Controlled substances and concurrent cannabis use

[SpongeBob DoctorPants]

I recently had a new patient who came to me on a number of medications, plus a couple of controlled substances (Adderall and Klonopin). He also admitted to being a regular user of marijuana. I explained my policy on the prescribing of controlled substances and had him sign an agreement stating that he would not use illicit substances such as marijuana, and he agreed to it. The marijuana use continued, however, and after a couple of months a recent drug screen came back positive for THC so I decided to stop the Adderall and begin tapering the Klonopin. Of course this led to the patient protesting, explaining why he needed the medication, asking if I can at least continue the medication until the next appointment or until he finds a new provider, etc. My inclination is to stick with my original plan, and if he is able to have 3 consecutive drug screens which are appropriately clean over the next few months, I would consider restarting the controlled meds. I'm wondering how others address this sort of situation.

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[wolfvgang22]

This is generally what I do. However, increasingly I'm coming across people who use marijuana more and more, especially with it being legalized all around us.
I really don't care when a person uses marijuana once in a while socially, as with alcohol, and I discuss risks of overuse of any psychoactive substance, even caffeine, with my patients. I am wondering if my strict stance of no cannabis use while being prescribed stimulants for ADHD will remain tenable.

 

[clausewitz2]

I am wondering if my strict stance of no cannabis use while being prescribed stimulants for ADHD will remain tenable.

Given the trends you identify I suspect this stance will actually simply lead to you not prescribing stimulants to the people who are willing to be honest about their cannabis use.

 

[Sushirolls]

Stick to plan A.
Other clinicians can and do stop cold turkey.
Offer remeron and lesser so neurontin as possible assistance with cannabis cessation if he wants pharmacotherapy help.
If you resume any of those after clear UDS, keep on monthly follow ups for awhile with UDS at each visit.

 

[Sushirolls]

Given the trends you identify I suspect this stance will actually simply lead to you not prescribing stimulants to the people who are willing to be honest about their cannabis use.

I obtained CLIA lab certification and test at each visit and reserve right for random testing and random pill counts. I perform the test, and result it myself at same time as appointment.

I recently picked up a Cocaine positive, that I also confirmed with GC/MS, in a patient that my counter transference bias wouldn't have suspected.

 

[clausewitz2]

I obtained CLIA lab certification and test at each visit and reserve right for random testing and random pill counts. I perform the test, and result it myself at same time as appointment.

I recently picked up a Cocaine positive, that I also confirmed with GC/MS, in a patient that my counter transference bias wouldn't have suspected.

Fair enough, I am sure you are going to catch people using all kinds of things that you didn't suspect. Was the cocaine plausibly a major contributor to what he was dealing with or sort of peripheral?

If the focus of treatment is substance use I absolutely get the need for close monitoring like this. I even get the point of pursuing this if something doesn't seem right or make sense about the presentation or things don't really add up. I am just not persuaded it is super helpful with the typical population at a general psychiatry clinic (although the typical AMC resident clinic would probably benefit from it tremendously).

EDIT: then again @Sushirolls given our previous sparring sessions re: Z-drugs I imagine we are never going to agree about this.

 

[Sushirolls]

Fair enough, I am sure you are going to catch people using all kinds of things that you didn't suspect. Was the cocaine plausibly a major contributor to what he was dealing with or sort of peripheral?

If the focus of treatment is substance use I absolutely get the need for close monitoring like this. I even get the point of pursuing this if something doesn't seem right or make sense about the presentation or things don't really add up. I am just not persuaded it is super helpful with the typical population at a general psychiatry clinic (although the typical AMC resident clinic would probably benefit from it tremendously).

EDIT: then again @Sushirolls given our previous sparring sessions re: Z-drugs I imagine we are never going to agree about this.

Young college male. Peripheral catch. So at risk for SUDs, first break psychosis, failing out of school, etc, etc Now keeping closer follow up visits to capture any downward spiral sooner rather than later.

 

[downwithDTB]

This is generally what I do. However, increasingly I'm coming across people who use marijuana more and more, especially with it being legalized all around us.
I really don't care when a person uses marijuana once in a while socially, as with alcohol, and I discuss risks of overuse of any psychoactive substance, even caffeine, with my patients. I am wondering if my strict stance of no cannabis use while being prescribed stimulants for ADHD will remain tenable.

The number of people that I know that have become persistently psychotic while using daily mj and stimulants, while completely anecdotal, leads me to be highly concerned about the combination. I agree with your initial plan.

 

[clausewitz2]

The number of people that I know that have become persistently psychotic while using daily mj and stimulants, while completely anecdotal, leads me to be highly concerned about the combination. I agree with your initial plan.

MJ and psychosis is definitely a chicken and egg problem. Stimulants simply do not induce psychosis if someone is taking them as prescribed. That last is obviously something that is sometimes very much in question.

 

[downwithDTB]

Stimulants simply do not induce psychosis if someone is taking them as prescribed.

Are we completely sure that this is the case? I am not anti-stimulants and think that the adhd literature is fairly convincing on the whole for those who don't misuse them...

However, see:

Prescription Stimulant Use is Associated with Earlier Onset of Psychosis - PMC

A childhood history of attention deficit hyperactivity disorder (ADHD) is common in psychotic disorders, yet prescription stimulants may interact adversely with the physiology of these disorders. Specifically, exposure to stimulants leads to ...

www.ncbi.nlm.nih.gov

Attention-deficit/hyperactivity disorder, methylphenidate use and the risk of developing schizophrenia spectrum disorders: A nationwide population-based study in Taiwan - PubMed

This study estimated the risk of developing psychotic disorders by comparing children with ADHD to non-ADHD controls, and to examine whether methylphenidate (MPH) treatment influences the risks of psychotic disorders. A nationwide cohort of patients who were newly diagnosed with ADHD (n=73,049)...

www.ncbi.nlm.nih.gov

If you know of a study looking at long term use (many years) and psychosis risk (by young adulthood) that is adequately controlled, please share. I'm always open to learn.

I *know* that there are some clear confounds, but it's food for thought and enough food for thought that I don't feel like I need to prescribe stimulants to people with active substance abuse, especially MJ/other stimulants.

 

[cara susanna]

I just attended a conference on psychosis and basically the psychiatrist presenting said that he tells patients smoking MJ is basically playing with fire if you have any sort of genetic predisposition or risk for schizophrenia.

 

[Mass Effect]

I recently had a new patient who came to me on a number of medications, plus a couple of controlled substances (Adderall and Klonopin). He also admitted to being a regular user of marijuana. I explained my policy on the prescribing of controlled substances and had him sign an agreement stating that he would not use illicit substances such as marijuana, and he agreed to it. The marijuana use continued, however, and after a couple of months a recent drug screen came back positive for THC so I decided to stop the Adderall and begin tapering the Klonopin. Of course this led to the patient protesting, explaining why he needed the medication, asking if I can at least continue the medication until the next appointment or until he finds a new provider, etc. My inclination is to stick with my original plan, and if he is able to have 3 consecutive drug screens which are appropriately clean over the next few months, I would consider restarting the controlled meds. I'm wondering how others address this sort of situation.

Honestly, I'd be more concerned about prescribing him a benzo and a stimulant than marijuana use. Why does he need both Klonopin and Adderall?

 

[WisNeuro]

I just attended a conference on psychosis and basically the psychiatrist presenting said that he tells patients smoking MJ is basically playing with fire if you have any sort of genetic predisposition or risk for schizophrenia.

At least from what I've seen, this only corresponds to adolescent use. Nearly all of the large longitudinal studies I have reviewed looked at moderate to heavy exposure in pre-teen into adolescent years as increasing this risk. I haven't seen very strong evidence linking use that started in adulthood to significantly increased risk of psychosis. If someone has some links to some good studies looking at this, I'd appreciate some links.

 

[cara susanna]

At least from what I've seen, this only corresponds to adolescent use. Nearly all of the large longitudinal studies I have reviewed looked at moderate to heavy exposure in pre-teen into adolescent years as increasing this risk. I haven't seen very strong evidence linking use that started in adulthood to significantly increased risk of psychosis. If someone has some links to some good studies looking at this, I'd appreciate some links.

Oh, yeah, I think he was referring to teenagers.

 

[SpongeBob DoctorPants]

Honestly, I'd be more concerned about prescribing him a benzo and a stimulant than marijuana use. Why does he need both Klonopin and Adderall?

Yes, that is also a concern of mine, of which I informed the patient on day one. He is agreeable to gradually tapering off the Klonopin. I am fine with continuing the Adderall so long as it is appropriate. His mother attends each visit with him, and affirms that basically without all of his current meds he would likely end up in the hospital, because it has happened before. I do plan to get him off the benzo as soon as I can, but I didn't bring it up in this thread because it wasn't the main point of my post, which pertains more to the continuance of controlled substances when there is ongoing substance use.

 

[Mass Effect]

Yes, that is also a concern of mine, of which I informed the patient on day one. He is agreeable to gradually tapering off the Klonopin. I am fine with continuing the Adderall so long as it is appropriate. His mother attends each visit with him, and affirms that basically without all of his current meds he would likely end up in the hospital, because it has happened before. I do plan to get him off the benzo as soon as I can, but I didn't bring it up in this thread because it wasn't the main point of my post, which pertains more to the continuance of controlled substances when there is ongoing substance use.

But it's not just about controlled substance continuance in general. To me, this is a question of polypharm controlled substance use with ongoing substance use. That said, I respect you trying to taper Klonopin very slowly. That's the way to do it.

On another note, Adderall is appropriate for some people, but I have a hard time believing someone would end up in the hospital without it. Same goes for the benzo, actually, outside of patients who are manic/psychotic or something, which I assume this patient isn't given Adderall use.