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11 Articles in this Series
Introduction
A PAINWeek 2019 preview with EVP Debra Weiner
Comparing Marijuana and Hemp
Fibromyalgia: What’s New in Diagnosis and Pain Management
Life Hacks to Teach Patients with Chronic Pain
Managing Pain (and Function) in Osteoarthritis: Are Patients and Physicians on the Same Page?
Marijuana: How to Proceed When Controlled Substances are Involved
Menopause Comes with More than Mood Swings - It Deserves its Place Among Chronic Pain Conditions
More APPs Are Coming to the Forefront of Pain Care
Motivational Interviewing and Its Extension into Pain Management
Revisiting Documentation
Side Chat: Modern Analgesic Trials

Marijuana: How to Proceed When Controlled Substances are Involved

with Jennifer Bolen, JD, and Douglas Gourlay, MD

 

PAINWeek, or any pain management meeting of late, would not be complete without at least one session on cannabis. The 2019 Las Vegas conference was no exception as Jennifer Bolen, JD, former federal prosecutor and consultant to Paradigm Labs/Healthcare, and Douglas Gourlay, MD, MSc, FRPC, DFASAM, addressed how to manage marijuana use in patients who are also on prescription medications for chronic pain.

First, Get to Know the Clinical Terms around Cannabis

“’Medical marijuana,’ in my opinion, is a politically charged term,” said Dr. Gourlay. What clinicians need to know is that, while medical cannabinoids are still being defined and while the legal concepts are a bit of a mess, this group of molecules is emerging as a legitimate pharmacotherapy.

“Cannabis” is essentially the herbal product. Both tetrahydrocannabinol (THC) and cannabidiol (CBD), among more than 60 other compounds that act on receptors in the body’s endocannabinoid system, are known as“cannabinoids.” Cannabinoids can be extracted from the plant itself (either the marijuana plant or the hemp plant) or produced as synthetic isolated versions. “Hemp-derived CBD” is a federally regulated term, noted Dr. Gourlay, defined as a cannabis product with less than 0.3% THC. (More on hemp classification.)

THC is the most psychoactive cannabinoid found in cannabis and is primarily responsible for the “high” associated with cannabis. It can also reduce nausea and increase appetite. CBD does not provide the euphoria associated with THC and has been associated with reduced pain and inflammation.THC is illegal in every state at the federal level, despite each state having its own positions on licensing, use, risks, and more.

It is crucial to ask patients if they are using marijuana, even if recreationally, when prescribing controlled substances such as opioids. (Image: 123RF)

Questions on Clinicians’ Minds

Dr. Gourlay and Bolen addressed a series of questions during their PAINWeek panel that may be at the top of clinicians’ minds when patients inquire about cannabis for pain and pain-related symptoms. Below are a few highlights.

Legality

If cannabis is legal in my state, can I ignore “medical endorsements” (ie, medical cards)?The short answer: No. It’s best to continue abiding by any standard procedures around documenting and approving the medical use of cannabis.

Further, Can I lawfully federally write a prescription for a controlled medication to a patient using marijuana? Bolen suggests checking with your licensing board for both marijuana and opioid prescribing guidelines. Understand what needs to go into your recommendation and patient conversation about marijuana if you decide to prescribe as such. Your rationale and documentation will be important if an issue arises. “You may see the opioid or controlled dose going down as marijuana use is added to a treatment plan,” she added.  “This shows that you are addressing the plan.”

It is also key to learn your state’s rules for housing cannabis products in your practice office or clinic. There are regulations state-line transportation, testing of products before they are shipped and/or used, and storage. “There is an entire cottage industry around this type of security,” said Bolen. “Even the FDA has not finalized regulations around this—so far, they are treating CBD products like dietary supplements, but they are working toward it.”

Driving

Can/should my patients drive when on recreational or medical cannabis?The short answer: No. The science is simply not there yet to definitively answer this question and caution should take precedent.  A very real problem with this drug is that, even after prolonged abstinence, most regular users will remain positive of THC and its definitive metabolite.  This makes the legal aspects of defining impairment in regular cannabis users somewhat difficult to define.

Screening

Should I be asking my patients about use or testing them for THC? The short answer: Yes. Clinicians should always be prepared to comment on and support documentation of safe and legitimate use. In this country, medical experts are hard pressed to support clinicians who are not doing testing, noted Bolen. “If a clinician is doing testing, finding medical expert support will be easier if called to task. Good faith efforts exist at the bottom of the law—it is wise to use monitoring and risk-based decision making,” she said.  However, as Dr Gourlay stated, how a clinician acts on these results may determine whether this is an adversarial or patient-centered use of testing. 

Prescribing: Ask and Document

Do I need to stop prescribing controlled medications to patients who use marijuana? The short answer: No. The law does not say that at this time, noted Bolen. Further, added Dr. Gourlay, there is no current evidence that opioids and cannabis interact in a negative way. In some literature, data shows marijuana as opioid-sparing; other papers counteract those claims. At the very least, cannabis is simply additive to the effects of other mood altering substances.  At worst, the effect could be synergistic.  However, if a patient has broken boundaries in the Patient Agreement, you should address it and document your conversations.

It is also important to note that whether a patient is using marijuana recreationally or medically does not matter in the need to document, advised Dr. Gourlay. As a clinician, you should be aware of your patient’s use either way and proceed accordingly. Asking, “Is there anything else I need to know” as you walk out the door is not going to capture this information adequately. Ask patients how much of their prescribed medications they use in a day and what they do when they’re running out. Get into the details and trends of their cannabis use. Sometimes, quantification of use is better done by how much they spend. This is what an expert will do if asked to do so for a particular case. Engage the family as well on any changes seen with cannabis use, added Bolen. Consider whether those benefits change the overall risk and document your decision process.

Dr. Gourlay emphasized that cannabis offers different things to different people, whether it be for sleep, anxiety, pain, or something else. “So, don’t assume a low-risk patient isn’t using. Ask them. If they are at higher risk or clinical circumstances indicate, ask your pharmacist’s opinion as to how they are doing.” And remember, “Even if a patient is using cannabis for medical reasons doesn’t mean they can’t get into trouble with it,” said Dr. Gourlay. Charting the risks and realities is important. Documentation of your thoughts and actions is critical in defending your

At the end of the day, clinicians are bound by rules and the legal framework, but there are opportunities with urine drug testing (not just for cannabis but also for fully engaged risk-managed therapy) and in documenting those risks. Dr. Gourlay and Ms. Bolen used case-based discussions to demonstrate these points.

 

See where hemp fits in, with Stephen Ziegler, PhD, JD.

A controlled substances primer.

 

Next summary: Menopause Comes with More than Mood Swings - It Deserves its Place Among Chronic Pain Conditions
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