A recent reader comment asks the question, "What should be done by a primary physician when a patient intended to be on chronic opiates is using marijuana, especially when repeatedly positive on testing or outright admitting that marijuana use is ongoing?" In an effort to respond, I requested a clinical opinion from my friend and colleague, John Femino, MD, FASAM. John’s response, provided below, outlines his clinical experience with this common scenario. John’s approach aims to involve patients in the therapy process to best understand the reasons behind illicit marijuana usage.
As the reader notes, marijuana use is extremely prevalent in society and the drug has historically been labeled as the most commonly used illicit substance. The current trend of medical marijuana widens the use of the drug in clinical settings across the United States. The reader remarks that marijuana usage is not widely covered in research or educational discussions in the field.
John’s response recognizes both illicit and medical marijuana use as common concerns of clinicians. John provides a usable, practical strategy for prescribing physicians of various medical specialties to treat or refer patients in this scenario, rather than deny them necessary treatment.
“David – The situation is quite analogous to the issue of using/abusing opiates from other sources than the doctor who has been prescribing medication. In Rhode Island, we come across this every day with the advent of the Medical Marijuana Law. Although I feel that the issue of the legality and the proximity of the user to other illicit drugs is a valid concern, it is one that is true for all patients and not just the individual patient on prescribed medication.
I prefer to view this problem as one that’s amenable to a risk benefit analysis – whether the person is getting any benefits from the marijuana use, is experiencing any side effects, or is having other co-morbid problems associated with the chronic pain (e.g., depression, anxiety disorder, sleep, cognitive disturbance, memory problems, or other behavioral issues such as isolation and withdrawal). If the chronic marijuana use is worsening or interfering with the management of the underlying condition, then the risk/benefit profile for ongoing marijuana use would suggest that the treating physician should recommend that the marijuana use be stopped. Since marijuana may be helping the pain control issues, I also suggest that the physician utilize pain scales, pain diaries, and any other patient centered data collection devices that might assist in getting a better “movie” of the impact of the marijuana use on these conditions and complaints. In our experience, when we utilize pain scales to document the effectiveness of marijuana on pain relief, we find that it is very short-lived, paralleling the perceived high and often associated with numerous “side effects”. The experienced marijuana abuser usually experiences the “side effects” as the “desired effect”, whereas the marijuana naïve individual experiences the side effects as an undesired effect, representing for them the “stop signal” rather than the “Ah signal”.
Clearly the most significant benefit of this approach is that it is specific to each individual patient, and demonstrates to the patient that the effect of marijuana is interfering with the medical management and overall course of monitoring prescribed medications and other therapeutic approaches. I emphasize that for most patients in this situation that the side effects will confuse the physician’s interpretation of the patient’s symptoms, possibly exposing them to more medications that could have more significant and potentially dangerous side effects than the marijuana itself. I furthermore point out that most chronic marijuana users are also poly substance users and that adding marijuana to chronic opiates could set them up for relapse back to their drug of choice.
I much prefer a dialogue over the medical risks and benefits than a legalistic approach or one that discharges the patient from appropriate medical care, simply because of their use of illegal substances. On the other hand, we frequently discharge patients for chronic marijuana use because the use represents abuse and dependence and has resulted in more complicated clinical course than if the patient was on alternative medications or non medication treatments.
Documentation in the medical record would include these discussions as well as a quantitative creatinine adjusted cannabinoids level. Often we find that these patients have extremely high levels of marijuana in their system, such that presenting it back to the patient can demonstrate to them that their use may be interfering with other prescribed medications. If the patient listens carefully to your concerns as the primary prescriber, they will make adaptations based upon your suggestions to come up with a better therapeutic alternative. If the patient resist these recommendations and refuses to adapt their marijuana usage despite well-documented negative consequences of the marijuana use, then documentation in the medical record will assist in any medical legal challenges. Documentation of this information into the medical record including a diagnosis of marijuana dependence, can now be presented to the patient and coded on the appropriate billing forms. Most patients get quite concerned when their records reflect that their use is being documented as abuse or dependence rather than their personal preference for a drug that they believe should be legalized. For those primary care physicians who are in this situation, we recommend that an addiction medicine evaluation be performed. Documentation of that consultation in the medical record will also assist in the event of a regulatory review.
For the patient who persists in smoking marijuana despite such documentation and refusal of treatment recommendations, then the primary care physician should consider transfer of that patient to an addiction specialist who can manage their chronic pain and addiction to the marijuana itself. Such patients now have to make a choice that can be an opportunity for them to learn more about their marijuana use as well as reflect upon the importance of their therapeutic relationship with their prescribing physician.
We also like to point out to the patient that their choice of jeopardizing an important therapeutic relationship in their life is indicative of the seriousness of marijuana dependence. Those patients who truly have a terminal condition or one in which their use of marijuana truly has a favorable risk benefit ratio, then the physician can decide that continued use of marijuana is acceptable and will be continue to be monitored closely in the future. In this way any time delay that may be necessary to collect for the data is documented, rather than being viewed by a regulatory agency as “looking the other way”. Our experience with this approach has demonstrated that those patients, who have tried marijuana and found it helpful, may now find with a more careful scrutiny, that other side effects that they had attributed to other medications were really from the marijuana, thereby, assisting them in cooperating with the recommendation to cease marijuana use. For those states that have passed medical marijuana laws, this approach allows an individual basis specific recommendations that are based upon each patients set of symptoms, circumstances, and other environmental situations. It also avoids the endless arguments about legalization by focusing completely on the effect of the drug rather than its legal status.
I hope that this information is useful and I would be glad to participate in any further discussions regarding these topics – John Femino, MD, FASAM.”
John provides a usable strategy for approaching patients being treated in primary care, pain management, addiction medicine and other specialties. There are always, of course, individual case scenarios that will require more or less effort than John suggests. This “hot button” topic of marijuana use will continue to present us with challenges in the clinical setting. Ultimately, as the reader suggests, it’s about treating the “whole” patient. We recognize that there are certainly more viewpoints from a clinical perspective. Please add your opinions and case examples from your experience in the comments.