Medical Marijuana

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scharnhorst

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How many FP docs here prescribe medical marijuana in their practice
I live in IL and its relatively new here , curious to see what the experience has been of doctors across the country
any CMEs you would recommend about this ?

thanks
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Dangerous in today's political climate, a marijuana crackdown at the federal level seems to be growing ever more likely
 
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Weed docs are usually sketchy as all get-out, anyway. I'd think hard before running with that crowd.
 
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I know several docs who are doing it in IL but for no other reason other than $$$
they could not convince me of the benefits and I approached this issue with an open mind
 
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Our network doesn’t allow current physicians to rx medical marijuana . There are 2 physicians in the area who are setting up to start rx’ing medical marijuana- initial and f/up assessments are cash payments only - booked out for 4minths already- cash cow man.

It’s a tricky situation - federal considers illegal, but state does not. We have a DEA, which could become suspended/revoked if federal seems warranted.

Last case against a physician and the federal govt was in early 2000s - Supreme Court upheld that the physician making a recommendation and not directly rx’ing the marijuana does not implicate the physician. No lawsuit since (my understanding) from the federal govt against a physician.

I highly doubt a repeat lawsuit would occur, but certainly a risk. There’s money there, but I just don’t believe in it that much to recommend rx’ing it to place my livelihood at risk.
 
scharnhorst said:
How many FP docs here prescribe medical marijuana in their practice
I live in IL and its relatively new here , curious to see what the experience has been of doctors across the country
any CMEs you would recommend about this ?

thanks
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I have at least one patient per week ask about it but they all don't understand that in IL you need to have a qualifying debilitating condition. I also explain that it's an alternative treatment and that they would need to have failed standard therapies first. I usually talk about the whole illegal on a federal level vs my license / DEA concern. As a primary care provider a lot of the conditions approved for use are beyond my scope of practice. But If I truly felt someone would benefit, treatment options were exhausted and wholeheartedly tried, they were low risk for misuse, and if it would do minimal harm to the community and patient - then I would consider prescribing.

Thing is the vast vast majority of patients asking for it are currently using it illegally so...

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Also, the current rx’ing physicians in my area require you to be off all controlled substances, which for some with TRUE chronic pain, this period of not taking any meds would be horrible and not worth it.
 
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Ive seen providers in my area Rx them, but usually to patients who are chronically/terminally ill only. No other controlled substances. Must be seeking adjunct standard of care treatment as well.
 
Our system legal consult advised providers are absolutely not allowed to participate in this (NM). We receive federal funds but I think that the concern they raised could apply to any provider. The issue is that marijuana is still CS 1 on a federal level so there is theoretical potential that you will not be protected if legal consequences follow from "medical" marijuana that you have advised as a provider. Unless someone is hugely passionate about the world of marijuana advocacy, I don't see the theoretical liability as worth it.
If you are looking to expand to Lyme disease specialty clinic's practice, then you should ABSOLUTELY add "medical" marijuana to your list of services =).
 
I work for an fqhc, and in any case do not feel comfortable in the medical applications so do not foresee that becoming part of my practice in future. I neither encourage not discourage my patients with chronic pain who express interest, I simply tell them to use google if they want to look into it. I live in California, I don’t feel this is a service I need to provide as I think the market is pretty saturated :D
 
The fact that smiley face kind of looks like it has been using marijuana is an accident
 
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More than enough evidence to warrant in certain conditions (epilepsy, cancer, HIV/AIDS, neurospasticity, etc.) therapeutic index is through the roof so there isn’t any reason not to consider it for well-known conditions. As long as it’s used as an adjunct therapy and recommended judiciously, physicians aren’t going to be used as martyrs.

Also, the CS I issue is why most legal states have worded this as physician recommendations and not prescriptions.
 
IntheClouds4ever said:
More than enough evidence to warrant in certain conditions (epilepsy, cancer, HIV/AIDS, neurospasticity, etc.) therapeutic index is through the roof so there isn’t any reason not to consider it for well-known conditions. As long as it’s used as an adjunct therapy and recommended judiciously, physicians aren’t going to be used as martyrs.

Also, the CS I issue is why most legal states have worded this as physician recommendations and not prescriptions.
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Depends what you are using to determine toxicity with therapeutic index. If you use death then I think your assertion holds. I would also question your assertion that there is "more than enough evidence to warrant" use as a therapy in any condition. I haven't seen enough evidence to persuade myself or any practicing physician who I personally know. However, there is a great deal of solid science showing that marijuana has clear risks and harms and I have seen most reputable medical organizations weighing in on this side of the discussion...not the pro treatment side.
 
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simpler2 said:
Depends what you are using to determine toxicity with therapeutic index. If you use death then I think your assertion holds. I would also question your assertion that there is "more than enough evidence to warrant" use as a therapy in any condition. I haven't seen enough evidence to persuade myself or any practicing physician who I personally know. However, there is a great deal of solid science showing that marijuana has clear risks and harms and I have seen most reputable medical organizations weighing in on this side of the discussion...not the pro treatment side.
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Pharmaceutical derivatives are already being used and developed for numerous conditions. I didn't say "any" condition.. Here is just a small sample of pharmaceutically derived cannabinoids (some already in Phase III), cannabis is just as much a medicinal plant as willow bark, foxglove, colchicine, etc. I never said there weren't any risks, but the risks that are present are still below that of opiates, benzos, and other accepted pharmaceuticals for seizures (just an example). I have talked to numerous physicians in my area that are interested in it for certain conditions, but that doesn't mean they want to prescribe it for anything and everything.
 

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Im not trying to argue that its a cure all or anything of the sort (that is thrown out by political activists). Im just pointing out that turning a blind eye to the growing body of evidence on the endocannabinoid systems vast influence on the body, and our ability to modulate it, may be to some patients detriment due to their refractory diseases. Is it perfect? No, but there are some patients/cases/diseases that the possible benefit could vastly improve their quality of life and reduce other more harmful medications (when they work synergistically, which isn't always the case)
 
IntheClouds4ever said:
Im not trying to argue that its a cure all or anything of the sort (that is thrown out by political activists). Im just pointing out that turning a blind eye to the growing body of evidence on the endocannabinoid systems vast influence on the body, and our ability to modulate it, may be to some patients detriment due to their refractory diseases. Is it perfect? No, but there are some patients/cases/diseases that the possible benefit could vastly improve their quality of life and reduce other more harmful medications (when they work synergistically, which isn't always the case)
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I didn't interpret your original post as a statement marijuana should be used in "any" condition. I was trying to say that I do not see evidence to support use of marijuana in its current available form and practice for any of the conditions that it is being evaluated/recommended for. I think it is great that further research is happening to look at the possible health benefits of some of the components of marijuana. Once those medications and data supporting their use is commercially available, I'm totally on board with considering prescribing/recommending treatment. The currently available "medical marijuana" culture and programs simply don't cut muster for myself or other physicians I know to have interest in recommend or use marijuana as a treatment modality, regardless of diagnosis/condition.

Its great that you are interested in the topic (curious scientists are what help us discover new treatment options). My post was not intended to be combative. I was more trying to add perspective of an attending physician (and what I see is largely the opinion of most attending physicians).
 
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simpler2 said:
I didn't interpret your original post as a statement marijuana should be used in "any" condition. I was trying to say that I do not see evidence to support use of marijuana in its current available form and practice for any of the conditions that it is being evaluated/recommended for. I think it is great that further research is happening to look at the possible health benefits of some of the components of marijuana. Once those medications and data supporting their use is commercially available, I'm totally on board with considering prescribing/recommending treatment. The currently available "medical marijuana" culture and programs simply don't cut muster for myself or other physicians I know to have interest in recommend or use marijuana as a treatment modality, regardless of diagnosis/condition.

Its great that you are interested in the topic (curious scientists are what help us discover new treatment options). My post was not intended to be combative. I was more trying to add perspective of an attending physician (and what I see is largely the opinion of most attending physicians).
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Health benefits aside, even those in drug policy have taken notice of the benefits that cannabis has had on opioid use and overdose. If patients prefer cannabis over opiates and it reduces the number of opiates prescribed, its something that should at least be on our radar. If a legitimate pain patient requests cannabis over opiates, I would much rather try it before turning to opiates, even if I felt that cannabis doesn't have enough formal research to unequivocally prove its efficacy. Personally, I would sleep better at night knowing that the potential risks for cannabis are still FAR below that of opiates in any category (addictive, impairment, other organ systems, etc.)

From Prohibition to Progress: A Status Report on Marijuana Legalization
 
IntheClouds4ever said:
Health benefits aside, even those in drug policy have taken notice of the benefits that cannabis has had on opioid use and overdose. If patients prefer cannabis over opiates and it reduces the number of opiates prescribed, its something that should at least be on our radar. If a legitimate pain patient requests cannabis over opiates, I would much rather try it before turning to opiates, even if I felt that cannabis doesn't have enough formal research to unequivocally prove its efficacy. Personally, I would sleep better at night knowing that the potential risks for cannabis are still FAR below that of opiates in any category (addictive, impairment, other organ systems, etc.)

From Prohibition to Progress: A Status Report on Marijuana Legalization
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Go ask the pain management people what they think of marijuana...
 
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One of the big problems with medical "marijuana" is what you mean exactly by marijuana. If you've ever been to a weed dispensary you know there are anywhere from dozens to hundreds of different strains with varying concentrations of different cannabinoids. Then you've got variations with sattiva/indica/hybrid. Then there are different preparations from plant/flower marijuana most people think about, to hash oil, to edibles, and so on. And we don't have specific research to know which variant may or may not be good for a certain condition. So, you may prescribe or recommend marijuana for a diagnosis and the patient gets a variation of marijuana that is totally ineffective, or maybe detrimental.

Another problem is effective dosing has not been established. We don't do this with any other medication. Does your patient take 1 puff daily, or 50 mg of edibles t.i.d., or maybe just stay totally baked all the time? Could you imagine rx'ing lisinopril in this manner.

Until cannabis is moved to DEA schedule II, and good studies can be done, there will be underwhelming available research to make medical recommendations with much confidence.
 
nexus73 said:
One of the big problems with medical "marijuana" is what you mean exactly by marijuana. If you've ever been to a weed dispensary you know there are anywhere from dozens to hundreds of different strains with varying concentrations of different cannabinoids. Then you've got variations with sattiva/indica/hybrid. Then there are different preparations from plant/flower marijuana most people think about, to hash oil, to edibles, and so on. And we don't have specific research to know which variant may or may not be good for a certain condition. So, you may prescribe or recommend marijuana for a diagnosis and the patient gets a variation of marijuana that is totally ineffective, or maybe detrimental.

Another problem is effective dosing has not been established. We don't do this with any other medication. Does your patient take 1 puff daily, or 50 mg of edibles t.i.d., or maybe just stay totally baked all the time? Could you imagine rx'ing lisinopril in this manner.

Until cannabis is moved to DEA schedule II, and good studies can be done, there will be underwhelming available research to make medical recommendations with much confidence.
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"Specific Strains" just have altering compositions of THC, CBD, CBN, THCA, CBDA etc. This is why most reputable dispensaries have the profiles tested. Sativa/Indica/Hybrid etc is an old school classification system that is useless in todays realm of cannabinoid content testing. There are many different preparations but that doesn't mean that active content for a recommended dose changes, Dronabinol is recommended anywhere from 5-25mg (this really only concerns THC as its the only psychoactive component and we already use it medicinally). You can guide patients on where to start using this same criteria while also informing them of the various delivery systems and how it will affect them. (Ie: edibles will take longer and generally will need a higher dose to achieve the same effect as submucosal or vaporized cannabis.) Take painkillers and NSAIDs for example, we give a quantified dose to begin with and say take this PRN, but don't X amount or you'll go into liver failure. We don't do this with Lisinopril because it will cause the BP to bottom out and cause a crisis event. Again, you have to take into consideration that cannabis has one of the safest therapeutic profiles, meaning its not going to send the patient into liver failure like NSAIDs could. For the most part, Medicine is sliding scale guess work to see what benefits the patient the most. We start low, titrate slowly so I don't see cannabis as any different.

Again, Id be more worried about what their combination of their other OTC meds and alcohol have on their health and state of mind, more so than cannabis. That doesn't mean cannabis is perfect, but lets step back and compare it to other medications and drugs that are legal and OTC. Of course there will be abusers of anything from fast food to opiates, but that doesn't mean we cant utilize a safe substance for those patients that have the potential to gain true benefits and a better QOL.
 
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There are enough dispensaries around the country why would you even have to Rx it? Slippery slope and I ain't doin it.
 
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cabinbuilder said:
There are enough dispensaries around the country why would you even have to Rx it? Slippery slope and I ain't doin it.
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Most medical prices are much cheaper and taxed less than recreational (looking at you Colorado). Also, many patients will still be asking you as a physician about it and expect you to have some knowledge on it. Its not just about writing scripts.. Acetaminophen and Naproxen can be scripted but isn't truly necessary. Patients still want recommendations on how to appropriately use OTC medications. Same thing is going to/already is happening with cannabis.
 
IntheClouds4ever said:
Health benefits aside, even those in drug policy have taken notice of the benefits that cannabis has had on opioid use and overdose. If patients prefer cannabis over opiates and it reduces the number of opiates prescribed, its something that should at least be on our radar. If a legitimate pain patient requests cannabis over opiates, I would much rather try it before turning to opiates, even if I felt that cannabis doesn't have enough formal research to unequivocally prove its efficacy. Personally, I would sleep better at night knowing that the potential risks for cannabis are still FAR below that of opiates in any category (addictive, impairment, other organ systems, etc.)

From Prohibition to Progress: A Status Report on Marijuana Legalization
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Logically, I want to agree with you.. opiates are bad BUT marijuana isn't the standard of care for treating anything (yet?), so can you really sleep better at night knowing that you're professionally recommending to a patient something that isn't SoC, and thus the ownus of proving your treatment is effective (and or better than SoC) is on you, lets say, if you got litigated for something as a result of a patient's use of marijuana? I know I can't/wouldn't.
 
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Rx’ing an opioid isnt the end of the world if done in a resonspible, appropriate and monitored setting. Yes, the docs who are providing oxy 10 QID with OxyContin 30 TID for fibromyalgia (I saw this exact pt last wk) we can all say is inappropriate, but this was driven by irresponsible rx’ing practices not from the rx itself. Opioids do treat pain, and many ppl are in stable doses without divergence and have improved their overall functionality in life. There is risk with pain meds treating psychosocial aspects, but when a pt is stating that the dose needs to be increased you really have to take the time and figure out if what level of functioning are they achieving , underlying “pain generator”, and psychosocial factors that may be driving the bus.
 
septoplasty said:
Logically, I want to agree with you.. opiates are bad BUT marijuana isn't the standard of care for treating anything (yet?), so can you really sleep better at night knowing that you're professionally recommending to a patient something that isn't SoC, and thus the ownus of proving your treatment is effective (and or better than SoC) is on you, lets say, if you got litigated for something as a result of a patient's use of marijuana? I know I can't/wouldn't.
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Yes. Document, document, document.. if the patient is saying they are tolerating and effective treating their pain with cannabis rather than opiates then the treatment is effective. With the known issues of opiates and even sleep meds like ambien, I think trying to stretch the issue to cannabis is a bit much considering this hasn’t happened in a legal state (doc litigated for patient driving high for example). Even so, I wouldn’t have a problem with informing a judge/jury of my stance to let the patient try cannabis before going to opiates. There is research showing the therapeutic potential for pain and with the current opioid epidemic, I highly doubt you’ll be chastised for trying an alternative therapy. If the patient keeps coming back asking for more/other pain meds or plant counts, etc.. yes it needs to be stopped and the issue needs to be explored further for the biopsychosocial aspects that may be rendering your approach ineffective and put the patient and public at risk for whatever reason.
 
DoubleBogey said:
Rx’ing an opioid isnt the end of the world if done in a resonspible, appropriate and monitored setting. Yes, the docs who are providing oxy 10 QID with OxyContin 30 TID for fibromyalgia (I saw this exact pt last wk) we can all say is inappropriate, but this was driven by irresponsible rx’ing practices not from the rx itself. Opioids do treat pain, and many ppl are in stable doses without divergence and have improved their overall functionality in life. There is risk with pain meds treating psychosocial aspects, but when a pt is stating that the dose needs to be increased you really have to take the time and figure out if what level of functioning are they achieving , underlying “pain generator”, and psychosocial factors that may be driving the bus.
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Just like opiates can be used responsibly, so can cannabis. The sky isn’t going to fall. I’m not bashing opiates for fun, I’m just stating that cannabis could be used as an alternatively therapy for many patients before opiates to cut down the amount of scripts and known serious issues that come with chronic use. I’m not saying cannabis is perfect, but there’s potential to bridge a gap between OTC pain meds and the highly addictive/deadly pain scripts.
 
IntheClouds4ever said:
Just like opiates can be used responsibly, so can cannabis. The sky isn’t going to fall. I’m not bashing opiates for fun, I’m just stating that cannabis could be used as an alternatively therapy for many patients before opiates to cut down the amount of scripts and known serious issues that come with chronic use. I’m not saying cannabis is perfect, but there’s potential to bridge a gap between OTC pain meds and the highly addictive/deadly pain scripts.
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ididitguysimadeastonerjoke.jpg
 
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IntheClouds4ever said:
Just like opiates can be used responsibly, so can cannabis. The sky isn’t going to fall. I’m not bashing opiates for fun, I’m just stating that cannabis could be used as an alternatively therapy for many patients before opiates to cut down the amount of scripts and known serious issues that come with chronic use. I’m not saying cannabis is perfect, but there’s potential to bridge a gap between OTC pain meds and the highly addictive/deadly pain scripts.
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Not necessarily.

"The contrasting associations from the state-level and the person-level analyses should serve as a caution to eager advocates and puzzled policy makers."

Marijuana May Raise, Not Reduce, Risk for Opioid Use Disorder
Medscape: Medscape Access
 
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