Help with writing opioid/ marijuana protocol

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thecentral09

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I am writing/updating an opioid policy for my small hospital. I have a bunch of PCPs who routinely Rx high dose opioids, and if that’s not enough they now want to Rx Med marijuana. I have always practiced that opioids marijuana should not be concurrently prescribed d/t increased risk of sub abuse, but do we have any protocols or guidlines discussing concurrent prescribing of these two?
 
It is illegal bruh. It also doesn't work.
 
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We do not prescribe opioids in conjunction with recreational or medical marijuana. Only exception is low dose intrathecal opioids. It is going down the road of polySUD and it will be very difficult to dig out of that hole. I would caution against throwing more medication at poorly controlled pain in setting of high dose opioids. Likely OIH and complex persistent dependence. Need multidisciplinary care and lower opioid doses. Now I will step off my soapbox.
 
start simply. you can remind them of the Controlled Substance Act, and the tenants listed in there are the ones that doctors must follow.

while most opioid supporting people do not like the CDC guidelines and rail against them, but most of what is listed in there are commonplace measures. and as of right now, represent the only guidelines "released" by the feds.
 
Here is my template I use in the clinic:

Patient has been identified as a user of marijuana products. While legal at the state level under certain circumstances, marijuana is still considered by the federal government to be a Schedule-1 controlled substance. Schedule-1 substances are defined as drugs with no accepted medical use and high potential for abuse, potentially leading to severe psychological or physical dependence. Marijuana use has also been associated with impaired body movement, difficulty thinking and problem-solving, impaired memory, anxiety, depression, hallucinations, early-onset psychosis, paranoia, poor school performance, and decreased IQ. In addition, users of marijuana have been shown to have lower life satisfaction, poorer physical and mental health, less academic and career success, and more job absences, accidents, and injuries. In addition, people who use marijuana have been shown to be more likely to use prescription drugs for both medical and nonmedical purposes. I recommend the patient stop using marijuana products.
Drug Fact sheet from the NIH has been given to the patient regarding marijuana.
Marijuana

I think that sums it up nicely.
 
It is simple.

Marijuna is a Schedule I drug. It is federally illegal. Physicians and patients are expected to follow federal law.

You don't need to go into any further details. If they argue, let them argue with the FDA. If they FDA grants them permission, then and only then do you need to explain to them it makes things worse anyway.
 
thecentral09 said:
I am writing/updating an opioid policy for my small hospital. I have a bunch of PCPs who routinely Rx high dose opioids, and if that’s not enough they now want to Rx Med marijuana. I have always practiced that opioids marijuana should not be concurrently prescribed d/t increased risk of sub abuse, but do we have any protocols or guidlines discussing concurrent prescribing of these two?
Click to expand...
"Opiod policy: Follow CDC guidelines. If those change, this policy will be reviewed.
Marijuana policy: Our policy is to follow federal law. Marijuana is a schedule I drug, illegal in all 50 states per federal law and will be treated as such along with all other schedule I illegal drugs without legitimate medical use. This policy will be reviewed if and when those laws change."

Don't try to reinvent the wheel. Federal guidelines have the force of law and of course, the law is the law. When it comes to something we can only do under federal and state licensing, we can only do that which is within the box they draw for us. There are no rewards for stepping outside that box.
 
emd123 said:
"Opiod policy: Follow CDC guidelines. If those change, this policy will be reviewed.
Marijuana policy: Our policy is to follow federal law. Marijuana is a schedule I drug, illegal in all 50 states per federal law and will be treated as such along with all other schedule I illegal drugs without legitimate medical use. This policy will be reviewed if and when those laws change."

Don't try to reinvent the wheel. Federal guidelines have the force of law and of course, the law is the law. When it comes to something we can only do under federal and state licensing, we can only do that which is within the box they draw for us. There are no rewards for stepping outside that box.
Click to expand...

beautifully stated.
 
Why is everyone always trying to figure out ways to accommodate patients who desire COT?? If you keep throwing yourself on grenades to “save” your patients you will eventually get blown to bits and your patient with forget your name in a heartbeat.
 
NJPAIN said:
Why is everyone always trying to figure out ways to accommodate patients who desire COT?? If you keep throwing yourself on grenades to “save” your patients you will eventually get blown to bits and your patient with forget your name in a heartbeat.
Click to expand...
Like I’ve always said, the mindset needs to be, “When in doubt, avoid prescribing or increasing opiates. Look for reasons to stop opiates, not to increase them and not to start them.”

The mindset should not longer be, “When in doubt, prescribe until there’s a reason not to. Look for reasons to start, increase or continue opiates.”

The statements sound almost identical, but there’s a drastic difference in real world results.
 
OTOH:

Cannabinoids for adult cancer-related pain: systematic review and meta-analysis | BMJ Supportive & Palliative Care

spcare.bmj.com

Cannabinoids for adult cancer-related pain: systematic review and meta-analysis
FREE

  1. Elaine G Boland1,
  2. Michael I Bennett2,
  3. Victoria Allgar3 and
  4. Jason W Boland4
Author affiliations

Abstract
Objectives There is increased interest in cannabinoids for cancer pain management and legislative changes are in progress in many countries. This study aims to determine the beneficial and adverse effects of cannabis/cannabinoids compared with placebo/other active agents for the treatment of cancer-related pain in adults.
Methods Systematic review and meta-analysis to identify randomised controlled trials of cannabinoids compared with placebo/other active agents for the treatment of cancer-related pain in adults to determine the effect on pain intensity (primary outcome) and adverse effects, including dropouts. Searches included Embase, MEDLINE, PsycINFO, Web of Science, ClinicalTrials.gov, Cochrane and grey literature. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed.
Results We identified 2805 unique records, of which six randomised controlled trials were included in this systematic review (n=1460 participants). Five studies were included in the meta-analysis (1442 participants). All had a low risk of bias. There was no difference between cannabinoids and placebo for the difference in the change in average Numeric Rating Scale pain scores (mean difference −0.21 (−0.48 to 0.07, p=0.14)); this remained when only phase III studies were meta-analysed: mean difference −0.02 (−0.21 to 0.16, p=0.80). Cannabinoids had a higher risk of adverse events when compared with placebo, especially somnolence (OR 2.69 (1.54 to 4.71), p<0.001) and dizziness (OR 1.58 (0.99 to 2.51), p=0.05). No treatment-related deaths were reported. Dropouts and mortality rates were high.
Conclusions Studies with a low risk of bias showed that for adults with advanced cancer, the addition of cannabinoids to opioids did not reduce cancer pain.
Click to expand...
no benefit.
 
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