Medical Marijuana

[Sushirolls]

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Just saw "medical marijuana" show up on the controlled substance database report with pharmacies for a patient. First time seen that. This one was prescribed by an EM physician. [shakes head]

[put long rant here]

[put demoralization and feelings of defeat summary here]

 

[clozareal]

Medical marijuana means a bunch of things, including FDA approved medications such as cannabidiol (Epidiolex) to synthetic cannabinoids such as dronabinol and nabilone, all of which you take orally rather than smoking it. However, the public mainly knows the latter which is not how many of the studies on the effectiveness medical marijuana for certain conditions (chemotherapy induced nausea/vomiting, appetite inducer, seizures, spasticity pain as a result of MS, etc) were conducted.

 

[calvnandhobbs68]

Just saw "medical marijuana" show up on the controlled substance database report with pharmacies for a patient. First time seen that. This one was prescribed by an EM physician. [shakes head]

[put long rant here]

[put demoralization and feelings of defeat summary here]

Yeah it showed up in the controlled substance database in the last state I was in as well, not my current state though, think it's a state to state thing. I actually prefer that because I can actually quantify how much the patient is going through (or should be going through) looking at their fills rather than asking them and getting answers like "idk 5 hits of my vape every night?". I think it also shows you the THC:CBD ratio for a lot of them too which is kind of helpful.

 

[comp1]

I'm guessing dronabinol would show up differently than medical marijuana in a state controlled substance database. I concur with the above poster saying it's nice to be able to quantify. That said, I also agree with the OP that it is sad an EM provider did this.

 

[Merovinge]

No wonder the field of EM is going down the tubes when they are prescribing medical marijuana... I don't envy EM docs, they have a very tough job, but good God Lemon.

 

[annoyedpsychiatrist]

Epidiolex is an amazing seizure medication for LGS and dravets. I remember seeing it work wonders in kids


But yeah, i have a patient here who works for a plastic surgeon who owns a medical marijuana clinic on the side.

 

[calvnandhobbs68]

I'm guessing dronabinol would show up differently than medical marijuana in a state controlled substance database. I concur with the above poster saying it's nice to be able to quantify. That said, I also agree with the OP that it is sad an EM provider did this.

No wonder the field of EM is going down the tubes when they are prescribing medical marijuana... I don't envy EM docs, they have a very tough job, but good God Lemon.

Nah this isn't that atypical. It's probably someone who does EM and then sells med marijuana cards on the side. It doesn't mean they're doing this from the ER. We all know whole "medical marijuana" process is a pay to play joke anyway.

 

[WisNeuro]

Compared to the medication messes I see in a lot of my patients, MJ is one of the least of my worries.

 

[comp1]

Not for me. I see THC induced psychosis pretty regularly and it is a mess. They literally soak the buds in acetone to extract the THC then boil the solvent off to leave shatter and consume it directly.

 

[WisNeuro]

Not for me. I see THC induced psychosis pretty regularly and it is a mess. They literally soak the buds in acetone to extract the THC then boil the solvent off to leave shatter and consume it directly.

The most consistent work I've seen is that there may be an association in early use, but still rare, but that link becomes tenuous in adult use. Is there newer, quality work on this topic that would bolster an argument about an explosion in cases? At least for those using something as prescribed?

 

[calvnandhobbs68]

At least for those using something as prescribed?

Can you elaborate on this, considering there's basically no evidence for any type of dosing of THC? Here's some interesting advice from one of the "clinics" in Florida, which is one of the few states that actually requires people to "prescribe" some sort of dosing:

"When you visit MMTCFL, your physician will provide you with a recommended dose of medical marijuana that he or she believes will suit your needs. You should view this dose as a starting point and feel free to raise or lower the dose as you see fit. If you have any questions about dosing, contact your MMTCFL physician, and they will be happy to help guide you."

Anyways:

Meta-analysis of the Association Between the Level of Cannabis Use and Risk of Psychosis - PMC

Cannabis use has been reported to induce long-lasting psychotic disorders and a dose-response relationship has been observed. We performed a systematic review of studies that investigate the association between the degree of cannabis consumption and ...

www.ncbi.nlm.nih.gov

Development Over Time of the Population-Attributable Risk Fraction for Cannabis Use Disorder in Schizophrenia in Denmark - PubMed

The results from these longitudinal analyses show the proportion of cases of schizophrenia associated with cannabis use disorder has increased 3- to 4-fold during the past 2 decades, which is expected given previously described increases in the use and potency of cannabis. This finding has...

pubmed.ncbi.nlm.nih.gov

The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): a multicentre case-control study - PubMed

Medical Research Council, the European Community's Seventh Framework Program grant, São Paulo Research Foundation, National Institute for Health Research (NIHR) Biomedical Research Centre (BRC) at South London and Maudsley NHS Foundation Trust and King's College London and the NIHR BRC at...

pubmed.ncbi.nlm.nih.gov

I could keep going

 

[allantois]

Lol DEA licenses marijuana facilities

 

[allantois]

You can’t “prescribe” marijuana. Physicians whor** certify that the patient has a qualifying condition, which they usually don’t

 

[annoyedpsychiatrist]

You can’t “prescribe” marijuana. Physicians whor** certify that the patient has a qualifying condition, which they usually don’t

ive yet to see a condition that doesnt qualify for it. Insomnia? MM. Pain? MM. Depression? MM. Bad day? MM. Girlfriend dumped you? MM

 

[Stagg737]

The most consistent work I've seen is that there may be an association in early use, but still rare, but that link becomes tenuous in adult use. Is there newer, quality work on this topic that would bolster an argument about an explosion in cases? At least for those using something as prescribed?

In the ER and see it all the time, at least 3-4x per month. Saw one yesterday that was 100% THC-induced as patient was using a home-grown source. Not necessarily chronic psychosis, but patients using some form of THC or Delta-whatever who come in with really bizarre behaviors and delusions. Sometimes they clear up in a day or two and other times they spend a week or so in our psych unit clearing up. Occasionally family will bring them in after the symptoms are there for a couple weeks and they end up going to the state hospital. Idk if I'd say there's an "explosion" in cases, but it's certainly not uncommon where I'm at.

 

[annoyedpsychiatrist]

As the world grows sicker and more chaotic, people start to want an escape more than learning coping skills and life improvement.

 

[Stagg737]

In the ER and see it all the time, at least 3-4x per month. Saw one yesterday that was 100% THC-induced as patient was using a home-grown source. Not necessarily chronic psychosis, but patients using some form of THC or Delta-whatever who come in with really bizarre behaviors and delusions. Sometimes they clear up in a day or two and other times they spend a week or so in our psych unit clearing up. Occasionally family will bring them in after the symptoms are there for a couple weeks and they end up going to the state hospital. Idk if I'd say there's an "explosion" in cases, but it's certainly not uncommon where I'm at.

Update, saw another one this morning. Patient started using a new dispensary a few weeks ago and per SO has been psychotic for the past week, hallucinating, bizarre behaviors, very guarded/paranoid, etc. Been in our ER for ~36 hours and wasn't seen by psych yesterday because EMS gave ketamine in the field and patient had to be sedated due to agitation and aggression. Today was linear and pleasant and actually pretty insightful about their substance use. Only other psychotic history was as a teenager and when using K2. SO provided collateral, pretty straightforward.

 

[Sushirolls]

ive yet to see a condition that doesnt qualify for it. Insomnia? MM. Pain? MM. Depression? MM. Bad day? MM. Girlfriend dumped you? MM

Before cannabis there was tobacco. And this song captures the sentiment. If you jump to 2:04 you'll hear everything it cures.

 

[PsyDr]

If I can see such "professional" terms as "Purple Haze Tincture" on lists of controlled medications, why can't every medication have a fun name?

 

[clausewitz2]

If I can see such "professional" terms as "Purple Haze Tincture" on lists of controlled medications, why can't every medication have a fun name?

Toreupirone

 

[B52slinger]

Lol DEA licenses marijuana facilities

I wonder what the liability is like for the physicians working there full-time. Doing hundreds of marijuana certifications per month with the expectation for every patient to be certified and for none to be denied....

 

[Merovinge]

I wonder what the liability is like for the physicians working there full-time. Doing hundreds of marijuana certifications per month with the expectation for every patient to be certified and for none to be denied....

The same as the doctors "overseeing" 100 NPs prescribing Adderall IR to 95% of the patients they see.

 

[allantois]

Any patient with family history of addiction/SMI should stay far away from marijuana

 

[Merovinge]

Any patient with family history of addiction/SMI should stay far away from marijuana

Yes AND anyone who is using on a regular basis, particularly high quantities/amounts, should expect for increased glutamate firing actively worsening anxiety anytime they are not acutely intoxicated. This is not any better than using benzos on a daily basis. People somehow are trying to argue that they are solving their problem by using "natural" THC, you know the THC that grew around 5% in concentration in the wild, is now 20% in all the plant matter and 80-100% pure in carts/dabs/edibles. The fix to your problem is not just ingesting a substance, I'm not sure how the US population came to be this way to believe otherwise (I say as someone prescribing psychotropics all day long).

 

[MacDonaldTriad]

I hate the term "medical" marijuana. I don't care what you smoke, just don't put doctors in the loop of approving it. You will find some doctors are willing, but they are generally sleaze balls that you wouldn't want to treat a real illness if you had one. I had a patient who went to a THC doctor and he said his indication was asthma. So smoking pot is a treatment for asthma now.

 

[Candidate2017]

Yes AND anyone who is using on a regular basis, particularly high quantities/amounts, should expect for increased glutamate firing actively worsening anxiety anytime they are not acutely intoxicated. This is not any better than using benzos on a daily basis.

Shut up, that's absolutely nonsense [according to my patients].

 

[yomike333]

That's interesting, I'm a pharmacist, and I've started seeing that pop up occasionally too, though usually it's from a PCP. My guess is it’s a state-level PDMP integration, some states mandate reporting for all sales from licensed dispensaries, regardless of federal Schedule I status.

When I was looking for a legitimate recommendation service, I picked LeafyRX California precisely because they are rigorous about the paperwork, and that compliance might include state-level reporting. It's an issue of state-vs-federal reporting requirements.

 

[Attending1985]

Is anyone seeing a lot of gi issues with chronic cannabis users. I see this often in young people around 18-25 who’ve been using heavily and are losing weight due to low appetite/nausea. They say only thing that helps is cannabis. Do my best to explain what’s happening with their endocannabinoid receptors but no one seems to care.

 

[mistafab]

All the time. Also since I work in the ED I also see cannabis induced hyperemesis frequently. They don't care because they are addicted and are in denial that it is causing all the issues they think it is fixing.

What they don't see (due to addiction) is all the issues it is 'fixing' in the short term are indeed the same ones it is creating long term.

Is anyone seeing a lot of gi issues with chronic cannabis users. I see this often in young people around 18-25 who’ve been using heavily and are losing weight due to low appetite/nausea. They say only thing that helps is cannabis. Do my best to explain what’s happening with their endocannabinoid receptors but no one seems to care.

 

[Attending1985]

All the time. Also since I work in the ED I also see cannabis induced hyperemesis frequently. They don't care because they are addicted and are in denial that it is causing all the issues they think it is fixing.

What they don't see (due to addiction) is all the issues it is 'fixing' in the short term are indeed the same ones it is

I read a good article recently saying that what I’m seeking is essentially a prodrome to cannabis hyperemesis syndrome and the prodrome can last years.
There’s also a lot of negative cardiovascular effects of cannabis that I’m more recently reading about.

 

[mistafab]

I read a good article recently saying that what I’m seeking is essentially a prodrome to cannabis hyperemesis syndrome and the prodrome can last years.
There’s also a lot of negative cardiovascular effects of cannabis that I’m more recently reading about.

Very interesting.

Purely speculative on my part, but I'm guessing that since we know endocannabinoids are involved in anti-emetic effects (like how it is used in cancer), what we are seeing is in some people they have chronically altered their endocannabinoid-nausea/emesis pathways much like someone who is abusing laxatives will become chronically constipated. Or like how a chronic opioid user will get opioid-induced hyperalgesia.

Certain people must be prone to this, or perhaps just the extensiveness/frequency of use/addiction becomes so high that it becomes inevitable for some.

 

[Attending1985]

Very interesting.

Purely speculative on my part, but I'm guessing that since we know endocannabinoids are involved in anti-emetic effects (like how it is used in cancer), what we are seeing is in some people they have chronically altered their endocannabinoid-nausea/emesis pathways much like someone who is abusing laxatives will become chronically constipated. Or like how a chronic opioid user will get opioid-induced hyperalgesia.

Certain people must be prone to this, or perhaps just the extensiveness/frequency of use/addiction becomes so high that it becomes inevitable for some.

Yeah doesn’t seem to happen to everyone. I tend to see it in young females. I hope it’s reversible.

 

[Sushirolls]

Each person is different for when or how cannabis will tear into their health.
Some first use.
Others 30 years later with debilitating anxiety.

Just a matter of when, not if, it leads to consequences.
Cannabis is not a medicine.

 

[Stagg737]

Yep, consults here and all see it all the time. Typically patients either are dismissive that the cannabis is causing problems and they’re mad that GI can’t find the “real” reason and are angry that we’re there OR they had nausea or sleep issues and say cannabis is the only thing that has helped. The latter sometimes does recognize that continuing to use cannabis will only make things worse, but they are desperate enough or have poor enough impulse control that they continue to use anyway.

Yeah doesn’t seem to happen to everyone. I tend to see it in young females. I hope it’s reversible.

I definitely see it more in women in general, and young women more I think because they’re more likely to use it. I’ve seen it with more than a few young men too though. Anecdotally, patients frequently will have noticeable cluster B traits or multiple other psychosomatic problems.

 

[Stagg737]

Also, I have actually seen more than a couple cases of this with GLP-1s also. Almost always in patients that started taking it for weight loss and not an actual medical problem where they then develop severe nausea and months after discontinuation it is still present.

 

[aim-agm]

One thing I've wondered at is if fluvoxamine (which inhibits essentially all the cannabis breakdown pathways) could have any role in managing hyperemesis/withdrawals by making the drop in levels after cessation more gradual.

On the other hand, even if it does have utility I suspect that we'd have a rash of people seeking fluvoxamine ("I got the OCD real bad doc") when they figure out it lets them get more cannabis out of their cannabis.

 

[Merovinge]

One thing I've wondered at is if fluvoxamine (which inhibits essentially all the cannabis breakdown pathways) could have any role in managing hyperemesis/withdrawals by making the drop in levels after cessation more gradual.

On the other hand, even if it does have utility I suspect that we'd have a rash of people seeking fluvoxamine ("I got the OCD real bad doc") when they figure out it lets them get more cannabis out of their cannabis.

I really doubt that. THC is (unfortunately) comically cheap, event from dispensaries in many states, not withstanding the lower prices black markets have gone to keep up. I find it very hard to imagine someone trying to scam a Luvox script out to extend a high.

I get the most mileage out of Remeron for withdrawals, although I'm also happy to load up on some Zofran or even Reglan if needed for the GI sx.

 

[clausewitz2]

Yep, consults here and all see it all the time. Typically patients either are dismissive that the cannabis is causing problems and they’re mad that GI can’t find the “real” reason and are angry that we’re there OR they had nausea or sleep issues and say cannabis is the only thing that has helped.

I sometimes mention to these folks, when introducing the idea of cannabis hyperemesis, the one patient I had with this issue who took to carrying a bucket around with them wherever they went, just in case. It at least offers a very concrete and vivid example of how bad things can get to anchor on.

I have seen a number of people diagnosed with CVS turn to cannabis to manage it and then it seems to morph into cannabis hyperemesis over a few years (in the sense the vomiting stops being cyclic in any meaningful sense and more correlated with cannabis consumption). I wish I knew a good GI around here who was not avoidant of "psych" issues.

 

[Stagg737]

I really doubt that. THC is (unfortunately) comically cheap, event from dispensaries in many states, not withstanding the lower prices black markets have gone to keep up. I find it very hard to imagine someone trying to scam a Luvox script out to extend a high.

I get the most mileage out of Remeron for withdrawals, although I'm also happy to load up on some Zofran or even Reglan if needed for the GI sx.

Better mileage from quetiapine. The mitigation of withdrawal effects is pretty much the entire reason it has street value and I think it’s the only non-controlled substance (other than gabapentin, but that’s semi-controlledish) that someone has tried to get from me that they clearly didn’t need. Street value is high enough that prisons in my state done have it on formulary due to the abuse potential.

 

[Merovinge]

Better mileage from quetiapine. The mitigation of withdrawal effects is pretty much the entire reason it has street value and I think it’s the only non-controlled substance (other than gabapentin, but that’s semi-controlledish) that someone has tried to get from me that they clearly didn’t need. Street value is high enough that prisons in my state done have it on formulary due to the abuse potential.

Absolutely down for Seroquel usage in this setting as well. I like that if Remeron is effective some people will continue with it for the very high depression/anxiety co-morbidity in this population, whereas Seroquel you want to keep short-term much more and people run into issues with longer term use just perpetuating. But yes, people should certainly consider it for significant THC withdrawal, it's a great point.

 

[LeaveNoTrace]

Is anyone seeing a lot of gi issues with chronic cannabis users. I see this often in young people around 18-25 who’ve been using heavily and are losing weight due to low appetite/nausea. They say only thing that helps is cannabis. Do my best to explain what’s happening with their endocannabinoid receptors but no one seems to care.

I am thinking that it is similar to cannabinoid hyperemesis syndrome - it seems that smoking pot causes a rebound effect where it alleviates symptoms in the short term and causes them in the medium and long term. There is also probably some self selection at work.

 

[clubdeac]

Interesting recent study