that you reference the quote you are directly responding to. This will eliminate any confusion as to your statement/response. For my part, I will make an effort to completely read (not just bourse) the thread prior to responding. Having said that..... RealityChecks point is valid.. MJ impairs ones judgement and one should not be in control of a motor vehicle while under the influence of MJ. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted August 13, 2015 Administrator Share Posted August 13, 2015 So, from my standpoint as a Washington PA, MJ is still schedule 1, so I have no desire to be a test case. I haven't ever prescribed it, and won't. My authority to prescribe drugs comes from the DEA who says it's a no-no. As stupid as we may think that is, it's still federal law, so if any of my patients want to toke or whatever, it's not with my recommendation. I do end up refilling narcotics for patients who are also on MJ, but I didn't put them there in the first place--another provider OK'ed that and I'm simply not changing their plan. Link to comment Share on other sites More sharing options...
BruceBanner Posted August 13, 2015 Share Posted August 13, 2015 Pot is one of those subjects that is pretty divisive among providers. My take is that the people who were against it before becoming a provider will be against it after, and the people who had a more permissive attitude or used it themselves will be more likely to have a relaxed approach to it. To say that there is a higher risk of lung CA with MJ use over cigarettes is patently false and to date there is no solid evidence to support that. A cohort study with self-reported data is not high quality evidence. Furthermore those longitudinal studies are frequently compounded by tobacco use. Also, as noted earlier in this thread, to say that MJ impairs driver to the same degree as etOH is also complete BS; although I would never make a case for stoned driving. The big legal issue now is how does law enforcement reliably quantify how stoned someone is and what is the threshold for true impairment? I think within the next 10 years it is going to be a non-issue from a prescription standpoint, as legalization or at least decriminalization on the federal level is a foregone conclusion. Link to comment Share on other sites More sharing options...
cinntsp Posted August 13, 2015 Share Posted August 13, 2015 In the future I would suggest that you reference the quote you are directly responding to. This will eliminate any confusion as to your statement/response. I did quote what I was responding to and the person it was directed at would have understood the context, but I'll keep your advice in mind since I am new to the interweb. Sent from my Nexus 5 using Tapatalk Link to comment Share on other sites More sharing options...
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