Cannabis Use in Pts Rx'd Opioids

[ampaphb]

The Prevalence and Significance of Cannabis Use in Patients Prescribed Chronic Opioid Therapy: A Review of the Extant Literature.

Reisfield GM, Wasan AD, Jamison RN
Pain Med. 2009 Sep 29. [Epub ahead of print]

Background. Cannabis is the most widely consumed illicit drug in the United States. Its use, particularly in early initiates, is associated with subsequent development of other drug and alcohol use disorders.

Objective. The authors examined the prevalence of cannabis use and the association between cannabis use and aberrant opioid-related behaviors in patients prescribed chronic opioid therapy for persistent pain.

Methods. PubMed was queried for studies of chronic opioid therapy in which aberrant opioid-related behaviors were quantitatively examined and in which cannabis use data (as determined by cannabinoid-positive urine drug tests) were extricable from that of other substances of abuse.

Results. The prevalence of cannabis use among patients prescribed chronic opioid therapy in these studies ranged from 6.2% to 39%, compared with 5.8% in the general United States population. Furthermore, cannabis use in chronic opioid patients shows statistically significant associations with present and future aberrant opioid-related behaviors.

Conclusion. Cannabis use is prevalent in patients prescribed chronic opioid therapy and is associated with opioid misuse. Further research is necessary to clarify the strength and the nature of the association between cannabis use and opioid misuse, and to address additional questions about the consequences of cannabis use in the context of chronic opioid therapy.

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[Aether2000]

Other reasons why cannabis should never be prescribed:
1. The naive legislatures in the states that have the so called "medical marijuana" are simply catering to drug addicts. There is very sparse medical evidence that cannabis has any useful effect at all in chronic pain aside from sedation and making people fat and effectively drunk (motor coordination loss). These legislatures were persuaded by those in their midst who a. had used marijuana themselves recreationally and believe it may have medical merit or b. were persuaded by the very poorly conducted studies showing it has significant medical benefits. The glaucoma rate skyrocketed in California after "marijuana cards" began to be handed out.
2. Recent studies show potency varies from 1.7 to 13.9% so physicians dumb enough to "prescribe" marijuana are giving prescriptions for an uncontrolled street drug with unknown potency. The amount of THC varies widely and is also steadily increasing in many countries.
3. Purity is also not assayed....the literature has examples of pneumonia caused by silica used as an additive to give more weight to the weed and there are cases of lead poisoning due to marijuana.
4. Physicians do not have enough knowlege to be prescribing the street drug. What should be prescribed? Cannabis sativa or indicus? Do you know the difference and the differences in ratios of THC to cannabidiol? What about resin or hashish? Green dragon vs Mexican gold? And the method of use via waterpipe, oral, or inhalation makes a huge difference in the amount delivered. And what about the amount? One puff of a 6% THC content marijuana gives blood levels 5 times higher than that of 20mg marinol with virtually 100% of the patients experiencing psychopharmaceutical effects from the drug. What is the right dose?

Frankly doctors prescribing a street drug should have their license revoked by the state medical boards, if not the DEA, and the legislators should have their heads drilled for coming up with such a lame brained idea.

 

[drusso]

Other reasons why cannabis should never be prescribed:
1. The naive legislatures in the states that have the so called "medical marijuana" are simply catering to drug addicts. There is very sparse medical evidence that cannabis has any useful effect at all in chronic pain aside from sedation and making people fat and effectively drunk (motor coordination loss). These legislatures were persuaded by those in their midst who a. had used marijuana themselves recreationally and believe it may have medical merit or b. were persuaded by the very poorly conducted studies showing it has significant medical benefits. The glaucoma rate skyrocketed in California after "marijuana cards" began to be handed out.
2. Recent studies show potency varies from 1.7 to 13.9% so physicians dumb enough to "prescribe" marijuana are giving prescriptions for an uncontrolled street drug with unknown potency. The amount of THC varies widely and is also steadily increasing in many countries.
3. Purity is also not assayed....the literature has examples of pneumonia caused by silica used as an additive to give more weight to the weed and there are cases of lead poisoning due to marijuana.
4. Physicians do not have enough knowlege to be prescribing the street drug. What should be prescribed? Cannabis sativa or indicus? Do you know the difference and the differences in ratios of THC to cannabidiol? What about resin or hashish? Green dragon vs Mexican gold? And the method of use via waterpipe, oral, or inhalation makes a huge difference in the amount delivered. And what about the amount? One puff of a 6% THC content marijuana gives blood levels 5 times higher than that of 20mg marinol with virtually 100% of the patients experiencing psychopharmaceutical effects from the drug. What is the right dose?

Frankly doctors prescribing a street drug should have their license revoked by the state medical boards, if not the DEA, and the legislators should have their heads drilled for coming up with such a lame brained idea.

Agree 100%.

 

[Diamox]

So what about Cannabinoids for neuropathic pain or spasticity?

And why does the thought of cannabinoid Rx evoke such emotional reactions in the US?

 

[mille125]

Agree 100%.

i also agree

 

[lobelsteve]

Other reasons why cannabis should never be prescribed:
1. The naive legislatures in the states that have the so called "medical marijuana" are simply catering to drug addicts. There is very sparse medical evidence that cannabis has any useful effect at all in chronic pain aside from sedation and making people fat and effectively drunk (motor coordination loss). These legislatures were persuaded by those in their midst who a. had used marijuana themselves recreationally and believe it may have medical merit or b. were persuaded by the very poorly conducted studies showing it has significant medical benefits. The glaucoma rate skyrocketed in California after "marijuana cards" began to be handed out.
2. Recent studies show potency varies from 1.7 to 13.9% so physicians dumb enough to "prescribe" marijuana are giving prescriptions for an uncontrolled street drug with unknown potency. The amount of THC varies widely and is also steadily increasing in many countries.
3. Purity is also not assayed....the literature has examples of pneumonia caused by silica used as an additive to give more weight to the weed and there are cases of lead poisoning due to marijuana.
4. Physicians do not have enough knowlege to be prescribing the street drug. What should be prescribed? Cannabis sativa or indicus? Do you know the difference and the differences in ratios of THC to cannabidiol? What about resin or hashish? Green dragon vs Mexican gold? And the method of use via waterpipe, oral, or inhalation makes a huge difference in the amount delivered. And what about the amount? One puff of a 6% THC content marijuana gives blood levels 5 times higher than that of 20mg marinol with virtually 100% of the patients experiencing psychopharmaceutical effects from the drug. What is the right dose?

Frankly doctors prescribing a street drug should have their license revoked by the state medical boards, if not the DEA, and the legislators should have their heads drilled for coming up with such a lame brained idea.

Ditto.

I'd like to get a UDS on all legislators who voted for these laws, as well as all docs Rx'ing medical marijuana. Third arm would be pain docs in states where med mar is not allowed. Food for thought.

 

[DigableCat]

If you think your golden DEA prescription pad which allows legalized opiate writing with it's inherent drug diversion/abuse, acceptable tolerance issues, hellish withdrawal effects, and dare I say physical and psychological addiction is infinitely better than prescribing someone medicinal marijuana(in the appropriate patient population) than you are really deluding yourselves.

For the record, I have not prescribed medicinal marijuana.

 

[lonelobo]

If you think your golden DEA prescription pad which allows legalized opiate writing with it's inherent drug diversion/abuse, acceptable tolerance issues, hellish withdrawal effects, and dare I say physical and psychological addiction is infinitely better than prescribing someone medicinal marijuana(in the appropriate patient population) than you are really deluding yourselves.

For the record, I have not prescribed medicinal marijuana.

Digable Cat now you are talking some sense

 

[Mister Mxyzptlk]

MJ was demonized back in the days of Harry Anslinger and William Randolph Hearst. The history of propaganda against it is a lesson in stupidity. It is less addictive than either alcohol or tobacco, which are over the counter in whatever quantities you please.

When Congress outlawed it the vast majority didn't even know what MJ was, and the AMA opposed the legislation. When the bill came up for discussion someone asked what the AMA position was and one of the committee members who heard the AMA testimony outright lied and said the AMA approved of the legislation.

Learn your history folks. It's all in the newspapers of the day and the Congressional Record. And while you're at it, read the recommendations of Nixon's blue-ribbon panel on MJ. Nixon didn't like it, so he ignored it. Look at the names of the people on that panel. They were hardly left-wing druggies.

Then as a bonus homework assignment, try figure out why alcohol and tobacco are not C-I drugs. They certainly meet the definition. Heroin, OTOH, does not meet the definition of a C-I.

This is all about politics and money. It has nothing to do with MJ as a drug per se. If you think that MJ is the "demon weed with roots in Hell" then you bought into propaganda that is more than twice as old as you are.

 

[lobelsteve]

If you think that MJ is the "demon weed with roots in Hell" then you bought into propaganda that is more than twice as old as you are.

And only half as old as you are?

I have no problem if someone wants to smoke MJ.

As long as:

1. They are not an impaired driver.
2. They are not flying an airplane
3. They are not my patient and putting me at risk of DEA investigation.

But really, no matter what you smoke, it is not good for you. I say regulate and tax, like cigarettes.

 

[mille125]

MJ was demonized back in the days of Harry Anslinger and William Randolph Hearst. The history of propaganda against it is a lesson in stupidity. It is less addictive than either alcohol or tobacco, which are over the counter in whatever quantities you please.

When Congress outlawed it the vast majority didn't even know what MJ was, and the AMA opposed the legislation. When the bill came up for discussion someone asked what the AMA position was and one of the committee members who heard the AMA testimony outright lied and said the AMA approved of the legislation.

Learn your history folks. It's all in the newspapers of the day and the Congressional Record. And while you're at it, read the recommendations of Nixon's blue-ribbon panel on MJ. Nixon didn't like it, so he ignored it. Look at the names of the people on that panel. They were hardly left-wing druggies.

Then as a bonus homework assignment, try figure out why alcohol and tobacco are not C-I drugs. They certainly meet the definition. Heroin, OTOH, does not meet the definition of a C-I.
This is all about politics and money. It has nothing to do with MJ as a drug per se. If you think that MJ is the "demon weed with roots in Hell" then you bought into propaganda that is more than twice as old as you are.

I dont understand your point. If you are trying to make a case for legalization of MJ so be it. However, I think that most of this discussion is on doctors prescribing MJ. Most docs that I know would not write a script for medical alcohol, nicotine, or MJ. There is good evidence that nicotine helps with depression. Should we start writing scripts for medical nicotine?

I agree with Steve. I am not trying to play policeman or moral authority to the world. If a patient wants to smoke MJ, that is his choice and he will need to deal with the consequences. However, I am very clear at the outset that all pain meds written by me will be tapered in this situation.

 

[SleepIsGood]

3. They are not my patient and putting me at risk of DEA investigation.

But really, no matter what you smoke, it is not good for you. I say regulate and tax, like cigarettes.

Can you explain....obviously I'm new to this...could you expand on this for me? I know there are 'urine tox screens' that are randomized,etc.

However, yes you want to know that whatever you are prescribing desnt get diverted,etc. But if someone smokes weed, etc. And you are prescribing them stuff what is the medical/legal concern? Respiratory depression from the MJ and being on opiods?

Just asking..

For example, let's say you are a doctor's office that doesnt screen urine....your pt smokes marijuana...you dont know that he/she does...what kind of LEGAL repercussions are there? If any?

 

[SSdoc33]

i have absolutely no idea how to prescribe it, and at what doses, concentrations, and frequencies. i don think im alone. something tells me that even if i did, it would all get smoked the same day as i wrote the script.

 

[lobelsteve]

Can you explain....obviously I'm new to this...could you expand on this for me? I know there are 'urine tox screens' that are randomized,etc.

However, yes you want to know that whatever you are prescribing desnt get diverted,etc. But if someone smokes weed, etc. And you are prescribing them stuff what is the medical/legal concern? Respiratory depression from the MJ and being on opiods?

Just asking..

For example, let's say you are a doctor's office that doesnt screen urine....your pt smokes marijuana...you dont know that he/she does...what kind of LEGAL repercussions are there? If any?

The standpoint of the DEA and your state medical board is as follows:

1. You are prescribing a controlled substance.
2. The patient is involved in illegal activities (known to the prescriber) that deals with obtaining narcotics.
3. You must assume that the person who is selling them the illicit narcotics is willing to take your prescribed narcotics in lieu of payment.
4. Your continuation of their narcotics enables them to continue committing a felony.
5. Your DEA registration and license are at risk.

Failure to perform due diligence in opiate prescribing is cause for loss of DEA registration and medical board sanction.

Please visit FSMB Opioid Prescribing Guidelines, Wisconsin Pain Policy Research Study Group, and your states medical board website.
Briefly: Due diligence: no Rx's on new patients without obtaining records, contacting their pharmacy, UDS, screening tool for opioid abuse (SOAPP-R, ORT)
Regular office visits, occasional UDS, appropriate imaging, impeccable documentation including the 4A's and a physical exam.

There is much more, but it becomes state dependent. If you are not doing the above, put down the pen. You are in violation of your state's medical practice act.

 

[Pain_doc]

Hmmm. Algosdoc seems to know alot about MJ....

There was an interesting case in northern Indiana recently. An individual driving a car ran over a 4 and 6 year old. A family memeber of the driver informed reporters that the driver was under the influence of MJ....as recommended by his physician.

 

[mdvol]

"2. The patient is involved in illegal activities (known to the prescriber) that deals with obtaining narcotics.
3. You must assume that the person who is selling them the illicit narcotics is willing to take your prescribed narcotics in lieu of payment."

Bingo.

 

[Aether2000]

My discussion was based on doctors prescribing a street drug which should be prohibited, not championed by state legislators. If marijuana is to be legalized for medical usage it must be assayed for purity, quality, quantity just as are any other psychoactive medical drugs in the US.
Whether we should close our eyes to patients using the drug is a moot point: the usage of the drug is illegal anywhere in the US under federal law, and the federal authorities control our DEA licenses. If it is to be legalized, then it must be done via process, not by fiat of reefer legislators deluded into believing there is any such thing as "medical marijuana".

 

[PMR 4 MSK]

The standpoint of the DEA and your state medical board is as follows:

1. You are prescribing a controlled substance.
2. The patient is involved in illegal activities (known to the prescriber) that deals with obtaining narcotics.
3. You must assume that the person who is selling them the illicit narcotics is willing to take your prescribed narcotics in lieu of payment.
4. Your continuation of their narcotics enables them to continue committing a felony.
5. Your DEA registration and license are at risk.

Failure to perform due diligence in opiate prescribing is cause for loss of DEA registration and medical board sanction.

Please visit FSMB Opioid Prescribing Guidelines, Wisconsin Pain Policy Research Study Group, and your states medical board website.
Briefly: Due diligence: no Rx's on new patients without obtaining records, contacting their pharmacy, UDS, screening tool for opioid abuse (SOAPP-R, ORT)
Regular office visits, occasional UDS, appropriate imaging, impeccable documentation including the 4A's and a physical exam.

There is much more, but it becomes state dependent. If you are not doing the above, put down the pen. You are in violation of your state's medical practice act.

#2 does not follow - they are involved in an illegal activity, i.e. the purchase or possession of MJ. That does not mean they are a rapist, a murderer, a wife-beater or an opioid addict. You cannot assume one crime means they are committing another. Many polysubstance abusers simply like to mix their drugs together...

Also for #3, 'cmon, MJ ain't that expensive. I know people on unemployment who can still afford their weed. Sure, there are people who trade pills for weed, but I wouldn't say anyone would tell you to assume it in 100% of cases. While never personally purchasing it, I am aware of it's past and current street value. You can get high for $1-2/day. Even the dopeheads'll tell you it's cheeaper than alcohol, and the hangover not as bad. One vicodin is $5+ and you need several/day for the same effect.

 

[lobelsteve]

#2 does not follow - they are involved in an illegal activity, i.e. the purchase or possession of MJ. That does not mean they are a rapist, a murderer, a wife-beater or an opioid addict. You cannot assume one crime means they are committing another. Many polysubstance abusers simply like to mix their drugs together...

Also for #3, 'cmon, MJ ain't that expensive. I know people on unemployment who can still afford their weed. Sure, there are people who trade pills for weed, but I wouldn't say anyone would tell you to assume it in 100% of cases. While never personally purchasing it, I am aware of it's past and current street value. You can get high for $1-2/day. Even the dopeheads'll tell you it's cheeaper than alcohol, and the hangover not as bad. One vicodin is $5+ and you need several/day for the same effect.

That's funny. Let me preface the preceeding again with:

This is how the medical board and DEA look at it. It is also how I look at it when reviewing physician files to help determine standards of care and to mete out punishments. Caveat emptor.

 

[mille125]

That's funny. Let me preface the preceeding again with:

This is how the medical board and DEA look at it. It is also how I look at it when reviewing physician files to help determine standards of care and to mete out punishments. Caveat emptor.

PMR you really need to listen to steve. You need to look at things in the same manner that the DEA would. That is the world that we live in. You really should listen to what he is saying..

 

[Mister Mxyzptlk]

I have a patient with polymyositis and peripheral neuropathy who was smoking MJ for nerve pain. It was the only thing that ever worked and we tried a lot of meds. I asked him to stop and gave him a script for Marinol. It worked. However, insurance won't pay for it and he can't afford it. Can he go back to using the only drug that has provided relief of his nerve pain? If so, do I have to stop his opioid prescriptions?

I don't know about the rest of you, but I am seeing increased THC positives in the elderly. They get together to play bridge and pass around a doobie. They tell me they get it from their kids. They always offer to stop using it if I want them to.

Legal issues aside, would you prefer to have your opioid patients using THC or EtOH? I have never heard of anyone smoking a joint and starting a bar fight or beating up his wife. It doesn't rot out your liver. There's no hangover. Far less addictive. What's the potentiation of opioid-induced respiratory depression with THC vs EtOH?

I think concomitant MJ use and opioid prescribing are context-sensitive. A young guy with facet pain taking Vicodin testing positive for THC is a bad sign. An 80 year old lady s/p CABG and CEA catching a buzz with her friends is hardly a menace to society. Someone with rip-roaring neuropathy using it for pain relief is about as benign as it gets.

In Texas MJ possession is a misdemeanor, punishable by a fine. Even the DEA isn't busting the med-MJ clinics at any great rate. They could - they know exactly where they are but the clinics remain open.

The FBI has to keep lowering the bar on previous illicit drug use in recruits. Used to be you couldn't have ever used any illicit drugs, then it was for a certain period of years, and now I think it's "not lately".

Canada exports more MJ than wheat.

Time to stop the hypocrisy. Besides, if you legalize it now it could save California's economy.

 

[mille125]

MJ was demonized back in the days of Harry Anslinger and William Randolph Hearst. The history of propaganda against it is a lesson in stupidity. It is less addictive than either alcohol or tobacco, which are over the counter in whatever quantities you please.

When Congress outlawed it the vast majority didn't even know what MJ was, and the AMA opposed the legislation. When the bill came up for discussion someone asked what the AMA position was and one of the committee members who heard the AMA testimony outright lied and said the AMA approved of the legislation.

Learn your history folks. It's all in the newspapers of the day and the Congressional Record. And while you're at it, read the recommendations of Nixon's blue-ribbon panel on MJ. Nixon didn't like it, so he ignored it. Look at the names of the people on that panel. They were hardly left-wing druggies.

Then as a bonus homework assignment, try figure out why alcohol and tobacco are not C-I drugs. They certainly meet the definition. Heroin, OTOH, does not meet the definition of a C-I.

This is all about politics and money. It has nothing to do with MJ as a drug per se. If you think that MJ is the "demon weed with roots in Hell" then you bought into propaganda that is more than twice as old as you are.

These may be your personal feelings but you need to protect your practice by doing the appropriate things. You know what those are....

 

[Aether2000]

I agree with Mille. The DEA and other branches of the federal government do not believe in context sensitive law. It is legal or it isn't, period. Doesn't matter what the person's age is nor why they are using illicit drugs...it is illegal. Doesn't matter if they state it is the only thing that works. Why would you permit your patients to take marijuana and continue prescribing opiates if you would not do the same for those taking heroin or cocaine (a schedule II drug) or methamphetamine (a schedule II drug)? Or do you? There comes a time when physicians that are given the legal responsibility imposed by society to prescribe opioids in a manner that is ethical must just say no when patients want to use whatever works to get high 100% of the time for minimal reductions in pain as demonstrated at the AAPM earlier this year in the poster presentation on marijuana. MJ is not a great pain med, but is a great way to totally zone out of life and society. It has many side effects and complications including increased risk of dental caries, periodontal diseases, dysplastic changes and pre-malignant lesions within the oral mucosa,and oral infections, possibly due to the immunosuppressive effects (Aust J Dent Jun 2005). Published in the European Respiratory Journal, a study of lung cancer patients found that there is a 5.7 times risk of lung cancer smoking 1 joint a day for 10 years and 5 times the risk smoking 2 joints a day for 5 years. The researchers also found the carbon monoxide level is 5 times higher for marijuana smokers compared to cigarette smokers. MJ is also associated with birth defects, psychosis, and an increased risk of severe hepatic fibrosis in those with Hep C. In a review published in Clinical Toxicology July 2009, chronic MJ use is associated with "evidence of psychiatric, respiratory, cardiovascular, and bone toxicity associated with chronic cannabis use. Cannabis has now been implicated in the etiology of many major long-term psychiatric conditions including depression, anxiety, psychosis, bipolar disorder, and an amotivational state. Respiratory conditions linked with cannabis include reduced lung density, lung cysts, and chronic bronchitis. Cannabis has been linked in a dose-dependent manner with elevated rates of myocardial infarction and cardiac arrythmias. It is known to affect bone metabolism and also has teratogenic effects on the developing brain following perinatal exposure. Cannabis has been linked to cancers at eight sites, including children after in utero maternal exposure, and multiple molecular pathways to oncogenesis exist." MJ use results in a 7 fold increase risk of being involved in motor vehicle accidents.
The arguments that MJ is a benign drug as used in the US are simply ignoring the cumulative medical knowledge that has determined otherwise.
If MJ is to be legalized then it should be studied, controlled, taxed into oblivion just like cigarettes, and require responsible use of the drug if it is safe enough to use in our society. The argument that because alcohol and cigarettes exist that we should legalize marijuana is counterintuitive to our prime directive as physicians since the introduction of other deleterious psychoactive drugs with serious side effects is not promoting health.

 

[SSdoc33]

I agree with Mille. The DEA and other branches of the federal government do not believe in context sensitive law. It is legal or it isn't, period. Doesn't matter what the person's age is nor why they are using illicit drugs...it is illegal. Doesn't matter if they state it is the only thing that works. Why would you permit your patients to take marijuana and continue prescribing opiates if you would not do the same for those taking heroin or cocaine (a schedule II drug) or methamphetamine (a schedule II drug)? Or do you? There comes a time when physicians that are given the legal responsibility imposed by society to prescribe opioids in a manner that is ethical must just say no when patients want to use whatever works to get high 100% of the time for minimal reductions in pain as demonstrated at the AAPM earlier this year in the poster presentation on marijuana. MJ is not a great pain med, but is a great way to totally zone out of life and society. It has many side effects and complications including increased risk of dental caries, periodontal diseases, dysplastic changes and pre-malignant lesions within the oral mucosa,and oral infections, possibly due to the immunosuppressive effects (Aust J Dent Jun 2005). Published in the European Respiratory Journal, a study of lung cancer patients found that there is a 5.7 times risk of lung cancer smoking 1 joint a day for 10 years and 5 times the risk smoking 2 joints a day for 5 years. The researchers also found the carbon monoxide level is 5 times higher for marijuana smokers compared to cigarette smokers. MJ is also associated with birth defects, psychosis, and an increased risk of severe hepatic fibrosis in those with Hep C. In a review published in Clinical Toxicology July 2009, chronic MJ use is associated with "evidence of psychiatric, respiratory, cardiovascular, and bone toxicity associated with chronic cannabis use. Cannabis has now been implicated in the etiology of many major long-term psychiatric conditions including depression, anxiety, psychosis, bipolar disorder, and an amotivational state. Respiratory conditions linked with cannabis include reduced lung density, lung cysts, and chronic bronchitis. Cannabis has been linked in a dose-dependent manner with elevated rates of myocardial infarction and cardiac arrythmias. It is known to affect bone metabolism and also has teratogenic effects on the developing brain following perinatal exposure. Cannabis has been linked to cancers at eight sites, including children after in utero maternal exposure, and multiple molecular pathways to oncogenesis exist." MJ use results in a 7 fold increase risk of being involved in motor vehicle accidents.
The arguments that MJ is a benign drug as used in the US are simply ignoring the cumulative medical knowledge that has determined otherwise.
If MJ is to be legalized then it should be studied, controlled, taxed into oblivion just like cigarettes, and require responsible use of the drug if it is safe enough to use in our society. The argument that because alcohol and cigarettes exist that we should legalize marijuana is counterintuitive to our prime directive as physicians since the introduction of other deleterious psychoactive drugs with serious side effects is not promoting health.

fyi: never disagree with algos on anything.

 

[DigableCat]

If they document appropriately.

Chapter 69.51A RCW
Medical marijuana

Physicians excepted from state's criminal laws.
A physician licensed under chapter 18.71 or 18.57 RCW shall be excepted from the state's criminal laws and shall not be penalized in any manner, or denied any right or privilege, for:

(1) Advising a qualifying patient about the risks and benefits of medical use of marijuana or that the qualifying patient may benefit from the medical use of marijuana where such use is within a professional standard of care or in the individual physician's medical judgment; or

(2) Providing a qualifying patient with valid documentation, based upon the physician's assessment of the qualifying patient's medical history and current medical condition, that the medical use of marijuana may benefit a particular qualifying patient

So there's that...

But maybe some of you would like to come to Washington to make a legal class action suit and prosecute physicians for doing such. I hear people are running out of other things to complain about....

 

[lobelsteve]

If they document appropriately.

Chapter 69.51A RCW
Medical marijuana

Physicians excepted from state's criminal laws.
A physician licensed under chapter 18.71 or 18.57 RCW shall be excepted from the state's criminal laws and shall not be penalized in any manner, or denied any right or privilege, for:

(1) Advising a qualifying patient about the risks and benefits of medical use of marijuana or that the qualifying patient may benefit from the medical use of marijuana where such use is within a professional standard of care or in the individual physician's medical judgment; or

(2) Providing a qualifying patient with valid documentation, based upon the physician's assessment of the qualifying patient's medical history and current medical condition, that the medical use of marijuana may benefit a particular qualifying patient

So there's that...

But maybe some of you would like to come to Washington to make a legal class action suit and prosecute physicians for doing such. I hear people are running out of other things to complain about....

You are an idiot. Sorry, had to say it.

DEA= Federal agency, holding your registration. Federal law states marijuana is illegal. Continued prescribing in the face of known illegal activity is grounds for DEA investigation and loss of registration.

But hey, we're all just anti-dope kool-aid drinkers from the Reagan era. Unsure of who you are or who trained you, but if an attending did not get you this lecture in fellowship- consider yourself a little more educated.

 

[mid|ine]

Thats the key, I don't think its prescribed, its "recommended". It may vary from state to state but I don't live in a state with medical MJ so Im not an expert here.

I would not continue to give opioids to anyone testing positive for MJ, to cover myself.

In terms of the linkage of MJ with many other diseases, have you read the studies? I know many I have looked at are scientifically invalid and only published with a clear bias to establish the evils of the plants. Its far from harmless, but on par with EtOH and tobacco. I don't use MJ. Nor to I smoke or drink. However I do believe we are wasting our tax dollars telling people they can't use MJ. The primary reason it was ever made illegal was out of racism, not health or safety. Regulate and tax it.

 

[PMR 4 MSK]

There's prescribing MJ - clearly illegal under federal law, legal by California state law, we'll let the two fight it out. Even if it was legal in my state, you'd never get an Rx from me to fire up a blunt daily.

There's recommending MJ - What the Washington state law seems to cover. That's not prescribing, but is indicating someone would likely benefit from a drug, sorta like recommending Aleve. Not sure federal law covers reccomendations to patients about MJ. I don't see any real medical use for it, so I'd never utilize this law. Even if someone told me that it was the only thing that helped them, I still would not recommend or document ni the chart to them that I reccomend they use it. Not enough EBM for it in my book.

There's condoning MJ use. That's where a pt tells you he's smoking a dooby now and then (or daily, or whatever), and you say, "well that's your choice, same as your choice to drive without a seatbelt, or eating McDonalds everyday (not illegal, probably should be...). I would not codone MJ use in writing, and I document every time that I advised the pt to stop use of it. Clearly it's a health hazard, and my job as a physician is to advise pts on health issues.

Then there's ignoring MJ use. A pt tells you he's using it, or you find it on a UDS, or a joint falls out of his pocket in front of you (had that happen in my solo practice once...). You decline to document any response to it or advise the pt on it. You stick your head in the sand. Is there any federal law that says you must address it? You will say yes, there is, but that's your interpretation. Many docs do just that - ignore it.

All of this can occur in the context of a patient on opioids, benzos or other restricted drugs, or in a pt who is not on any of them. Certainly part of job as physicians is to monitor patients recieving scheduled drugs from us. Certainly there is a huge black market for these drugs. And certainly we are called on to police our own practices.

I suspect that no one here would prescribe MJ, a few might reccomend it in the right pt if law allowed, some would codone and some are ignoring it. Most are probably condemning it as illegal under federal law and a threat to our licenses if we don't. But I don't believe the law is clear or stated that we have any obligation to discharge pt or withdraw them from opioids for a positive UDS for MJ. I believe we are given discretion to treat patients in a context.

Please educate me that there is stated law or case law showing that physicians are under the obligation to deny opioids to a patient who has used marjuana. Show me a case (and not, "I know of a guy..") where a physician was sanctioned for a case of allowing a pt to smoke pot, and not part of a bigger problem of trading scripts for money, sex or drugs or simply running a pill mill.

Otherwise, as Steve said yesterday

I'll just do my job, and not add to fear mongering without any data to back it up. But if someone has data- help me out.

 

[Aether2000]

The state medical licensure boards take a dim view of physicians prescribing opiates to those using MJ and this has been one of the factors in licensure revocation in several states. In a poll of county prosecutors here in Indiana, 75% stated they would consider the physician an accessory to a crime if the patient was using marijuana or other illicit drugs and the physician knew about this, and the patient was arrested for selling or trading prescription drugs for illicit drugs. So even though some reefer legislatures don't mind doctors condoning or recommending or prescribing illegal uncontrolled potentially toxic street drugs, the medical boards and prosecutors are not of a like mind, and can trap the docs on technicalities if they deem them to be a nuisance to society.

 

[Mister Mxyzptlk]

The state medical licensure boards take a dim view of physicians prescribing opiates to those using MJ and this has been one of the factors in licensure revocation in several states. In a poll of county prosecutors here in Indiana, 75% stated they would consider the physician an accessory to a crime if the patient was using marijuana or other illicit drugs and the physician knew about this, and the patient was arrested for selling or trading prescription drugs for illicit drugs. So even though some reefer legislatures don't mind doctors condoning or recommending or prescribing illegal uncontrolled potentially toxic street drugs, the medical boards and prosecutors are not of a like mind, and can trap the docs on technicalities if they deem them to be a nuisance to society.

You are mixing together two different things. One is prescribing to someone that you know is using MJ. The other is prescribing to someone who you know is diverting his scripts.

There is a difference between something "looking bad" and "being illegal". So far, all I have heard is "it looks bad", and "someone might come after you".

Please post the relevant law that says a physician may not prescribe opioids to an otherwise compliant pt who uses MJ? I am unaware of any such proscription.

Please cite a case where a doctor was prescribing narcotics to someone whom he knew used MJ, the doctor was otherwise an upstanding member of the medical community, who was investigated, disciplined or criminally prosecuted for this one action?

By extension, should we deny medications to other minor lawbreakers (in Texas MJ possession is a misdemeanor)? Perhaps we should not prescribe to people convicted of speeding, driving without a license, writing a hot check, etc.

 

[DigableCat]

DEA= Federal agency, holding your registration. Federal law states marijuana is illegal. Continued prescribing in the face of known illegal activity is grounds for DEA investigation and loss of registration.

But hey, we're all just anti-dope kool-aid drinkers from the Reagan era. Unsure of who you are or who trained you, but if an attending did not get you this lecture in fellowship- consider yourself a little more educated...

Hey thanks for the "education"...but never did I say that I would prescribe in the face of known illegal drug taking activity. However, if someone can provide a currently valid medicinal marijuana card or documentation from a physician that practices in the state of Washington... I may counsel them that it may not be in their best interest(especially if I feel if it is more for anxiety and not for pain), but I would still treat them appropriately. Whether that is with or without opiates is patient dependent.

You are an idiot. Sorry, had to say it...

Niiiice...and very professional by the way. Any respect I may have had for you has just evaporated. You don't get to say disparaging remarks and then because you say sorry it makes it cool

For example:

Your mom's a *****
Sorry...had to say it.

See...doesn't work very well does it? Didn't think so.

 

[PMR 4 MSK]

The state medical licensure boards take a dim view of physicians prescribing opiates to those using MJ and this has been one of the factors in licensure revocation in several states. In a poll of county prosecutors here in Indiana, 75% stated they would consider the physician an accessory to a crime if the patient was using marijuana or other illicit drugs and the physician knew about this, and the patient was arrested for selling or trading prescription drugs for illicit drugs. So even though some reefer legislatures don't mind doctors condoning or recommending or prescribing illegal uncontrolled potentially toxic street drugs, the medical boards and prosecutors are not of a like mind, and can trap the docs on technicalities if they deem them to be a nuisance to society.

OK, so Zero Tolerence. We tell patients: if you smoke marijuana, and we find out, we mark your chart with a scarlet MJ and you are forever banned from Rx medication that may relieve your pain.

I'm cool with that. I rarely prescribe opiates as I find they have about the same utility for chronic pain that MJ has - highly abused, poor literature to support it's use, great controversy among physicians, high desirability among patients, illegal street value, government watchdogs looking to put notches on their prosecutorial belt, etc. I use opiates monstly for acute pain, and transition those on them who become chronic to non-opioids.

For the few on opioids I do UDS, and those who test positive for MJ are withdrawn. Basically, I don't care anymore about the "It was only one time... I was in a room with 10 people smoking it... I promise it'll never happen again!" In the past, when I've given second chances 70% tested positive again on a future UDS for MJ. So I've become a prick and don't give second chances. It's in the opioid agreement and I tell people about it verbally. I also don't give second chances for lost/stolen prescriptions, running out early, etc. Drug seekers rarely come to me anymore.

But I still believe several things:

MJ is probably the most benign recreational illegal drug out there, and likely does less harm to society and individuals than alcohol or tobacco. If I'm not giving someone opiates, I couldn not care less how often they fire up a fatty.

If a physician condones the use of MJ and documents it, that should be b/w the pt and the physician, not the doc and the government (just my opinion.)

Prohibition in any form simply does not work. Never has, never will.

And I believe stupidity and bad decisions are inalienable rights in America. If not a right, then at least maybe a source for my entertainment and my salary.

 

[Aether2000]

The prosecutors don't care if the physician knew they were diverting or not... the fact that they are using illicit drugs is so frequently associated with drug diversion that the doctor should have known better than to continue prescribing opioids to those that are using illicit drugs. Besides, if the patient doesn't give a flip about the laws of the land, why should the physician believe the patient is going to be compliant with clinic drug policies? Get real. It ain't gonna happen. Drug abusers are drug abusers and they will say or do anything to continue their supply of illicit drugs- even trying to dupe their pain doctors. The presumption of this behavior is borne out by the first study in this thread. If prohibition does not work then why try stopping any illicit drug use at all? Why try controlling heroin use in the US? Why bother? What about methamphetamine? Shouldn't the destructive nature of this drug be between the person and their drug dealer and not the government? Why should the government interfere in whatever we want to do with our bodies? Give me a break.... If Mister Mxyzptlk wants to continue prescribing opioids to those using illicit drugs, then fine. But he should expect there will be a long line of physicians standing to decry such as substandard care bordering on lack of ethics. I would be first in that long line to testify before the state medical licensing agencies.

 

[PMR 4 MSK]

I would be first in that long line to testify before the state medical licensing agencies.

With all due respect Algos...

It is sad they we are so out to get one another and assist the government in prosecuting physicians who do things we don't agree with.

I see that quite often on this and other physician forums.

 

[nvrsumr]

This is a huge issue in CO right now. Medical marijauna clinics are popping up all over(I have one 2 blocks from my house!). Docs are "prescribing" the MJ- $80 a pop with no face to face visit but just the intake form the "patient" filled out at the MJ shop.

I agree with Steve. DEA is federal and no way Im putting my license even 1% at risk. My guesstimate is over 90% of the MJ patients are recreational users in CO. I can just see a patient of mine crashing his car with a bottle of percocet I prescribed filled with MJ in his pocket.....

Personally I think MJ is no more harmful than high fructose corn syrup...

I believe I saw a study purporting no increase risk of lung CA which the authors thought to be due to MJ anti-inflamatory effect. Of course risk of COPD likely increased.

 

[drusso]

I agree with Mille. The DEA and other branches of the federal government do not believe in context sensitive law. It is legal or it isn't, period. Doesn't matter what the person's age is nor why they are using illicit drugs...it is illegal. Doesn't matter if they state it is the only thing that works. Why would you permit your patients to take marijuana and continue prescribing opiates if you would not do the same for those taking heroin or cocaine (a schedule II drug) or methamphetamine (a schedule II drug)? Or do you? There comes a time when physicians that are given the legal responsibility imposed by society to prescribe opioids in a manner that is ethical must just say no when patients want to use whatever works to get high 100% of the time for minimal reductions in pain as demonstrated at the AAPM earlier this year in the poster presentation on marijuana. MJ is not a great pain med, but is a great way to totally zone out of life and society. It has many side effects and complications including increased risk of dental caries, periodontal diseases, dysplastic changes and pre-malignant lesions within the oral mucosa,and oral infections, possibly due to the immunosuppressive effects (Aust J Dent Jun 2005). Published in the European Respiratory Journal, a study of lung cancer patients found that there is a 5.7 times risk of lung cancer smoking 1 joint a day for 10 years and 5 times the risk smoking 2 joints a day for 5 years. The researchers also found the carbon monoxide level is 5 times higher for marijuana smokers compared to cigarette smokers. MJ is also associated with birth defects, psychosis, and an increased risk of severe hepatic fibrosis in those with Hep C. In a review published in Clinical Toxicology July 2009, chronic MJ use is associated with "evidence of psychiatric, respiratory, cardiovascular, and bone toxicity associated with chronic cannabis use. Cannabis has now been implicated in the etiology of many major long-term psychiatric conditions including depression, anxiety, psychosis, bipolar disorder, and an amotivational state. Respiratory conditions linked with cannabis include reduced lung density, lung cysts, and chronic bronchitis. Cannabis has been linked in a dose-dependent manner with elevated rates of myocardial infarction and cardiac arrythmias. It is known to affect bone metabolism and also has teratogenic effects on the developing brain following perinatal exposure. Cannabis has been linked to cancers at eight sites, including children after in utero maternal exposure, and multiple molecular pathways to oncogenesis exist." MJ use results in a 7 fold increase risk of being involved in motor vehicle accidents.
The arguments that MJ is a benign drug as used in the US are simply ignoring the cumulative medical knowledge that has determined otherwise.
If MJ is to be legalized then it should be studied, controlled, taxed into oblivion just like cigarettes, and require responsible use of the drug if it is safe enough to use in our society. The argument that because alcohol and cigarettes exist that we should legalize marijuana is counterintuitive to our prime directive as physicians since the introduction of other deleterious psychoactive drugs with serious side effects is not promoting health.

I agree 100% with algos.

I have no *moral* issue with people using MJ; but I'm not going to RX their opioids.

If/when THC becomes a standard grade pharmaceutical I may re-evaluate its proper use and context in pain management. Until then its an illicit substance regardless of what any given state legislature says about it.

Moreover, my personal experience has been that people who are taking opioids and smoking MJ are not getting more functional from the combination. I'm waiting to meet the patient that tells me, "Gee, doc there is no way I could I would work this 45 hr/week job, maintain my commercial driver's license, coach the kid's baseball team, and do my 2 mile run every morning without my 5 Vicodin and 3 bowls per day."

I just haven't met that patient yet...

 

[Mister Mxyzptlk]

The prosecutors don't care if the physician knew they were diverting or not... the fact that they are using illicit drugs is so frequently associated with drug diversion that the doctor should have known better than to continue prescribing opioids to those that are using illicit drugs. Besides, if the patient doesn't give a flip about the laws of the land, why should the physician believe the patient is going to be compliant with clinic drug policies? Get real. It ain't gonna happen. Drug abusers are drug abusers and they will say or do anything to continue their supply of illicit drugs- even trying to dupe their pain doctors. The presumption of this behavior is borne out by the first study in this thread. If prohibition does not work then why try stopping any illicit drug use at all? Why try controlling heroin use in the US? Why bother? What about methamphetamine? Shouldn't the destructive nature of this drug be between the person and their drug dealer and not the government? Why should the government interfere in whatever we want to do with our bodies? Give me a break.... If Mister Mxyzptlk wants to continue prescribing opioids to those using illicit drugs, then fine. But he should expect there will be a long line of physicians standing to decry such as substandard care bordering on lack of ethics. I would be first in that long line to testify before the state medical licensing agencies.

This is the typical hysteria and table-pounding that has surrounded prescribing controlled substances for decades. I have helped state and federal officers with drug investigations. They recently completed one of the biggest busts in the history of this area, and if I hadn't poked and prodded and advised them it never would have happened.

here's how strapped they are: I was recently asked to testify in a pill mill case. They originally asked someone in another city but they literally did not have the funds to even pay his airfare. He gave them my name and I agreed to do it for free.

When it comes to looking at doctors, the tall blades of grass are the first ones cut. They simply do not have the time or manpower to investigate a doctor who they heard might be prescribing Norco to a patient who smokes MJ. They can not afford to spend their shrinking budgets on something like looking the other way while Granny smokes pot for her DPN.

They might use something like this to take you down because they couldn't catch you on what they really wanted (like Al Capone going to jail for tax evasion). If that is the case, you're already on their hit list for other, more severe, offenses and the MJ take-down is a matter of practicality and convenience.

For the record, in case anyone hasn't already figured it out, prohibition doesn't work. It didn't work for alcohol, which is why the Controlled Substances Act of 1970 exempted caffeine, alcohol, and tobacco - addictive drugs with little or no medical purpose.

Why? They knew it would not work, lead to higher crime rates, etc.

BTW, heroin has several legitimate purposes (analgesia, cough suppression) but it's C-1.

In essence, a C-1 drug is an addictive drug that doesn't have social endorsement or powerful lobbying groups.

Narcotic prohibition has been going on now since the Harrison Act was hijacked by law enforcement decades ago. It. Doesn't. Work. You could put a cop in every house in America and not stop drug abuse. I have often wondered how things might have turned out if the Harrison Act had not been so abused, and doctors had been allowed to manage drug abuse problems for the past 90 years.

I just received an email from a Board prosecutor asking his opinion. I'm waiting for permission to reproduce it here, but for the moment here is a summary.

1. Unaware of any specific law about prescribing opioids to a known MJ user.
2. Has never seen a case or heard of a case where this was the SOLE issue.
3. Would be surprised to hear this brought before the Board for this one issue.
4. The decision needs to be based on the patient's medical condition.

Just one guy, but he is well-known in the field of drug diversion by both cops and docs, and has been doing this job for (my guess) 30 years or more.

 

[Aether2000]

It all comes down to whether we believe in the process of law in the US. If MJ is to be legalized, then states do not have the authority to usurp the power invoked in the federal government regarding regulation of illicit drugs on a national level (Supreme Court decision 2001). If our authority to prescribe potent opioids derives from the same federal government, then we cannot selectively decide what laws we will obey from day to day. Neither can our patients. If we believe in the US legal system, then there are methods of introducing changes at the federal level, but this requires that there be convincing evidence that legalization of a drug would not pose any significant deleterious effect to the individual or society. Thus far, the advocates of marijuana have been unable to produce this evidence, even when research in other countries have been available using MJ for years. It is not ethical or legal for us to selectively decide whether illicit drugs are "ok" because of ??????? what evidence?????? That authority derives from the federal government, not the states. Since prescription substance abuse and diversion go hand in hand with illicit drug use, those who prescribe to those who are known to be using illicit drugs by definition ignoring their patients substance abuse and drug diversion. The federal authorities enforce laws regarding drug diversion and work closely with state medical licensing boards in pursuing issues regarding pill mills that prescribe opioids without deference to patient illegal activities. The physicians in these pill mills are frequently viewed by these medical licensing boards simply as drug dealers with MD after their names and have their licenses revoked.

 

[Mister Mxyzptlk]

BTW, regarding this statement from the abstract in the original post:

"Background. Cannabis is the most widely consumed illicit drug in the United States. Its use, particularly in early initiates, is associated with subsequent development of other drug and alcohol use disorders."

Actually, there was a study conducted a few years ago (2003?) that looked at this issue, and IIRC the only correlation between teenage substance abuse and substance abuse after age 25 was the onset of use of ALCOHOL or TOBACCO in early teens. Not MJ. I don't recall much more than that or who wrote it. I think it was in JAMA.

If you want to address drug abuse through prohibition, you should also be starting up your own temperance movement against caffeine, alcohol and tobacco. They are all addictive drugs with no medical purpose. Someone explain to me the rationale for condoning alcohol but not meth. How are they so different that one is illegal and one can be purchased by the gallon?

 

[lobelsteve]

With all due respect Algos...

It is sad they we are so out to get one another and assist the government in prosecuting physicians who do things we don't agree with.

I see that quite often on this and other physician forums.

This is a fundamental issue in organized pain medicine.

We can argue standards of care, but we cannot argue the federal law. If the government makes smoking, possessing, etc of MJ a crime, and we are responsible for the oversight of patients (YES WE ARE) that we are prescribing opioids for, then it becomes our responsibility to society to ensure that all safety measures are incorporated. I stand with Algos and believe if a physician threatens to endanger the public by poor prescribing habits, they need to do something else.

Smoke all the weed you want, just not while I am your responsible provider.

 

[Mister Mxyzptlk]

This is a fundamental issue in organized pain medicine.

We can argue standards of care, but we cannot argue the federal law. If the government makes smoking, possessing, etc of MJ a crime, and we are responsible for the oversight of patients (YES WE ARE) that we are prescribing opioids for, then it becomes our responsibility to society to ensure that all safety measures are incorporated. I stand with Algos and believe if a physician threatens to endanger the public by poor prescribing habits, they need to do something else.

Smoke all the weed you want, just not while I am your responsible provider.

The interaction between alcohol and opioids is well-documented and is more profound than with MJ. There are about 75,000 alcohol-related traffic deaths annually. Don't you think you should make alcohol abstinence a condition of treatment as well?

 

[DigableCat]

I just received an email from a Board prosecutor asking his opinion. I'm waiting for permission to reproduce it here, but for the moment here is a summary.

1. Unaware of any specific law about prescribing opioids to a known MJ user.
2. Has never seen a case or heard of a case where this was the SOLE issue.
3. Would be surprised to hear this brought before the Board for this one issue.
4. The decision needs to be based on the patient's medical condition.

Just one guy, but he is well-known in the field of drug diversion by both cops and docs, and has been doing this job for (my guess) 30 years or more.

I'd be interested if anyone could come up with some notable disciplinary actions against physicians in these cases as well...

Seems to me like a lot IF, IF, IF...

And as Mr. M has stated, more eloquently than I could have...if you are being investigated by the DEA...odds are you are doing much more then allowing your patient on opiates to take marijuana.

 

[Aether2000]

Alcohol is not a street drug. One knows what the % ethanol content is in alcohol, but not so with MJ. One has a reasonable degree of certainty alcohol is not laced with poisons or pesticids or harmful fillers....not so with MJ. Alcohol is sold under license by the states and is taxed therefore we know exactly the consumption of alcohol in the US....not so with MJ.

But the dichotomy of how our society treats alcohol vs mj is frequently used by those that attempt diversion tactics to support their argument for MJ. The issue at hand does not involve alcohol or cigarettes which are legal, regulated substances. However MJ is illegal and unregulated and has a myriad of side effects and complications that have been demonstrated in many studies, but these are scoffed at by the MJ using population that really couldn't give a flip.....they feel GOOOOOOOOOOOOOOOOODDDDDDDDDDDDDDD with MJ , so laws be damned.

BTW, from the DEA website:
Criteria for Schedule I
• The drug or other substance has a high potential for abuse.

• The drug or other substance has no currently accepted medical use in treatment in the United States.

• There is a lack of accepted safety for use of the drug or other substance under medical supervision.

MJ is a schedule I because the quantities and purity are unknown. That is why MJ is schedule I and THC, the active ingredient is a schedule III
Heroin is a schedule I because it has no currently accepted medical use in treatment in the US.

 

[DigableCat]

MJ is a schedule I because the quantities and purity are unknown.

This is something that I can see many people, including myself, may have an issue with.

It would be nice if goverment required dispensaries to have consistency in their batches.

Regulating Tobacco - An FDA Perspective

Only recently has the tobacco industry had to be accountable...

The FSTPC Act gives FDA the authority to regulate tobacco products. The authority given FDA includes how tobacco products are manufactured, marketed, and distributed. Some of the key elements of the FSPTC Act are:

Requiring companies who manufacture or import tobacco products to provide FDA with a listing of the amounts of all ingredients in the tobacco products they produce.
Giving FDA the authority to require companies to provide information about the amount of nicotine in their products to FDA and the public.

Most herbal OTC medications do not have that requirement however, although they do have to display on their bottles what % of each compound is contained.

Patient safety is a factor. Although some of the card carrying medicinal MJ patient's I've met grow a small amount on their own. So, I'm not sure if the concerns regarding toxic chemical additives is an issue.

 

[PMR 4 MSK]

The interaction between alcohol and opioids is well-documented and is more profound than with MJ. There are about 75,000 alcohol-related traffic deaths annually. Don't you think you should make alcohol abstinence a condition of treatment as well?

I agree, if only we had a reliable test for whether a pt is drinking or not. I've withdrawn a handful of pts from opioids in the past when I was certain they were drinking a lot. In one case she always smelled of alcohol when she came in, but UDS was normal - I should have bought one of those BAC testers - breathalizers that you can get for about $100 or less. Another was a severe alcoholic who's story of when his last drink was changed every time I saw him. He also couldn't remember which AA meeting he had told me he was going to the last time I saw him and had a different answer each time.

 

[lobelsteve]

The interaction between alcohol and opioids is well-documented and is more profound than with MJ. There are about 75,000 alcohol-related traffic deaths annually. Don't you think you should make alcohol abstinence a condition of treatment as well?

Yes, I do. CAGE anyone?

I allow social alcohol use defines as 1-2 drinks no more than 1x per week, or heart healthy drinking 1 time per week.

I have given patients options between ETOH and medication. I have had my practice manager drive home a patient as she presented with her 7 y/o daughter and was impaired. Options included withdrawing opioids and getting a ride home, or calling the police and getting DFACs (DYFS) involved.

Also, alcohol is legal, MJ is not.

 

[Mister Mxyzptlk]

Oh, right guys. I forgot about the dosage variation and its dangers. That must be why we see so many MJ overdoses in the morgue.

And the known alcohol content of legal alcoholic beverages has saved many, many lives by careful titration, especially at college frat parties and has also made bar brawls a thing of the past.

 

[DigableCat]

And the known alcohol content of legal alcoholic beverages has saved many, many lives by careful titration, especially at college frat parties and has also made bar brawls a thing of the past.

 

[Aether2000]

Actually people do end up in the morgue from marijuana. The 2002 DAWN survey projected a minimum of 581 people died in 2002 associated with MJ use. It is an urban myth that people don't die associated with marijuana use. Of these victims, 22% were suicides (psychological aberrations due to MJ use are well documented), 34% were accidental/unexpected, and the remainder were catagorized as "all other".

 

[PMR 4 MSK]

Actually people do end up in the morgue from marijuana. The 2002 DAWN survey projected a minimum of 581 people died in 2002 associated with MJ use. It is an urban myth that people don't die associated with marijuana use. Of these victims, 22% were suicides (psychological aberrations due to MJ use are well documented), 34% were accidental/unexpected, and the remainder were catagorized as "all other".

Were any of these MJ in isolation? I would suspect polysubstance overdose in most, if not all cases.