Medical Cannabis

[Attending1985]

In my state ptsd is an indication for medical cannabis. For those of you who practice in a state like mine how often are you certifying people? I’ve done a handful. So many people are gonna use it anway and it’s probably safer than the poly pharmacy most end up on.

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[Sushirolls]

None. Know your history. Early 1900's physicians were jailed for prescribing opioids to people who met an Opioid Use Disorder diagnosis, despite good intentions to mitigate withdrawals.

Cannabis is still illegal federally. Not worth my license should the feds come knocking.

Medicinal marijuana is a farce. It is legislated medicine. Similar to the 5th vital sign, or even vaccination exemptions. When politicians interfere with medical establishment bad things happen. If cannabis is legal and people choose to use it, so be it. To prescribe though, I caution against it. Can you vouch for the purity? The strain? How would you respond when the patient drives intoxicated, kills some one, and now states "don't blame me, blame my doctor, (s)he over prescribed to me." Other issues are a well informed risk benefit discussion. Cannabis induced anxiety, depression, psychosis, cyclic vomiting syndrome. Or if the patient develops a mild/moderate/severe Use Disorder after the fact, can you stand up to the court case if there were one?

There are other, better options worthy of professional recommendations. Cannabis is not one of them.

 

[Crayola227]

I don't think you're aware of how medical marijuana works in these states.

You don't prescribe marijuana. You certify that the patient has a medical condition, one that is listed as a condition that may benefit from use of marijuana for managing symptoms, on a list drawn up by the state that the state agrees to. If you are signing then you may agree that marijuana may have benefit for certain symptoms. Essentially, you're stating a fact, and also agreeing with a statement. Last I knew, a medical opinion that is NOT a recommendation, is not illegal.

The only reason anyone looked at it was for glaucoma. Because yeah, it turns out it does have a pretty powerful effect on the muscles controlling the pupil and pressures. The MOA is real and it does stand up in terms of efficacy and side effect profile for use in glaucoma. Like cocaine, this is not a schedule 1 drug we are dealing with here. (Edit, I assumed because marijuana has some recognized medical uses, that it was not Schedule 1. It is still is. THC, but not the plant, was rescheduled more than once, from 1 --> 2 --> 3. Apparently it's been petitioned to be rescheduled Removal of cannabis from Schedule I of the Controlled Substances Act - Wikipedia)

So I don't find it crazy that it also has effects on appetite and nausea, that are also very well recognized. It is a drug, it does things (Cray Logic ©), it's hardly surprising it does things. Various things.

I champion its use for anyone with cancer or other extreme conditions where appetite and nausea symptom control is not only paramount to well being but also extremely difficult to treat otherwise.

Now, outside of these recognized applications, where I've seen a ton of what I think is improvement not in the vein of the 5th vital sign, is in harm reduction.

Maybe patients I had that quit using tobacco products and even went on to quit smoking marijuana, perhaps you could argue they could have done it otherwise. Same with patients that appear to use less opioids or other substances for pain or insomnia (some problems are so ubiquitous...) Maybe people are just gonna have a vice and do a drug, and anything we do that isn't advancing some straight edge agenda where they do not use any recreational substances, is just enabling primitive coping mechanisms or some such. So maybe harm reduction is a myth.

Anyway, at the end of the day what annoys me is that people don't really know what it means to "prescribe" marijuana so they don't really understand what actual medicolegal risks exist.

They do, don't get me wrong.

And since physicians are actually doing it, all of the concerns you brought up have been addressed in one way or another. It hasn't been that difficult to manage, actually.

I'm not advocating its use for PTSD as a statement. I am not minimizing the stated risks and side effects, I've seen them.

All of this is navigable, and I imagine the docs who do, do it because it seems to work. I think there is even data behind it.

 

[wolfvgang22]

I think docs that do it do it mainly for the money. Change my mind.

 

[TexasPhysician]

In my state ptsd is an indication for medical cannabis. For those of you who practice in a state like mine how often are you certifying people? I’ve done a handful. So many people are gonna use it anway and it’s probably safer than the poly pharmacy most end up on.

PTSD as an indication was placed there via politics, not scientific supporting data. I do not recommend, certify, rubber stamp, prescribe, or provide anything that I don’t believe in, especially without at least fair supporting data.

 

[SpongeBob DoctorPants]

Despite opposition from local psychiatric and medical organizations, medical marijuana became law in my state. And among the several conditions listed on the ballot as being treatable with marijuana were a few psychiatric problems, including PTSD, autism, and Alzheimer's. However, during my years of residency and fellowship training, which wasn't long ago, I never heard of marijuana being a good thing for mental health, and I have yet to see any legitimate research showing that it is, either. Maybe it's out there, but I haven't seen it. Shortly after this became law in my state, some of my patients asked about it as a possible treatment for their problems. My reply to them was that I'm not aware of any evidence that this is helpful for these conditions, so I can't recommend it.

 

[FlowRate]

In terms of evidence, CBD may be helpful for a very select set of diseases. THC is pretty much only helpful for cancer-related anorexia.

Marijuana (the plant) != medicine.

 

[VA Hopeful Dr]

Probably going to be legal in my state soon as well. I have already had a few patients that ask. I tell them that until the DEA makes it not schedule 1 and there is actually some decent evidence behind it, I will not be prescribing it. Period.

 

[clausewitz2]

Probably going to be legal in my state soon as well. I have already had a few patients that ask. I tell them that until the DEA makes it not schedule 1 and there is actually some decent evidence behind it, I will not be prescribing it. Period.

Unless your state does it very differently from how it works elsewhere, you will never be prescribing it. Typically physicians are only involved in certifying that the patient has one of the conditions that medical marijuana is legally approved for. I get why you would not want to do this as it facilitates the acquisition of the cannabis in question, but it is harder to argue that it is unethical to complete forms saying yes, this patient does have this condition that I have previously diagnosed them with/treated them for.

 

[Sushirolls]

Unless your state does it very differently from how it works elsewhere, you will never be prescribing it. Typically physicians are only involved in certifying that the patient has one of the conditions that medical marijuana is legally approved for. I get why you would not want to do this as it facilitates the acquisition of the cannabis in question, but it is harder to argue that it is unethical to complete forms saying yes, this patient does have this condition that I have previously diagnosed them with/treated them for.

There may be some fancy legalese that reflects that this is not a medical opinion as you allude to. But being directly opined to assent to its use in the context of agreeing that a person has a condition to the lay man is just as good as an opinion. When juries are formed it is not with a jury of 12 lawyers who will salivate over such minutiae but that of our peers, and this doesn't pass the common (wo)man test. In addition, patients routinely state "my doctor prescribed it for me!" which further supports the lay opinion.

And no, it is not unethical to opt out of completing a form that reaffirms a person's diagnosis.

 

[VA Hopeful Dr]

Unless your state does it very differently from how it works elsewhere, you will never be prescribing it. Typically physicians are only involved in certifying that the patient has one of the conditions that medical marijuana is legally approved for. I get why you would not want to do this as it facilitates the acquisition of the cannabis in question, but it is harder to argue that it is unethical to complete forms saying yes, this patient does have this condition that I have previously diagnosed them with/treated them for.

Umm, no. If I know precisely what the form is going to be used for, that argument doesn't really fly.

 

[clausewitz2]

There may be some fancy legalese that reflects that this is not a medical opinion as you allude to. But being directly opined to assent to its use in the context of agreeing that a person has a condition to the lay man is just as good as an opinion. When juries are formed it is not with a jury of 12 lawyers who will salivate over such minutiae but that of our peers, and this doesn't pass the common (wo)man test. In addition, patients routinely state "my doctor prescribed it for me!" which further supports the lay opinion.

And no, it is not unethical to opt out of completing a form that reaffirms a person's diagnosis.

I have to strongly disagree with this take and the concurrent opinion from @VA Hopeful Dr . If you think the patient has one of these diagnoses and have been charting that and billing based on it, you should have the courage of your convictions. It's one thing if you are very uncertain about the diagnosis; then equivocation seems unobjectionable because it reflects your epistemic state. But if you are actually pretty certain? Your idea of what their diagnosis is shouldn't change based on who's asking. If it is iffy enough that you are not comfortable saying "yes, I believe they do have it" on paper, you should really think long and hard about whether you should be treating that condition.

Note that this is exactly the same sort of problem as you run into at the sort of CMHC where eligibility of treatment is limited to a small number of diagnoses and then - quelle surprise! - everybody who turns up there acquires one of these diagnoses. You cannot object to it in that context but be fine with the same kind of chicanery when it comes to these forms.

I'm not really impressed with the suggestion that juries can't understand the difference between a form that says "this person has condition X" and a form saying "what you really need to do is smoke a whole bunch of weed all the time." We ask juries to decide cases based on far more technical points of the law all the time, this is not really a subtle distinction or minutiae.

Don't want to complete paperwork without getting paid? Fine, charge a paperwork fee if that's how you want your practice to run. You're not obligated to do it in that sense.

The only motivation I can understand for the position y'all are articulating is a sense of, I don't know, guilt or contamination by association due to cannabis possibly being involved at some point. I am struggling a bit to find compelling other reasons for it, especially if you accompany it with telling the patient and charting the various reasons why you think their smoking weed is a bad idea. That should settle any liability concerns, really, because the fact that you advised them strongly against it is clear as day in the written record.


EDIT: Say you were an oncologist that practiced in a state with legal euthanasia. Say also that that state has a particular form that has to be completed affirming that the patient's diagnosis is a terminal one. A patient comes to you with such a form who you are quite confident is going to die soon from his disease. If you don't support legal euthanasia, is it okay for you to refuse to sign such a form if it only asks about the prognosis?

Maybe you guys both think that's fine too, I guess fundamentally I don't.

 

[WisNeuro]

Luckily, won't be as much of an issue in the future with the recreational legalization dominoes falling. Legalize it, tax it, whatevs. Generally much safer than other legalized substances and much safer than most of the medication regimens I see.

 

[VA Hopeful Dr]

I have to strongly disagree with this take and the concurrent opinion from @VA Hopeful Dr . If you think the patient has one of these diagnoses and have been charting that and billing based on it, you should have the courage of your convictions. It's one thing if you are very uncertain about the diagnosis; then equivocation seems unobjectionable because it reflects your epistemic state. But if you are actually pretty certain? Your idea of what their diagnosis is shouldn't change based on who's asking. If it is iffy enough that you are not comfortable saying "yes, I believe they do have it" on paper, you should really think long and hard about whether you should be treating that condition.

Note that this is exactly the same sort of problem as you run into at the sort of CMHC where eligibility of treatment is limited to a small number of diagnoses and then - quelle surprise! - everybody who turns up there acquires one of these diagnoses. You cannot object to it in that context but be fine with the same kind of chicanery when it comes to these forms.

I'm not really impressed with the suggestion that juries can't understand the difference between a form that says "this person has condition X" and a form saying "what you really need to do is smoke a whole bunch of weed all the time." We ask juries to decide cases based on far more technical points of the law all the time, this is not really a subtle distinction or minutiae.

Don't want to complete paperwork without getting paid? Fine, charge a paperwork fee if that's how you want your practice to run. You're not obligated to do it in that sense.

The only motivation I can understand for the position y'all are articulating is a sense of, I don't know, guilt or contamination by association due to cannabis possibly being involved at some point. I am struggling a bit to find compelling other reasons for it, especially if you accompany it with telling the patient and charting the various reasons why you think their smoking weed is a bad idea. That should settle any liability concerns, really, because the fact that you advised them strongly against it is clear as day in the written record.

You don't see the problem if someone comes in with a form saying "I need you to certify that I have PTSD so I can get medical cannibis"?

 

[VA Hopeful Dr]

Luckily, won't be as much of an issue in the future with the recreational legalization dominoes falling. Legalize it, tax it, whatevs. Generally much safer than other legalized substances and much safer than most of the medication regimens I see.

Yep. I actually have no issue with legalizing it altogether, I just don't want it anywhere near my medical license or DEA number.

 

[WisNeuro]

Yep. I actually have no issue with legalizing it altogether, I just don't want it anywhere near my medical license or DEA number.

Fair enough, don't blame you on that one. Unless it's treating pediatric epilepsy that has not responded to other meds 🙂

 

[clausewitz2]

You don't see the problem if someone comes in with a form saying "I need you to certify that I have PTSD so I can get medical cannibis"?

If the form requires me to attest to or affirm "therefore this person ought to be able to get high, so high" then yeah, I'm not going to do it. In our state it is much more like "this person has been under my care and it is my opinion that they have x condition." If someone brings me that second form, whether I am okay with signing it depends on whether I think they have PTSD or not. If it's someone I've never met before then I am going to be pretty suspicious and I'm not signing it on a first visit. But someone who's quite established and has really convincing PTSD? Me signing the form doesn't really implicate me in them receiving the cannabis; I'm not recommending it, I'm not selling it, I'm not steering them towards it. I'm just willing to stand by my diagnostic opinion.

Again, if the particular form in your state contains language to the effect of "and because of this diagnosis give this man some chiba" I totally get the reluctance. Maybe that happens some places. Not what our forms look like.

 

[Attending1985]

Luckily, won't be as much of an issue in the future with the recreational legalization dominoes falling. Legalize it, tax it, whatevs. Generally much safer than other legalized substances and much safer than most of the medication regimens I see.

This is what I hope to see legalization in all states so I’m not making the call. I hear others reasoning that there is risk of harm and that evidence isn’t great. What I also know is that many of our treatments are probably worse. How many people end up on antipsychotics long term for insomnia or explosiveness with PTSD. If you look at the risk profile it’s hard to say that cannabis is worse.

 

[Attending1985]

Also if you know someone is smoking and buying off the street with no intention of stopping is it fair to say it’s less harmful to get it at a dispensary where its not laced with something god awful

 

[WisNeuro]

This is what I hope to see legalization in all states so I’m not making the call. I hear others reasoning that there is risk of harm and that evidence isn’t great. What I also know is that many of our treatments are probably worse. How many people end up on antipsychotics long term for insomnia or explosiveness with PTSD. If you look at the risk profile it’s hard to say that cannabis is worse.

Yeah, at least in my neuro world, the harm is pretty minimal, with the exception of heavy use in childhood/adolescence. But then again, almost any substance and many meds are not great for the developing brain either, so it's not really any different than what's already out there.

 

[dl2dp2]

In my state there's a $299 online course you have to take to get the license. Which is BS IMHO.

I'm considering charging $2500 for an evaluation for a letter, but I don't know if there'll be a market.

 

[Attending1985]

The couple that I did certify were able to get off benzos once they got on cannabis. I guess you could say you’re trading one dependence for another but it’s hard to say which is worse.

 

[VA Hopeful Dr]

If the form requires me to attest to or affirm "therefore this person ought to be able to get high, so high" then yeah, I'm not going to do it. In our state it is much more like "this person has been under my care and it is my opinion that they have x condition." If someone brings me that second form, whether I am okay with signing it depends on whether I think they have PTSD or not. If it's someone I've never met before then I am going to be pretty suspicious and I'm not signing it on a first visit. But someone who's quite established and has really convincing PTSD? Me signing the form doesn't really implicate me in them receiving the cannabis; I'm not recommending it, I'm not selling it, I'm not steering them towards it. I'm just willing to stand by my diagnostic opinion.

Again, if the particular form in your state contains language to the effect of "and because of this diagnosis give this man some chiba" I totally get the reluctance. Maybe that happens some places. Not what our forms look like.

It seems you're splitting hairs rather finely here. If you know its a form that will allow them to get cannabis and you sign it, even if its just confirming a diagnosis, you are implicitly saying that its OK for them to have it.

We don't have to agree here, but that's how I see it and so won't sign it.

As an aside, here's what it will look like in my state (SC, if it matters):

32) 'Written certification' means a document developed by the department and printed on tamper-resistant paper dated and signed by a physician stating that the patient has been diagnosed with a debilitating medical condition and that the potential benefits of using medical cannabis outweigh any risks...

 

[Attending1985]

I’m in MN and here’s a big reason not to certify. Once you certify they are approved for a year without exceptions and you cannot de-certify a patient. If they become psychotic or whatever there’s no way for you to prevent them from getting it until their year is up. This is the main reason I won’t certify anyone else.

 

[WisNeuro]

The couple that I did certify were able to get off benzos once they got on cannabis. I guess you could say you’re trading one dependence for another but it’s hard to say which is worse.

I think I'd rather my patients be on Cannabis than benzos, personally. At least for my population, less risk. Also, I imagine we'll be one of the next states to legalize here in MN.

 

[clausewitz2]

It seems you're splitting hairs rather finely here. If you know its a form that will allow them to get cannabis and you sign it, even if its just confirming a diagnosis, you are implicitly saying that its OK for them to have it.

We don't have to agree here, but that's how I see it and so won't sign it.

As an aside, here's what it will look like in my state (SC, if it matters):

32) 'Written certification' means a document developed by the department and printed on tamper-resistant paper dated and signed by a physician stating that the patient has been diagnosed with a debilitating medical condition and that the potential benefits of using medical cannabis outweigh any risks...

Yeah, in the case of your state I also would not be keen on signing it. I think we are in agreement there.

The distinction I'm drawing seems like splitting hairs to you and @Sushirolls , I know, but I remain baffled about how it is not super salient and clear. I guess I am coming from a place of considering all the ways that our patients (at least in psychiatry) use the diagnoses we give them for various purposes and agendas in the world or how they intermediate their interactions with a number of bureaucracies. I take it for granted that there is a good chance someone might take the fact they have been diagnosed with something in particular and use it for purposes that I wouldn't approve of or that might even be counter-productive. That sort of thing happens all the time, which is why I feel like I have to insist on "I'm going to base this diagnosis on my best clinical opinion independently of what purposes it might be used for." I don't care to get into the doublethink of "well should I really diagnose this person with condition X that I am 90% positive they have because what if such and such happens as a result, so maybe I should really give a diagnosis Y which I think is only like 10% likely..."; that allows for way too much of my non-clinical prejudices and philosophical commitments to infect what I'm doing.

FM may be different, a lot more of your conditions are defined (at least in part) by lab values which care a lot less about your philosophical commitments, but we have to live in the constant ambiguity (or just cover our eyes and pretend it doesn't exist). Lots of clinically optimal decisions are constrained by the finances of the system but assigning a diagnostic label is not, so why should I not document what I think is correct?

A necessary corollary of this stance is that if I truly believe what I am saying about the patient, allowing instrumental considerations based on my own self-interest/moral intuitions about pot/whatever other extraneous factor to trump that clinical judgement is ipso facto problematic.

You may not share the same axioms that lead me to that conclusion. That may be the source of our principled disagreement, I can respect that. But I hear a lot less of "actually I don't agree with the premises" when I talk to people about this and a lot more reflexive "not having anything to do with anything tangentially connected to marijuana, nope nope nope". That is what drives me a bit bonkers.

 

[VA Hopeful Dr]

Yeah, in the case of your state I also would not be keen on signing it. I think we are in agreement there.

The distinction I'm drawing seems like splitting hairs to you and @Sushirolls , I know, but I remain baffled about how it is not super salient and clear. I guess I am coming from a place of considering all the ways that our patients (at least in psychiatry) use the diagnoses we give them for various purposes and agendas in the world or how they intermediate their interactions with a number of bureaucracies. I take it for granted that there is a good chance someone might take the fact they have been diagnosed with something in particular and use it for purposes that I wouldn't approve of or that might even be counter-productive. That sort of thing happens all the time, which is why I feel like I have to insist on "I'm going to base this diagnosis on my best clinical opinion independently of what purposes it might be used for." I don't care to get into the doublethink of "well should I really diagnose this person with condition X that I am 90% positive they have because what if such and such happens as a result, so maybe I should really give a diagnosis Y which I think is only like 10% likely..."; that allows for way too much of my non-clinical prejudices and philosophical commitments to infect what I'm doing.

FM may be different, a lot more of your conditions are defined (at least in part) by lab values which care a lot less about your philosophical commitments, but we have to live in the constant ambiguity (or just cover our eyes and pretend it doesn't exist). Lots of clinically optimal decisions are constrained by the finances of the system but assigning a diagnostic label is not, so why should I not document what I think is correct?

A necessary corollary of this stance is that if I truly believe what I am saying about the patient, allowing instrumental considerations based on my own self-interest/moral intuitions about pot/whatever other extraneous factor to trump that clinical judgement is ipso facto problematic.

You may not share the same axioms that lead me to that conclusion. That may be the source of our principled disagreement, I can respect that. But I hear a lot less of "actually I don't agree with the premises" when I talk to people about this and a lot more reflexive "not having anything to do with anything tangentially connected to marijuana, nope nope nope". That is what drives me a bit bonkers.

OK, that does make your point of view make much more sense to me.

I'd love to say that most of my day is well defined conditions but given that at least 25% of my day is psych...

My issue is using my signature to allow the patient to do things without evidence of benefit (and potentially harmful). What I do see lots of are requests for disabled parking placards. Given how most of those asking for them are obese and/or arthritic (2 conditions that benefit from walking), I don't usually sign them. I couldn't care less who parks where, but it seems unwise to give people who should be walking an extra 20 yards a medical justification not to.

I see this as similar to that.

 

[clausewitz2]

OK, that does make your point of view make much more sense to me.

I'd love to say that most of my day is well defined conditions but given that at least 25% of my day is psych...

My issue is using my signature to allow the patient to do things without evidence of benefit (and potentially harmful). What I do see lots of are requests for disabled parking placards. Given how most of those asking for them are obese and/or arthritic (2 conditions that benefit from walking), I don't usually sign them. I couldn't care less who parks where, but it seems unwise to give people who should be walking an extra 20 yards a medical justification not to.

I see this as similar to that.

Makes sense. I understandably never fill out these disabled parking placard forms; do they just ask "what's the diagnosis?" or do they ask something like "what conditions do they have that impair their mobility" etc?

 

[PsyDr]

I’ll just leave this here:

Marijuana use is associated with worse outcomes in symptom severity and violent behavior in patients with posttraumatic stress disorder. - PubMed - NCBI

 

[VA Hopeful Dr]

Makes sense. I understandably never fill out these disabled parking placard forms; do they just ask "what's the diagnosis?" or do they ask something like "what conditions do they have that impair their mobility" etc?

Its somewhat in between.

The first qualifying thing is "An inabilty to ordinarily walk 100 feet nonstop without aggravating an existing medical condition, including the increase of pain"

 

[Jules A]

Also if you know someone is smoking and buying off the street with no intention of stopping is it fair to say it’s less harmful to get it at a dispensary where its not laced with something god awful

But is this much different from the patient using cocaine who is insisting I prescribe Adderall with the promise they will stop using cocaine? Or the person who requests Xanax 2mg tid so they don't have to continue buying it off the street or go into withdrawal?

 

[Attending1985]

But is this much different from the patient using cocaine who is insisting I prescribe Adderall with the promise they will stop using cocaine? Or the person who requests Xanax 2mg tid so they don't have to continue buying it off the street or go into withdrawal?

I see your point. It’s a reach. Maybe I’m wrong but I don’t see cannabis as harmful as benzos or stims for most.

 

[clausewitz2]

Its somewhat in between.

The first qualifying thing is "An inabilty to ordinarily walk 100 feet nonstop without aggravating an existing medical condition, including the increase of pain"

I guess you could argue there that the walking over a sufficient length of time would decrease the pain so sufficient sophistry could satisfy both of us!

 

[Attending1985]

After hearing everyone’s input it solidified that I will no longer certify. There is still a part of me though that thinks for some it’s benefits outweigh the risks. Problem is I have no data to back that up.

 

[Crayola227]

There may be some fancy legalese that reflects that this is not a medical opinion as you allude to. But being directly opined to assent to its use in the context of agreeing that a person has a condition to the lay man is just as good as an opinion. When juries are formed it is not with a jury of 12 lawyers who will salivate over such minutiae but that of our peers, and this doesn't pass the common (wo)man test. In addition, patients routinely state "my doctor prescribed it for me!" which further supports the lay opinion.

And no, it is not unethical to opt out of completing a form that reaffirms a person's diagnosis.

The point you're missing here, is that in the states that have legalized it, literally the majority of the voting age population support its use. Juries are formed from that same population. Furthermore, while a jury is not composed of lawyers, they are usually educated about the pertinent legal details, in detail, by the prosecution and defense, during a trial, whether they like it or not, and are instructed by the judge to make their decision with them in mind. Keep in mind as well, that it is up to the discretion of prosecutors what cases they pursue, and they do keep in mind both the legal minutiae and how they think a jury will react.

I believe during the Obama administration, although I don't know what's going on now, he instructed the DEA not to prioritize going after marijuana related crimes unless they were associated with other more serious crimes, and IIRC medical marijuana and states' rights was also something they were told not to get involved with. Physicians in a few states certifying that patients have medical conditions or even holding opinions that patients might benefit from them, as far as I know, were pretty low on the list. Nor have I heard of many physicians having legal troubles in the states that have legalized it.

Despite what is on the books, the President and other government departments and agencies, just as prosecutors and police do, have some degree of freedom to what extent they actually enforce law, and what policies are created/amended/enforced to that end. This is one reason why even without a bunch of laws being passed/repealed, the change of the executive branch and administration leaders is able to have a great effect on how things are actually run.

I know in Colorado, the feds mainly focused on busting anyone that crossed the border, as commerce, trafficking, and crimes across state lines do fall under the federal jurisdiction.

I am not sitting here making arguments about medically appropriate medical marijuana is. I'm pointing out the legal realities as I understand them. In case people were curious how physicians were faring and "getting away" with "prescribing" marijuana. The sky never fell.

And certainly, if in a physician's best medical judgement they think marijuana will be harmful to a patient, under no circumstances are they obligated to sign, nor should they. Even if a patient has a listed condition, the physician is free to decline to sign and to recommend against its use, and they should if it is for the good of the patient.

 

[Sushirolls]

I'm not missing the point. I'm keenly aware of what you have pointed out. But I also know history, the winds of political change, and that the literal cost of my medical education and the opportunity cost of achieving it, are not worth the slightest risk of supporting an illicit substance with little clinical evidence.

 

[TexasPhysician]

The point you're missing here, is that in the states that have legalized it, literally the majority of the voting age population support its use. Juries are formed from that same population. Furthermore, while a jury is not composed of lawyers, they are usually educated about the pertinent legal details, in detail, by the prosecution and defense, during a trial, whether they like it or not, and are instructed by the judge to make their decision with them in mind. Keep in mind as well, that it is up to the discretion of prosecutors what cases they pursue, and they do keep in mind both the legal minutiae and how they think a jury will react.

I believe during the Obama administration, although I don't know what's going on now, he instructed the DEA not to prioritize going after marijuana related crimes unless they were associated with other more serious crimes, and IIRC medical marijuana and states' rights was also something they were told not to get involved with. Physicians in a few states certifying that patients have medical conditions or even holding opinions that patients might benefit from them, as far as I know, were pretty low on the list. Nor have I heard of many physicians having legal troubles in the states that have legalized it.

Despite what is on the books, the President and other government departments and agencies, just as prosecutors and police do, have some degree of freedom to what extent they actually enforce law, and what policies are created/amended/enforced to that end. This is one reason why even without a bunch of laws being passed/repealed, the change of the executive branch and administration leaders is able to have a great effect on how things are actually run.

I know in Colorado, the feds mainly focused on busting anyone that crossed the border, as commerce, trafficking, and crimes across state lines do fall under the federal jurisdiction.

I’m not worried about a jury. The DEA is another beast. It is illegal at that level. Are they likely to enforce it currently, no. There is even some law that says they won’t enforce it unless they catch you doing something else that concerns them. The problem is that “something else” isn’t well defined.

If the DEA up and decide to take a stand in the future, I’m giving them no reason to look my way. It’s way too easy for the DEA to pull prescribing rights away.

Even though the risk is low of enforcement, the results could be catastrophic. Our field is in high demand with long waiting lists. There is no reason for us to take the risk.

 

[Crayola227]

I think docs that do it do it mainly for the money. Change my mind.

This is silly. Here's the thing, I'd have to go dig up some data that I'm sure exists, regarding how many of these forms are being signed by medical marijuana card issuing clinics, vs basically all the other docs that do it.

Opioid pill mills exist, and in some states accounted for literally the majority, like a huge whopping majority, of the number of pills even being prescribed in total. The number of physicians that actually prescribe opioids as part of their otherwise unremarkable standard of care practice on the other hand, is more.

So does this mean that doctors that prescribe opioids are mainly doing it for the money?

Some docs pass out benzos like candy. Do you ever prescribe benzos? Do you do it mainly for the money, or as part of a practice that is mostly guided by doing what you think is best for your patients?

In states that have now legalized recreational marijuana, clinics with docs dedicated to only signing these forms have mostly dried up. So who continues to sign them? Believe it or not, completely average docs in the course of their work. Patients without insurance can just pay slightly more at the dispensary for the MJ and don't need to pay to go to those clinics. Those that have insurance or otherwise are seeking general medical care, they just go to their regular provider. That's what patients do now. Physicians in the community that are not running MJ specific clinics are being approached all the time. Variable things happen from there. But now, a great deal of these cards are being signed by your average Joe Doc.

The average primary care faculty at an academic medical center, while some of their salary is RVUs, to my knowledge such appointments are not huge money-makers in the scheme of physician employment. Same with faculty at community residency programs. And omg lol, residents don't do anything in the clinic for money.

Also, if the patient is not paying out of pocket, and the visit is covered under insurance like any other visit, I still fail to see how using that visit to manage blood pressure as well as sign one of these forms as part of a comprehensive plan to address whatever condition its being used for, is all about the money. It's all the same. Not to mention, you don't really make more or less in a visit based on what you Rx, do you? I mean, you can hardly be in the pocket of big MJ.

When your patients see you for a med management visit, and you Rx paxil, is that for the money? How about when it happens to be ritalin?

The fact is, there are lots of docs signing these, and they most emphatically are not doing it for money, and I see no rational reason to think that they are, and to wave a broad brush over anyone that is not running a specialized clinic.

 

[Crayola227]

I'm not missing the point. I'm keenly aware of what you have pointed out. But I also know history, the winds of political change, and that the literal cost of my medical education and the opportunity cost of achieving it, are not worth the slightest risk of supporting an illicit substance with little clinical evidence.

I’m not worried about a jury. The DEA is another beast. It is illegal at that level. Are they likely to enforce it currently, no. There is even some law that says they won’t enforce it unless they catch you doing something else that concerns them. The problem is that “something else” isn’t well defined.

If the DEA up and decide to take a stand in the future, I’m giving them no reason to look my way. It’s way too easy for the DEA to pull prescribing rights away.

Even though the risk is low of enforcement, the results could be catastrophic. Our field is in high demand with long waiting lists. There is no reason for us to take the risk.

All very, very fair. And factual. I respect that some physicians are more conservative about some things, be it the evidence, early/late adopter, medicolegal risks, side effects, habituation, etc etc. Some are more risk averse, others like to blaze a trail.

Here's a neat article
Physicians, Medical Marijuana, and the Law

"This recommendation “loophole” was upheld by the US Court of Appeals for the Ninth Circuit in Conant v. Walters, which decided that a physician’s discussing the potential benefits of medicinal marijuana and making such recommendations constitute protected speech under the First Amendment [13]. The court reasoned that doctors should not be held liable for conduct that patients might engage in after leaving the office and that open and unrestricted communication is vital in preserving the patient-doctor relationship and ensuring proper treatment [11, 13]."

Well, it always helps when you already have federal court rulings on the books. Granted, those physicians on the forefront got to be made examples of, first.

The article is a bit behind the times, from 2014, some things have changed. For one, it used to be there was only one facility that could produce it for research, and it was hard to facilities to obtain it. That has basically been lifted and it's been much easier to conduct research.

That's the other issue in pointing out the lack of evidence about something. You have to consider why.

And I would always stand against any policy I thought prevented me from open communication with patients, or speaking my mind about what I thought best, or from ethical research, or what was best for my patients. Some docs do put their licenses and their very freedom on the line for these things.

 

[Crayola227]

"A study reported in April 2014 by WebMD surveyed 1,544 doctors in 12 specialties and 48 states [23] and found that 56 percent of those surveyed believed that medicinal marijuana should be legalized nationally and 69 percent believe it can deliver real benefits for certain treatments and conditions. The majority of positive responses came from oncologists and hematologists, probably because of marijuana’s use in treating cancer-related pain, counteracting nausea, and stimulating appetites reduced by chemotherapy [23]. Furthermore, a study published in the Journal of Adolescent Health in 2014 reviewed data measuring drug use and the perceptions of adolescents and found that legalizing medicinal marijuana at the state level causes no measured increase in youth marijuana use, thus addressing a key concern of those who oppose medicinal marijuana [24]. As more states legalize marijuana and others continue to expand and refine their regulations, physicians will likely play an important role as trusted sources for evidence on clinical efficacy and side effects and have a responsibility to be informed on the topic [3].

In late May of 2014, the Republican-controlled House of Representatives voted to block the federal government and its agencies from interfering with physicians, patients, and dispensaries acting in compliance with state medicinal marijuana laws [16]. Approval from the Senate would help settle conflicts between state and federal law [16].

Furthermore, the FDA announced in June 2014 that it will begin the process of reevaluating marijuana’s schedule 1 status [17]. This is good news for physicians concerned about the lack of data on marijuana; if its classification were lowered to schedule 2, more studies on its efficacy could be conducted and doctors would have a larger pool of data regarding its potential uses and side effects from which to draw judgments about its use [19]. As more states expand their laws, more patients consume the drug, and more data becomes available, physicians will become more confident about using medical marijuana.

Well, so really the point of me responding, is made in this article. No matter how you feel about medical MJ, we should all be aware.

Also, I'm pretty shocked that it was the Republican-controlled House that passed that legislation. I don't think Congress has become any more conservative about MJ, at least. I wasn't aware until today that it was legalized in Washington, D.C.

I think it's fair to wait until there is more legal protections, and despite the winds of change argument, as pointed out, once upon a time you'd get jail for opioids. At some point, history can only dictate current practice so much.

As far as evidence, that's the last bit and I'd have to go looking again, and I'll try.

 

[Jules A]

This is silly. Here's the thing, I'd have to go dig up some data that I'm sure exists, regarding how many of these forms are being signed by medical marijuana card issuing clinics, vs basically all the other docs that do it.
.

I looked briefly but wasn't successful. In Maryland it had been estimated that only 1% of physicians registered but that isn't a current statistic. What I was able to find is only a small 3 page list of MedChi doctors and an equally small list on a google search of medical cannabis doctors. Anecdotally I do not know of any PCPs or psychiatrists in my area offering it and 100% of the patients I have cared for receiving it have gone to a cash pay practice for the waiver.

In psychiatry I believe the potential for harm is likely greater than good but regardless would have prefered it simply be legalized for recreational use due to lack of FDA approval. The current situation is not only grossly unfair for those without means but a farce due to the lack of ability control the type that is purchased or the amount that is used.

 

[annoyedpsychiatrist]

no, real physicians dont typically suggest CBD as a solution to their issues. The OP is funny, if you look at indications in my state it treats basically anything reportedly. Better question would be who doesnt qualify for a medical marijuana card? Ive always wondered that. Does anyone ever get turned down? lol

 

[whopper]

Marijuana just like any medication has it's pros and cons.

The biggest cons I see are that adversely affects child brain development, increases the risk of schizophrenia and other psychotic disorders, can kill ambition, cause motor vehicle accidents, and pulmonary problems if smoked.

The biggest pros are it could benefit anxiety and chronic pain.

It, by definition is not schedule I, being that it has no medical benefit and is of the highest risk. Science has long known this yet only in the last few years have people tackled it to be taken off of schedule I. The substance, however, is not without risks. I am very convinced some of my schizophrenic patients wouldn't be schizophrenic had they not smoked marijuana.

IMHO children shouldn't be on it unless it's a very close to the bottom or last-line option due to the risk of schizophrenia.

 

[Merovinge]

Marijuana just like any medication has it's pros and cons.

The biggest cons I see are that adversely affects child brain development, increases the risk of schizophrenia and other psychotic disorders, can kill ambition, cause motor vehicle accidents, and pulmonary problems if smoked.

The biggest pros are it could benefit anxiety and chronic pain.

It, by definition is not schedule I, being that it has no medical benefit and is of the highest risk. Science has long known this yet only in the last few years have people tackled it to be taken off of schedule I. The substance, however, is not without risks. I am very convinced some of my schizophrenic patients wouldn't be schizophrenic had they not smoked marijuana.

IMHO children shouldn't be on it unless it's a very close to the bottom or last-line option due to the risk of schizophrenia.

The risks for adolescent brain development are for more than just schizophrenia. Given how high THC levels get in adolescent brains with vaping/concentrates being the main form of ingestion, there is very good recent literature about impact on both brain growth and brain pruning processes that are essential during this time. Prospective studies show worsening mood and anxiety with regular use. Legalization has absolutely increased THC use in adolescents.

Just because THC is "safer" than alcohol in adults (I'm not even sure how one compares this head to head, but say I agree that this is true), does not mean we should be treating things as we do now. Heck even the Netherlands famous for their allowance of THC classifies THC at >20% concentration a "hard" drug. Everyone knows the difference between drinking a can of beer and drinking 12oz of Vodka, but it appears to be lost on folks the difference between smoking a joint in college that was 5% THC concentration and kids dabbing on 99% pure THC.

 

[TheRightMedication]

Hold up. Did I miss a groundbreaking article somewhere, or is the evidence that cannabis is helpful for any psychiatric disorder still next to nil?

With a few exceptions, it's not medical, people!

You want to do drugs, do drugs, just don't implicate me or my field in the lie of "medical" marijuanna.

 

[calvnandhobbs68]

Hold up. Did I miss a groundbreaking article somewhere, or is the evidence that cannabis is helpful for any psychiatric disorder still next to nil?

With a few exceptions, it's not medical, people!

You want to do drugs, do drugs, just don't implicate me or my field in the lie of "medical" marijuanna.

Right this is where I end up actually in favor of legalization at this point. Stop making me argue with people that they're using their cannabis for "medicinal" purposes.

At a most basic level, what I argue with people now when they talk to me about "medical marijuana" is that if something's a "medicine" I should be able to note the studied dosages, frequency, purity and route of ingestion we should be utilizing to alleviate certain symptoms or at least have a ballpark of this stuff. When you get "prescribed" a medical marjuana card or get a certificaiton it's literally just saying go buy whatever you want. It'd be like if I certified someone had MDD and then said they could get a card that said they could buy "SSRI" or "stimulant" or "benzodiazepine" and that's it. I've had a few patients get a lightbulb moment with this lol.

 

[Sushirolls]

I'm so glad I moved my practice out of a cannabis legal state and Blue Metro. Not to say its not in my current red state, but so, so much less.
My assistant was even saying how the patients in this new locale are just nicer on the phone and more pleasant for interactions.
Less entitlement.

It was wearing on me banging my metaphorical head up against the wall, telling 20-80% of the consults for the week "stop the cannabis."

 

[smalltownpsych]

Marijuana just like any medication has it's pros and cons.

The biggest cons I see are that adversely affects child brain development, increases the risk of schizophrenia and other psychotic disorders, can kill ambition, cause motor vehicle accidents, and pulmonary problems if smoked.

The biggest pros are it could benefit anxiety and chronic pain.

It, by definition is not schedule I, being that it has no medical benefit and is of the highest risk. Science has long known this yet only in the last few years have people tackled it to be taken off of schedule I. The substance, however, is not without risks. I am very convinced some of my schizophrenic patients wouldn't be schizophrenic had they not smoked marijuana.

IMHO children shouldn't be on it unless it's a very close to the bottom or last-line option due to the risk of schizophrenia.

Completely agree with most of these points. As far as causing schizophrenia in patients, that will be hard to parse out, because although it is clearly a trigger for the active phase of the illness whether first break or subsequent breaks, we can’t say stress wouldn’t have brought it on as well. In our long term residential program with young people and psychosis we saw how both would trigger psychotic episodes. It did seem marijuana was more effective and longer lasting in its effects though. We had some patients who would smoke a joint and not stabilize for a couple of weeks and one in particular that it’s taking a couple of years and functioning declined precipitously. Stress also had an effect and in high doses over long periods could lead to same efffects, but it was easier to mitigate effects of that with a support team and contained environment.

 

[annoyedpsychiatrist]

if we completely legalize marijuana then a lot of these marijuana doctors are going to lose their jobs, then they may have to actually do something slightly more evidenced based. Perhaps they can go into naturopathic medicine which is probably comparable level of evidence.

In my state its pretty funny how it works, i have people who are abusing cocaine/alcohol/meth/etc and then getting "medical marijuana" to treat their anxiety, lol