Illinois adds PTSD to list of Medical Marijuana conditions, but takes the doctor out of the decision

[WingedOx]

http://capitolfax.com/2016/05/27/deal-emerges-on-medical-marijuana/

5. Doctors will no longer have to RECOMMEND cannabis, but will simply certify that there is a bona fide Doctor-Patient relationship and that the patient has a qualifying condition.

I expect the number of requests for letters from patients to go up exponentially. So even if I have a patient who absolutely should not be using cannabis (problems with paranoia on the stuff, etc), all he needs to get it from the state-licensed vendors is a letter from me stating he indeed has been coded as PTSD, despite my recommendations. Why even have my signature involved at all in this at all? What liability am I exposed to if something goes wrong?

Basically this ends up being the same process as when patients are getting "service dogs". They ask us to provide a letter stating patient has whatever condition, then the program determines their own approval. I'm not big on the ethics of that, but there are far bigger problems in the world than the fact that I have patients who are likely just getting around rules from their landlords, especially with the added degree of separation built in. Giving passive approval for a pharmacological treatment is something else.

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[Doctor Bagel]

This is part of why I voted for legalization of marijuana in my state -- "medical marijuana" is becoming less and less of a thing.

 

[WingedOx]

This is part of why I voted for legalization of marijuana in my state -- "medical marijuana" is becoming less and less of a thing.

and for good reason.

This is Illinois, and of course the only reason the program is expanding is the politically connected vendors aren't making enough yet. Can't find enough doctors willing to recommend it? Take the doctors out entirely.

 

[notdeadyet]

Yet another reason that we will have to view PTSD diagnoses with suspicion.

 

[lymphocyte]

Why even have my signature involved at all in this at all?

Exactly. It's theatre. Just legalize it already and be done with it.

Surely you could add in the notes and in the letter: "Patient requests X. I certify that I am her psychiatrist and that she has a qualifying condition. However, the patient also has the following contraindications to cannabis and I have strongly counselled her against using marijuana." Done. No liability.

You've met your duty of care. What they do beyond that is their business.

Psychiatrists should be in the business of making people better not policing behaviour.

 

[Information Underload]

This is part of why I voted for legalization of marijuana in my state -- "medical marijuana" is becoming less and less of a thing.

I would argue that "medical marijuana" is an oxymoron.

 

[PikminOC]

Exactly. It's theatre. Just legalize it already and be done with it.

Surely you could add in the notes and in the letter: "Patient requests X. I certify that I am her psychiatrist and that she has a qualifying condition. However, the patient also has the following contraindications to cannabis and I have strongly counselled her against using marijuana." Done. No liability.

You've met your duty of care. What they do beyond that is their business.

Psychiatrists should be in the business of making people better not policing behaviour.

Not policing behavior? How about for every controlled sub? How about for suboxone?

 

[hamstergang]

Not policing behavior? How about for every controlled sub? How about for suboxone?

Yeah, not policing, but working on actually making patients better.

 

[wolfvgang22]

Well, if I know a patient has a history of abusing animals I won't write the service dog note. So I'm ok with not writing the marijuana note. Also, I work for the feds, so I can't/won't write any letters for marijuana anyway.

 

[WingedOx]

Well, if I know a patient has a history of abusing animals I won't write the service dog note. So I'm ok with not writing the marijuana note. Also, I work for the feds, so I can't/won't write any letters for marijuana anyway.

Theoretically, the system allows the patient to get around the federal regulations, since we as VA physicians are neither recommending nor not recommending the treatment. We're simply (and ever so innocently) making note of the fact that the diagnosis exists. I have to assume that was by design since a huge number of the PTSD patients for this are going to be using the VA as their primary source of medical care.

 

[lymphocyte]

Not policing behavior? How about for every controlled sub? How about for suboxone?

It's getting late on this side of the world, and I'm sipping rum. Let me just jump into the deep end.

I'm generally not a fan Foucault, but there are two useful concepts to borrow from him. The first is "governmentality" and the second is psychiatry as a tool of the state to normalize or marginalize behavior.

Governmentality, roughly, refers to the insertion of governance into everyday affairs by changing modes of discourse: in the medical context, advice becomes notes; notes became legal documents; these legal documents determine the allocation of social services, justify involuntary commitment, permit or restrict behavior, etc. At every step, governmental control is incremented through the guise of legal or regulatory institutions. What was a therapeutic relationship between two people has now been intruded upon by a faceless third, and that is the government. This intrusion can be beneficial (as protection from poor practice) but it can also be harmful. Where it becomes most harmful is when psychiatry is used as a tool to police the normity of behavior. And the historical examples abound (political dissidents in the Soviet Union, homosexuality, slavery, moral hygiene and Cholera epidemic, etc.)

This form is a perfect example of governmentality. "If a doctor labels me with a certain diagnosis, then it must be okay... " Well, no, actually. Diagnosis is a semiotic act that imparts a certain conceptualization of disease and treatment. If that semiosis is altered to primarily facilitate the interests of the state, then what are even doing? How are we still psychiatrists? That's not what I signed up for. I want to help people get better. Full stop. If they ain't interested, that's fine, but I'd still write in the note "strongly counseled against A, because of X, Y, Z"--if I even agree to write such a note in the first place. Primum non nocere, and all that crap.

Okay, brb. Gonna get my PTSD script filled...

 

[Shikima]

I would argue that "medical marijuana" is an oxymoron.

We have medical heroin. And medical Ketamine. Medical alcohol too.

I'd like to see medical crack, not just power cocaine as discussed in the other thread.
Any use in reviewing medical LSD from past experiments?

 

[deleted480308]

does the law actually compel a physician to sign the form? or does it just lower the bar of culpability from prescribing to certifying a pre-existing diagnosis?

 

[Shikima]

does the law actually compel a physician to sign the form? or does it just lower the bar of culpability from prescribing to certifying a pre-existing diagnosis?

No law can force a physician to sign off on anything.

 

[deleted480308]

No law can force a physician to sign off on anything.

I would agree with you that it shouldn't, but that seemed to be the implication of the OP. The doctor isn't "taken out of the decision" if they don't want their patient on cannabis, they just don't sign the form

 

[sunlioness]

Nooooooooooooooooooo

I agree with allowing recreational use of marijuana.

Medical marijuana is a joke. Where's the data to show that marijuana is helpful for PTSD?

They don't even care.

It undermines the work we do.


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[sunlioness]

I would agree with you that it shouldn't, but that seemed to be the implication of the OP. The doctor isn't "taken out of the decision" if they don't want their patient on cannabis, they just don't sign the form

Or what if they just show up with an insurance EOB that has a qualifying dx on it?

Anyway. This will be interesting. When medical marijuana first went through we had a meeting and breathed a collective sigh of relief that Tourette's was the only thing we treated (and that rarely) on the list. We agreed that medical marijuana was something we weren't doing and made policy to that effect.

This kinda throws a wrench in that.

I remember walking along Venice Beach to Santa Monica and seeing all the pot clinics. They all had signs that said, "California address required (like your hotel!!)"

Freaking joke. All of it.

Legalize it or don't. But leave me out of it.


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[notdeadyet]

Medical marijuana is a joke. Where's the data to show that marijuana is helpful for PTSD?

Marijuana does help with symptoms of PTSD. Just like benzos. And alcohol. And opiates. But that doesn't make any of those substances good choices (or even safe choices) for treatment.

I agree with those who argue that marijuana shouldn't have the restrictions placed on it that it does that prevents it from being researched.

But I also have limited sympathy for the "medical marijuana" camp when the vast majority of users never attempt Marinol and most don't use edibles. There is a reason that SMOKING is not a format that we use in medicine. I realize that it's a better high, but it's a terrible way to administer what you consider medicine.

 

[sunlioness]

Yeah. That's precisely my point.

And when inhaled cannabis has jumped through all the hoops that the other meds I prescribe have, maybe then I'll consider prescribing it.

Until then ... No. No more than I'd recommend "Bourbon 1-2 shots TID prn panic attack."


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[FlowRate]

Marijuana does help with symptoms of PTSD. Just like benzos. And alcohol. And opiates. But that doesn't make any of those substances good choices (or even safe choices) for treatment.

In a sense these things help the same way that trigger warnings do.

Doctors don't recommend them as a treatment modality, but they might help avoid symptoms.

 

[WingedOx]

I would agree with you that it shouldn't, but that seemed to be the implication of the OP. The doctor isn't "taken out of the decision" if they don't want their patient on cannabis, they just don't sign the form

I do end up signing generic letters "Mr X is a patient under my care since [date] for [condition] and he has been adherent to treatment during this time" for various reasons. Most reason per the patient was for a parole officer. I'm going to have to be a lot more specific now to prevent "diversion."

 

[wolfvgang22]

For some reason the fact that smoking marijuana can cause cancer and lung disease much like smoking tobacco is overlooked by the public.
I'm not willing to give marijuana a tacit stamp of approval as a physician just because ending marijuana prohibition is the hip new cause. People can smoke if they want, but I'm not going to encourage anything that might damage health if I don't have to when there are better, more effective options or equally effective options with less risk. It's the same reason I recommend a healthier diet instead of ephedra for weight loss.

 

[Shikima]

Marijuana does help with symptoms of PTSD. Just like benzos. And alcohol. And opiates. But that doesn't make any of those substances good choices (or even safe choices) for treatment.

I agree with those who argue that marijuana shouldn't have the restrictions placed on it that it does that prevents it from being researched.

But I also have limited sympathy for the "medical marijuana" camp when the vast majority of users never attempt Marinol and most don't use edibles. There is a reason that SMOKING is not a format that we use in medicine. I realize that it's a better high, but it's a terrible way to administer what you consider medicine.

I've been saying this for years now. Good to know others see it.

 

[hamstergang]

smoking marijuana can cause cancer and lung disease much like smoking tobacco

That's not what I heard. I'll try to find my sources. Can you provide yours?

 

[Shikima]

That's not what I heard. I'll try to find my sources. Can you provide yours?

http://www.lung.org/stop-smoking/sm...-health.html?referrer=https://www.google.com/

 

[Dharma]

That's not what I heard. I'll try to find my sources. Can you provide yours?

Here's one of the sources you may be referring to @hamstergang. I've heard this in the past as well. Dr. Donald Tashkin, a pulmonologist from UCLA is the author.

http://www.ncbi.nlm.nih.gov/pubmed/23802821

 

[clausewitz2]

Here's one of the sources you may be referring to @hamstergang. I've heard this in the past as well. Dr. Donald Tashkin, a pulmonologist from UCLA is the author.

http://www.ncbi.nlm.nih.gov/pubmed/23802821

Good link. Also worth bearing in mind that even "heavy habitual use" of marijuana is going to entail a much smaller mass being incinerated and inhaled versus chain smokers going through three packs a day. .

 

[PsyDr]

I'll leave this here:

Wilkinson, S. T., et al. (2015). "Marijuana use is associated with worse outcomes in symptom severity and violent behavior in patients with posttraumatic stress disorder." J Clin Psychiatry 76(9): 1174-1180.

 

[hamstergang]

Here's one of the sources you may be referring to @hamstergang. I've heard this in the past as well. Dr. Donald Tashkin, a pulmonologist from UCLA is the author.

http://www.ncbi.nlm.nih.gov/pubmed/23802821

Ah, thanks, I actually forgot I made that post already. That's in line with what I was looking for.

 

[smalltownpsych]

The whole medical marijuana thing is ridiculous. Just legalize it already. Why should the medical community be in charge of whether or not people can use intoxicants? Maybe someone should have to get a doctors note for medicinal alcohol too. "Doc, I get really uncomfortable asking young women to dance at the club". "Here's a script for Long Island Iced Tea, just hand that to the gentleman at the bar and he'll set you up."

 

[WingedOx]

Apparently a Kava bar just opened up across the street from my old apartment.

"Fine, if you're not going to show up to the trauma-focused therapy we've set up for you, at least go have an expensive root juice slushy."

 

[WisNeuro]

The whole medical marijuana thing is ridiculous. Just legalize it already. Why should the medical community be in charge of whether or not people can use intoxicants? Maybe someone should have to get a doctors note for medicinal alcohol too. "Doc, I get really uncomfortable asking young women to dance at the club". "Here's a script for Long Island Iced Tea, just hand that to the gentleman at the bar and he'll set you up."

You know this actually happened, right?

 

[wolfvgang22]

I refuse to prescribe Long Island Iced Tea until we do more rigorous research on whether it is helpful for Social Anxiety Disorder. Be right back.

 

[WisNeuro]

I refuse to prescribe Long Island Iced Tea until we do more rigorous research on whether it is helpful for Social Anxiety Disorder. Be right back.

Too much sugar, you don't want to "cure" someone's SAD but cause their diabetes, do you?

 

[wolfvgang22]

Too much sugar, you don't want to "cure" someone's SAD but cause their diabetes, do you?

You're right! That is why I'm going to patent my "totally not sweetened with Stevia" Dr. W's Anxiety Elixir.

 

[WisNeuro]

I prefer tinctures, myself.

 

[smalltownpsych]

You know this actually happened, right?

I had heard it referred to as "for medicinal purposes" in various contexts, but after a little Google magic, now I know that it apparently was a real thing during prohibition.

The internet is so much better than breaking out the old encyclopedia to try to find interesting historical tidbits.

 

[sunlioness]

I prefer tinctures, myself.

I'm sipping on a rather nice pinot noir as we type.

 

[WisNeuro]

I'm sipping on a rather nice pinot noir as we type.

Ah, my preferred wine as well. I was just reading about rising temps are bad for the grapes for this. Let's enjoy it while we can!

 

[PikminOC]

It's getting late on this side of the world, and I'm sipping rum. Let me just jump into the deep end.

I'm generally not a fan Foucault, but there are two useful concepts to borrow from him. The first is "governmentality" and the second is psychiatry as a tool of the state to normalize or marginalize behavior.

Governmentality, roughly, refers to the insertion of governance into everyday affairs by changing modes of discourse: in the medical context, advice becomes notes; notes became legal documents; these legal documents determine the allocation of social services, justify involuntary commitment, permit or restrict behavior, etc. At every step, governmental control is incremented through the guise of legal or regulatory institutions. What was a therapeutic relationship between two people has now been intruded upon by a faceless third, and that is the government. This intrusion can be beneficial (as protection from poor practice) but it can also be harmful. Where it becomes most harmful is when psychiatry is used as a tool to police the normity of behavior. And the historical examples abound (political dissidents in the Soviet Union, homosexuality, slavery, moral hygiene and Cholera epidemic, etc.)

This form is a perfect example of governmentality. "If a doctor labels me with a certain diagnosis, then it must be okay... " Well, no, actually. Diagnosis is a semiotic act that imparts a certain conceptualization of disease and treatment. If that semiosis is altered to primarily facilitate the interests of the state, then what are even doing? How are we still psychiatrists? That's not what I signed up for. I want to help people get better. Full stop. If they ain't interested, that's fine, but I'd still write in the note "strongly counseled against A, because of X, Y, Z"--if I even agree to write such a note in the first place. Primum non nocere, and all that crap.

Okay, brb. Gonna get my PTSD script filled...

Easy to say. You ever deal with the medical board in your state?
https://www.nebraska.gov/LISSearch/actions/262235.pdf
License of Nebraska Psychiatrist suspended for 3 weeks. Then he was found ok. But business shut down arbitrarily for 3 weeks. That's a lot of money and angst

 

[lymphocyte]

Easy to say. You ever deal with the medical board in your state?
https://www.nebraska.gov/LISSearch/actions/262235.pdf
License of Nebraska Psychiatrist suspended for 3 weeks. Then he was found ok. But business shut down arbitrarily for 3 weeks. That's a lot of money and angst

But what's wrong with this? An accomplished and recognized psychogeriatrician (http://www.unmc.edu/psychiatry/about/faculty/magnuson.html) requested an emergency suspension of liscencure in the interest of public safety. Surely any medical board would have to take this request seriously, and what should the accused psychiatrist be doing in the meantime? Then, a speedy tribunal comprised of the accused's peers found him to be practicing within the standards of care. Great. Problem solved. The privilege of practicing medicine comes with peer oversight. I'd much rather have it this way than the other way round.

I'm not arguing that governmentality is always harmful; it's both harmful and useful--especially in rebalancing power in human relationships (e.g. just because you have a big rock doesn't mean you get to kill me; just because I trust your medical expertise doesn't mean you get to do whatever). However, we should be mindful about how it can abused, and it has most often been abused medically when using psychiatrists to police the normity of behaviour. Not our job.

 

[Shikima]

I'm sipping on a rather nice pinot noir as we type.

It has antioxidants.... so it must be good for you!

 

[milesed]

If interested in the whole debate, you should read this CME. It's free to read and only need to pay to take the test for credit. It explains very well how the different types of chemicals in marijuana impact different symptoms.
http://www.netce.com/coursecontent.php?courseid=1238

 

[VA Hopeful Dr]

Ah, my preferred wine as well. I was just reading about rising temps are bad for the grapes for this. Let's enjoy it while we can!

Good for the Washington State vineyards I would think

 

[WisNeuro]

Good for the Washington State vineyards I would think

Yeah, they've been talking about getting more good harvests with the Pinot grape in the Sound area. Although, I wonder how much the seemingly annual late spring through fall drought will impact that if it keeps up.