Positive cannabis on UDS

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nrmp

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I have a patient who appeared guarded about substance use. I did drug screen and positive for cannabis. How comfortable are you to continue stimulant and benzo?

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THC isn't that relevant, what is the rational for mixing Benzos and stimulants? Stimulants cause anxiety and insomnia, Benzos cause poor concentration.
 
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Does patient acknowledge its a positive and they have been using? If not, send off for confirmation testing. I let my patients know I won't prescribe any controlled substances with substances of abuse being used - including cannabis. Next question is this a new or follow up patient? I avoid the benzos by just not prescribing them, period (unless tapering off from previous clinician who had them on chronically).

THC is always relevant.
 
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Do you not prescribe controlled substances for casual drinkers? What about heavy coffee drinkers? What about people who use psychedelics for spiritual purposes? Not all drug use is abuse or bad or wrong or harmful.
 
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So is speeding. Do you prescribe controls to people who speed?
 
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So is speeding. Do you prescribe controls to people who speed?
Speeding is only illegal on federal property, so 99% of speeding isn't a federal violation.

As for the OP, I would tell the patient they have to stop any illegal substances if I'm going to prescribe them controlled substances. Since marijuana is in a weird grey area in lots of states, I give a warning. Things like cocaine and meth I do not.
 
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It's a f/u, have seen 3 times and patient denied using on last visit stating last use was end of December so I can't trust anymore. She has been those meds for long form prior provider so I didn't want to make her unstable and continued in the beginning.
 
THC isn't that relevant, what is the rational for mixing Benzos and stimulants? Stimulants cause anxiety and insomnia, Benzos cause poor concentration.

Many people are on stimulant since childhood or so. Later in their life when they have anxiety and panic attacks, they are not going to agree if you tell them that it's due to stimulant and let's just take that away and anxiety will go away
 
Do you not prescribe controlled substances for casual drinkers?

Not benzos and especially not when I catch them lying to me about their substance use.

What about heavy coffee drinkers?

What's their pattern? 5 cups every day like clockwork? Sporadic throughout the day? Binges that vary from day to day? I take a more detailed caffeine hx on my patients then most and I'm conscious of this when I prescribe as I've actually seen patients hospitalized with caffeine intake playing a significant factor.

What about people who use psychedelics for spiritual purposes?

Would depend on what they're taking and what I would be prescribing.


Bottom line is when they're using another substance that could have potentially harmful interactions with what I'm prescribing I'm always going to think twice about it. When I'm really unsure or not comfortable, they can find someone else to prescribe that to them. I'm not going to risk my license for a single patient, especially if I didn't feel like I could trust them.
 
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A positive UDS doesn’t tell you anything—doesn’t indicate frequency or severity, doesn’t indicate if it’s recreational, for therapeutic purposes, or indicates problematic use.

There are lots of things that are illegal. Does it matter if it’s locally legal and federally illegal? What if you live 10 miles from the Canadian border and consume there and return home? What do we care, are we in law enforcement?

Not all drug use is bad. The vast majority of people who use drugs do not have a use disorder. Prohibition is a new phenomenon, and hopefully one that won’t be around for very long.
 
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Do you not prescribe controlled substances for casual drinkers? What about heavy coffee drinkers? What about people who use psychedelics for spiritual purposes? Not all drug use is abuse or bad or wrong or harmful.
I absolutely agree, and I even think some times you can mix things. However, for those who are already mentally ill, all psychoactives, especially potpurris, especially potpurris with recreational substances, is a potential recipe for worsened mental health. I believe all patients should be warned away from all recreational substances, including caffeine or guarana or any of that hippy stuff, and then re-evaluate what adding minor to moderate amounts of the stuff, what that does to their mental health and whether or not that's acceptable to their goals of therapy.

I guess I will disclose that I have had struggles with depression. I remember going and visiting family (who can make anyone depressed) and just socially drinking with them. At some point, I was maybe having 2-3 drinks maybe once a month. We talked it through, my provider and I, and I realized that even one drink seemed to have a lasting effect on my mood, at least beyond maybe the moment of or the next day. I asked, "How much is OK?" He was like, "Ideally, none." At least for me. I had to decide just how in the dumps I was, and how badly I wanted out of them. Was it worth it? I think it says something that I decided I was so down I was willing to give up even one drink in some attempt to crawl my way back up, even an inch. I became something of a tee totaler. Not so much anymore, but I like to consider my default state and attitude as being totally dry. Alcohol, and THC, are not your friend to the extent that people like to think.

I think this attitude can apply to caffeine as well.

The script regarding psychoactive substances needs to be flipped in most people's minds. Yes, substances are fun. No, you really don't have to do them. If you give them up, they're not going anywhere. You can live without them - in fact, we might argue we're fairly designed to. You weren't born with a cigarette or cup of coffee in your hand. They're at minimum like cobwebs to the mind, and when you're ill you're basically needing to clear the cobwebs.

All that said, depending on the circumstances, I wouldn't say you can't prescribe a stim and benzo to someone with a positive UDS. It depends in my mind, on a number of factors. Do they wake and bake? Or was this some sort of social smoking? Are there extenuating factors? Is this a college student in a dorm living with a pot dealer, making total abstinence difficult? What symptoms am I treating them for? What does the combination of this potpurri seem to be doing? How is the cannabis negatively impacting treatment? Is the patient better off overall with my prescribing, despite their lifestyle choices? Do I really need to stop one of my prescriptions for best benefit given the patient's choices at home? (Last few questions are pretty standard for any prescribing you do, outside of a positive UDS) What kinds of coping mechanisms does this represent? Does the patient have insight into their usage? Can the patient eliminate the substance or keep it to a nuisance level? What are the chances they are lying? Diversion?

I wouldn't have a blanket policy. Goals of care I have are to get them as sober as I can, because I truly believe, and will tell patients as much, that is really the healthiest default state for humans, the rest of it is like chocolate cake, not exactly bad for you, not exactly good for you, but erring on deadly if you're not well like the morbidly obese. Cannabis isn't a big deal - except for maybe when you're literally fighting for your life on the mental health side. What is OK for Joe Blow the next door neighbor, just might not work well with where you are at with your mental health. Sometimes you cheat but you have to look at where that puts you. It's a bit silly to worsen or even cause mental illness with something that's meant to be recreational, which is sorta the opposite of "fun" times, and then have to take even more drugs, all of this having side effects, in order to deal with the cost of the former.

Last part of my goal of care with prescribing, is basically I'm always prescribing to make a condition better in the face of poor patient lifestyle choices that directly counteract whatever I'm trying to do. For example, COPD and cigarette smokers. Yes, I don't want to "enable" poor choices. No, I don't choose not to prescribe in order to "teach" my patients a lesson. Despite what they are doing, after education and counseling, the choice is pretty simple (although judging it is hard), if overall risk/benefit the patient is better medically from me whipping out the pad, then I whip it out. That is precisely how you have to justify it on paper as well.

Understandably, based on what I've said, there are a lot of providers that decide, based on the negative potpurri principle, not to add to the mix. That isn't exactly wrong, but I would say there is a more nuanced approach.

OTOH, this idea that psychoactive substances are NBD, I vehemently disagree with. That is only true for some people. That is probably less true for people with mental illness who are receiving psychoactive compounds by prescription - clearly psychoactive compounds have a substantial effect on their mental well being, so why not ones that aren't prescribed? Because we have some idea they do very little? That's hardly a supportable conclusion based on evidence, and just a cultural concept. As a future psychiatrist, don't buy into it. This isn't about the war on drugs, being counterculture, reacting to the sometimes overly Puritan attitude in medicine, nor is it about embracing some sort of hippie free spirit attitude.
 
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The COPD meds in current smoker is not a comparable metaphor. Controlled substance should not be given to people who are currently using addictive potential substances. My ADD patients I let know, I will stop/hold stimulants until UDS clears. Have monthly follow up for 1-2 months before getting back out to 90 day follow ups.

The solution for benzos is just don't use benzos.
 
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The COPD meds in current smoker is not a comparable metaphor. Controlled substance should not be given to people who are currently using addictive potential substances. My ADD patients I let know, I will stop/hold stimulants until UDS clears. Have monthly follow up for 1-2 months before getting back out to 90 day follow ups.

The solution for benzos is just don't use benzos.
The point is that, say you have a depressed patient. They drink moderate amounts of alcohol, say a 1 drink 3 times a week. Do you think it's best for their depression to consider a trial of no alcohol at all, for mood improvement? (Evidence says if nothing else, the effect on sleep would warrant trying no alcohol whatsoever, and sleep is an important aspect of managing mood). I'm assuming we agree, zero booze would be best, at least as a trial, especially if we're not getting as much improvement as we would like from other strategies. Do you withhold an SSRI in this case? Presumably, we agree that there is likely some interaction between the patient's mood, alcohol, and SSRI.

It may not seen as direct or dangerous an interaction as it might seem with a THC + benzo/stim. Although I would argue that inadequately managed depression and even moderate alcohol use is medically a fairly dangerous combination. I argue a main difference here, is that the alcohol doesn't have the same negative stigma to its usage, and the SSRI is not being held to be as dangerous a substance as say the benzo/stim. I argue that the reasons behind these assumptions have more to do with taboos in medicine than what is most rational. At least in the initiation phase of an SSRI, adding in alcohol in a depressed person could easily be as dangerous, maybe even moreso, than the THC + benzo/stim in someone with ADHD/anxiety minus depression. I mean, alcohol and benzos have the risk of aspiration and addiction, driving, etc. THC and benzos can be downers. But I don't believe, outside of comorbid depression, that ADHD/anxiety have the same mortality risk as depression, and I don't know for any given patient how "protective" SSRIs are to the effects of even moderate alcohol use on that. Even taking the risks I've mentioned with the THC/benzo/stim into account.

There are a lot of psychiatrists that take these sorts of stances on these things, and imho it's not really culturally sensitive. These disease entities exist. Our culture alone, not to mention other mitigating factors, makes it unrealistic to expect all our psych patients to give up all recreational substances even if we all might agree that would be best. We can then decide that we will not treat depression, anxiety, or ADHD until our patients make better lifestyle choices. My example stands, because my point is that in the context of culture, harm reduction, I don't think it's reasonable to say that you're only going to treat completely sober patients with controlled substances. Or completely honest ones. I think it does more harm than good to take such a stance. It might make clinic easier, but I don't think it actually makes the greatest positive impact on a population of the mentally ill.

Nevermind the examples of patients who actually stop using recreational substances when they are prescribed controlled ones.

If I had a penny for every ADHD or bipolar patient self-medicating with alcohol and THC....

Fair enough, these patients, if they're lucky they are enough providers, will doctor shop until they find someone to treat their mental illness in the face of what is considered culturally appropriate substance use in many cases. Good luck turning your average patient into a monk. Especially the mentally ill. The average "healthy" mentally "well" person in this country is pretty far from sober, and the subpopulation of the mentally ill has a real uphill battle beyond just the general culture, when you start looking at family history, family dynamics, other factors.

When I have a heroin user come in with pain (like, actual pain, not just withdrawal/drug seeking) they get higher doses until their pain is controlled. I'm not in the camp of people that won't prescribe narcotics to medical marijuana users. Different mechanisms of action, different effects. Narcotics cause nausea, THC is great for nausea. I treat my patients' issues, no matter what drug I'm using, no matter what drug they're using. It's trickier, riskier, but doing nothing is not in my mind often the best option.

The point about COPD, is that even when patients are doing things that directly counteract your interventions, you still intervene.
 
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I agree with others questioning simultaneous prescription of stimulants and benzos. I suppose it is possible that for some patients this could be justified but almost every time I have seen this it has simply been some pretty sloppy prescribing.

With regard to the question of whether I would stop prescribing a helpful controlled substance for someone using marijuana: No I wouldn't.

My personal opinion is that it's not helpful for me to be moralistic about marijuana use. I certainly tell my patients not to use it—especially those with psychotic or affective illnesses, but they have the right to ignore my advice on that. I don't consider it appropriate to manipulate my patients into not smoking weed by threatening to withhold medications that are helping them.
 
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I agree with others questioning simultaneous prescription of stimulants and benzos. I suppose it is possible that for some patients this could be justified but almost every time I have seen this it has simply been some pretty sloppy prescribing.

With regard to the question of whether I would stop prescribing a helpful controlled substance for someone using marijuana: No I wouldn't.

My personal opinion is that it's not helpful for me to be moralistic about marijuana use. I certainly tell my patients not to use it—especially those with psychotic or affective illnesses, but they have the right to ignore my advice on that. I don't consider it appropriate to manipulate my patients into not smoking weed by threatening to withhold medications that are helping them.

Agree but with caveats. First is that we don't really know if these were benefiting the above patient. All OP said was they'd been on benzos and stimulants for years. Also, a lot of the psych patients I've seen that regularly use pot do so because they say it helps with their depression or anxiety. So if they're self-medicating my first question is what is the problem with the prescribed meds? Are they not working? Is the patient non-compliant? Do they feel they just get extra benefit from the pot?

Second point is with the trust in the relationship. If I know my patient is lying to me about their substance use (saying they aren't using/haven't used but have positive UDS, sitting in front of me obviously impaired, recent admissions for substance detox, etc) how can I trust them with their controlled substances (or even any meds at all)? How do I know they're not abusing their stimulants or benzos? Obviously clinical judgment has to be used, but the dishonestly adds another layer to the relationship that is not conducive to me wanting to give them any medications with potential for abuse/diversion.

Am I going to stop prescribing for everyone who comes in and says they use marijuana? No, and I'd probably keep them on those meds most of the time. However, if I feel like the med isn't benefiting them or I feel like I can't trust them then I'm not going to keep giving them a potentially dangerous medication, especially if it's a controlled substance.
 
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Many people are on stimulant since childhood or so. Later in their life when they have anxiety and panic attacks, they are not going to agree if you tell them that it's due to stimulant and let's just take that away and anxiety will go away

Check and got it. If someone was put on speed as a kid, they should be allowed to continue on it as on adult upon request, no questions asked. On the other hand, I would bet that any patient who complains of anxiety while taking a dopamine agonist would most likely get relief from not agonizing dopamine rather than indirectly potentiating GABA. At least that is my opinion and I'm sticking to it.
 
I'll just go ahead and leave these here......

Lembke, A. (2012). "Time to abandon the self-medication hypothesis in patients with psychiatric disorders." Am J Drug Alcohol Abuse 38(6): 524-529.

Wilkinson, S. T., et al. (2015). "Marijuana use is associated with worse outcomes in symptom severity and violent behavior in patients with posttraumatic stress disorder." J Clin Psychiatry 76(9): 1174-1180.

Mammen, G., et al. (2018). "Association of Cannabis With Long-Term Clinical Symptoms in Anxiety and Mood Disorders: A Systematic Review of Prospective Studies." J Clin Psychiatry 79(4).
 
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Agree but with caveats. First is that we don't really know if these were benefiting the above patient. All OP said was they'd been on benzos and stimulants for years. Also, a lot of the psych patients I've seen that regularly use pot do so because they say it helps with their depression or anxiety. So if they're self-medicating my first question is what is the problem with the prescribed meds? Are they not working? Is the patient non-compliant? Do they feel they just get extra benefit from the pot?

Second point is with the trust in the relationship. If I know my patient is lying to me about their substance use (saying they aren't using/haven't used but have positive UDS, sitting in front of me obviously impaired, recent admissions for substance detox, etc) how can I trust them with their controlled substances (or even any meds at all)? How do I know they're not abusing their stimulants or benzos? Obviously clinical judgment has to be used, but the dishonestly adds another layer to the relationship that is not conducive to me wanting to give them any medications with potential for abuse/diversion.

Am I going to stop prescribing for everyone who comes in and says they use marijuana? No, and I'd probably keep them on those meds most of the time. However, if I feel like the med isn't benefiting them or I feel like I can't trust them then I'm not going to keep giving them a potentially dangerous medication, especially if it's a controlled substance.
If the medication wasn’t helping them, then you should probably be stopping it either way. The fact that they’re using marijuana in that case is irrelevant.

With regard to trust, sure I guess. I tend to think that people have all sorts of reasons to lie and that it’s sort of pointless for me to speculate. That said, we all have different levels of comfort with this kind of thing and I won’t argue with people about it.
 
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A positive UDS doesn’t tell you anything—doesn’t indicate frequency or severity, doesn’t indicate if it’s recreational, for therapeutic purposes, or indicates problematic use.

UDS's can have error rates in the around 10% area. When you've been practicing for years, yes you will get patients who don't abuse who sometimes, e.g. like once a year, will have a false positive.

If possible, you need to see the patient as a whole thing. What do I mean by that? If, for example, a Buprenorphine patient is sober for 14 months and relapses, is kicking them out the only option? No. In fact many addicts that successfully become permanently clean will often times fail a few times before the sobriety is permanent. You could have the guy do more visits, more UDSs, up the level of care.

If the UDS is (+) for cannabis, it should beg some questions. Why use it? Is the patient self-medicating something? If so figure out what it is then treat it. Kicking out patients for things like this is more like baseball. Some infarctions are more like strikes vs a quick out. Also some patients need to go into phases when stopping substances.

But don't use any of the above to enable or rationalize patients where appropriate boundaries need to be enforced. You will have to have absolutes where you kick out patients even for the first infarction.
 
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If you ask someone if they're using marijuana and they deny it and then do a drug test that shows them positive for marijuana, I don't really entirely see it as a lie.

If they take the test, they know there is going to be an incongruence between what they said and what shows up. And yet they do it anyway. That seems fairly transparent. Also the fact that you're testing for it means the first question wasn't really meant to be taken too seriously anyway.

I think denying marijuana use can be a polite fiction (famously Bill Clinton not inhaling). We've talked about the suicide question on this forum before, and I expressed that I thought that doctors motivate patients to downplay suicidality. I think the same could be true with marijuana. I'm not in the field of linguistics, but I would imagine there's even a phenomenon of disclosing increasingly precise information with the number or intensity of the questions. Such as, "You don't smoke marijuana, right?" "Nahh...." "So no marijuana?" "No, not really." "But maybe sometimes?" "I mean you know sometimes." I think it's a dance people do not out of malice but out of our nature.

Edit: And in that moment, what do you think a patient thinks you want them to say? And for what purpose? Is it like (what I think are perfunctory) suicidality questions to cross off a legal box? Will you deny treatment?
 
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When you are in a position of power (doctor-patient, parent-child, etc.) you can only be upset about someone lying to you when you as the person who holds the power sets up the conditions that encourage truth telling. If you give your patients a hard time, make them feel guilty or shameful or judged about using substances, they're understandably not going to want to reveal this info. So much of what I am hearing here sounds very close to people using "lying" and "illegality" as a justification for punishing behavior they disagree with. The only consideration should be: is the treatment I am prescribing more dangerous given a person's substance use and is that risk acceptable? (And I suppose if there are any red line legal requirements regarding particular treatments and drug use you should comply with those even if they are not best practice).
 
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I'll just go ahead and leave these here......

Lembke, A. (2012). "Time to abandon the self-medication hypothesis in patients with psychiatric disorders." Am J Drug Alcohol Abuse 38(6): 524-529.

Wilkinson, S. T., et al. (2015). "Marijuana use is associated with worse outcomes in symptom severity and violent behavior in patients with posttraumatic stress disorder." J Clin Psychiatry 76(9): 1174-1180.

Mammen, G., et al. (2018). "Association of Cannabis With Long-Term Clinical Symptoms in Anxiety and Mood Disorders: A Systematic Review of Prospective Studies." J Clin Psychiatry 79(4).
No one is denying that marijuana has pronounced negative effects on mood in many, if not most, people with habitual use.

I didn't even check out the first paper, just going off the title, yes people do drugs in an attempt to "feel good." That's why they're drugs.
 
I think people are getting very focused on the legality of drug use when the focus should stay on clinical importance. On the topic of legality, I have never heard of someone losing their license because they prescribed a controlled substance to someone who occasionally recreationally used marijuana. On what basis would your license be revoked? It seems unlikely.

More importantly to me though are two issues: honesty and ways of coping.

In terms of honesty, if a patient is adamantly denying use but getting apparent true positive drug screens then the veracity of their reporting is obviously called into question. In that case, I have to weigh the patient's dishonesty in any decision I make. They may claim they take the benzo as prescribed, never with alcohol, never with sedating recreational drugs, never driving under the influence, etc. but can I truly trust that? If the answer is no, then I have to ask whether I want to provide something that could be associated with a bad outcome (over sedation / overdose, crash caused by impaired driving, erratic behavior related to drug abuse, etc.). If they are honest with me about other use, that changes things and I might feel more comfortable prescribing.

In terms of clinical efficacy, if the patient demonstrates a pattern of using substances for escape from negative states (anxiety, low mood, etc.) then providing another substance that can be used as an escape is questionable (though to be fair, it is questionable even if this is not a pervasive pattern). Abuse of one drug (if that is occurring) also brings us back to increased likelihood of abuse of the prescribed one as well.
 
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My personal opinion is that it's not helpful for me to be moralistic about marijuana use. I certainly tell my patients not to use it—especially those with psychotic or affective illnesses, but they have the right to ignore my advice on that. I don't consider it appropriate to manipulate my patients into not smoking weed by threatening to withhold medications that are helping them.
^^^
This. I wish I had the talent of other people to say what I wanted to say, but didn't manage in 5 paragraphs, with a few sentences. I don't do it on purpose.
 
No one is denying that marijuana has pronounced negative effects on mood in many, if not most, people with habitual use.

I didn't even check out the first paper, just going off the title, yes people do drugs in an attempt to "feel good." That's why they're drugs.

I absolutely agree.

But that’s not the self medication hypothesis which is a very specific thing. Which was disproven. And then one of the authors changed the hypothesis. And then it was disproven again. And then one of the creators went to prison for child porn.

There’s a problem when the prevailing idea for substance abuse in the USA isn’t scientific. Which is why the other countries use different models.
 
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A doctor giving out controlled substances to a person that repeatedly uses illegal substances documented via UDS calls into question the credibility of such doctor. Have fun in court when the lawyer puts you up there and points out you are so negligent and give so little ****s about this patient that you continually give out potentially dangerous drugs ( benzos, stimulants, etc) to someone already “addicted” to an illegal drug. You’re gonna look very bad, but that’s the beauty of medicine everyone can do as they feel comfortable.
 
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A doctor giving out controlled substances to a person that repeatedly uses illegal substances documented via UDS calls into question the credibility of such doctor. Have fun in court when the lawyer puts you up there and points out you are so negligent and give so little ****s about this patient that you continually give out potentially dangerous drugs ( benzos, stimulants, etc) to someone already “addicted” to an illegal drug. You’re gonna look very bad, but that’s the beauty of medicine everyone can do as they feel comfortable.

You dramatically overestimate the legal risks here, at least wrt marijuana. Our early psychosis service would have have to close down completely if they started terminating people who use cannabis but that doesn't mean none of them get benzos in an appropriate fashion.

You need to be writing high volumes of controlled scripts for the DEA to care. Do read accounts of board or federal enforcement actions to get a better sense of the circumstances under which action is taken.

Someone getting 1 mg Klonopin daily who smokes weed a few times a day ain't it.
 
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I absolutely agree.

But that’s not the self medication hypothesis which is a very specific thing. Which was disproven. And then one of the authors changed the hypothesis. And then it was disproven again. And then one of the creators went to prison for child porn.

There’s a problem when the prevailing idea for substance abuse in the USA isn’t scientific. Which is why the other countries use different models.

What @Crayola227 is saying, though, is what most people I have ever worked with have meant be self medicating, not the specific hypothesis discussed in the papers you provided.

I agree the terminological overlap is not helping. Would "maladaptive coping strategy" go down easier?
 
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When you are in a position of power (doctor-patient, parent-child, etc.) you can only be upset about someone lying to you when you as the person who holds the power sets up the conditions that encourage truth telling. If you give your patients a hard time, make them feel guilty or shameful or judged about using substances, they're understandably not going to want to reveal this info.

I am trasparent about my substance abuse, but anyway I use to lie to specific questions because of this, I feel judged
 
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What @Crayola227 is saying, though, is what most people I have ever worked with have meant be self medicating, not the specific hypothesis discussed in the papers you provided.

I agree the terminological overlap is not helping. Would "maladaptive coping strategy" go down easier?

Absolutely. I get that people are not technical with their terms. And that I am, by merit of personality and work in forensics.

I do believe that the data seems to indicate that substance abuse is largely a trait vulnerability. Which is something that can be treated. I would assume we've all seen it in our personal and professional lives, with people who cannot handle having one drink or cigarette, or whatever.

The reason I bring this up is that the entire idea of "let's find out the hidden reasons someone abuses substances, and treat that." would miss the problem, if it's a trait vulnerability. The obvious exmaple is nicotine. Mental health, in general, doesn't try to treat nicotine addiction by finding what the hidden affective ailment is. It uses behavioral techniques, chantix, buproprion, nicotine replacement, etc.
 
This is probably going to look ignorant or offensive, but I happen to read Ann Coulter. And I think I've mentioned here before I'm progressive leaning. I feel I shouldn't have to disclaim that. I know she's a provocateur, but I like to dabble in a bit of everything. She just happened to write a book review recently of a book on the dangers of marijuana in developing mental illness. I am sure there is a better review that people would take more seriously of it elsewhere, but this is the one I happened to read. If it's true (the risk of increased psychosis), it's one I did not know about. And interestingly, I went through drug education (the DARE program) in school. They talked about lack of motivation, falling in with the wrong crowd, using harder drugs, etc. But I don't recall anything about increased risk of psychosis:


Of course, if all that information is true, it doesn't really have any bearing on whether you should stop prescribing to someone for marijuana use. Maybe the drugs you're prescribing are neuroprotective. I don't know. But good information is the best in my opinion. Sometimes facts can be very inconvenient but they are obstinate. And so if these facts are true, I don't think it would change whether or not you drop a client but instead the case you make for why a substance might be problematic. In this case, however, I have no idea if the assertions are true. They did perk my ears.
 
This is probably going to look ignorant or offensive, but I happen to read Ann Coulter. And I think I've mentioned here before I'm progressive leaning. I feel I shouldn't have to disclaim that. I know she's a provocateur, but I like to dabble in a bit of everything. She just happened to write a book review recently of a book on the dangers of marijuana in developing mental illness. I am sure there is a better review that people would take more seriously of it elsewhere, but this is the one I happened to read. If it's true (the risk of increased psychosis), it's one I did not know about. And interestingly, I went through drug education (the DARE program) in school. They talked about lack of motivation, falling in with the wrong crowd, using harder drugs, etc. But I don't recall anything about increased risk of psychosis:


Of course, if all that information is true, it doesn't really have any bearing on whether you should stop prescribing to someone for marijuana use. Maybe the drugs you're prescribing are neuroprotective. I don't know. But good information is the best in my opinion. Sometimes facts can be very inconvenient but they are obstinate. And so if these facts are true, I don't think it would change whether or not you drop a client but instead the case you make for why a substance might be problematic. In this case, however, I have no idea if the assertions are true. They did perk my ears.

Yes the psychosis risk appears real, and although it's been very difficult to tease conferred risk out from confounding, there have now been several prospective studies that took baseline risk into account and continue to find that MJ exposure is associated with increase in risk for later onset of psychosis.

I don't believe this was known in the 1980s when the DARE campaign was launched. Meanwhile the 'gateway drug' theory has been largely debunked.
 
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If the medication wasn’t helping them, then you should probably be stopping it either way. The fact that they’re using marijuana in that case is irrelevant.

With regard to trust, sure I guess. I tend to think that people have all sorts of reasons to lie and that it’s sort of pointless for me to speculate. That said, we all have different levels of comfort with this kind of thing and I won’t argue with people about it.

Except the substance use is relevant if it's causing dysphoria and interfering with the prescribed medication's effectiveness. These are not always independent of one another and it is certainly. If the medication is ineffective independent of pot use, then it obviously shouldn't be used anyway, but that's not really the point of this thread.

To the second bolded: it's not really pointless at all, and I'd argue that it should be something you follow up on. Are they lying to score more and divert? Are they lying because of general underlying trust issues which they should be seeking therapy for? Are they lying because they have a personality disorder that hasn't been addressed/documented? Are they lying because they have a true use disorder and would benefit from treatment? Obviously you can't force them to tell the truth, but I think ignoring it or failing to dig a little deeper is doing the patient a disservice.

The only consideration should be: is the treatment I am prescribing more dangerous given a person's substance use and is that risk acceptable?

Not really. You also have to ask if the use of these substances is having any effects on the efficacy of what you're prescribing. Bartleby hit on this nicely in regards to the honesty and trust point as well. If they're lying about substance use, then how can I know they're going to be honest about their compliance with what I prescribe? It's something you have to keep in mind when developing/adjusting their treatment plan.

Someone getting 1 mg Klonopin daily who smokes weed a few times a day ain't it.

Not your point, but if someone is smoking weed a few times per day I'm going to be looking into/questioning why they're also getting Klonopin as that's not a normal or healthy pattern of use. Do they have a use disorder? If so I'd have to ask if I want to be prescribing them an addictive substance. Are they smoking that much because they're coping/'self-medicating'? If so, then I'm again asking if the Klonopin is appropriate.

Absolutely. I get that people are not technical with their terms. And that I am, by merit of personality and work in forensics.

I do believe that the data seems to indicate that substance abuse is largely a trait vulnerability. Which is something that can be treated. I would assume we've all seen it in our personal and professional lives, with people who cannot handle having one drink or cigarette, or whatever.

The reason I bring this up is that the entire idea of "let's find out the hidden reasons someone abuses substances, and treat that." would miss the problem, if it's a trait vulnerability. The obvious exmaple is nicotine. Mental health, in general, doesn't try to treat nicotine addiction by finding what the hidden affective ailment is. It uses behavioral techniques, chantix, buproprion, nicotine replacement, etc.

I think this is more variable than you're implying. Yes, there are going to be those who largely have a pre-disposition to substance abuse which we treat directly. However, there are also people who use those substances as a means of coping with trauma or psychosocial stressors and whose best treatment courses are to address those factors. I think the best way to address this (at least initially) is with a strong social history which is unfortunately a highly variable practice from what I've seen thus far.
 
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Yeah, birchswing made a good point, that for many people, it's practically a cultural expectation for them to lie to their doctors, particularly about "certain" things and particularly if they think those things "won't matter that much." I'm more than happy to do an informal poll of people I know, but I'm guessing occasional (as in, not daily) MJ use fits most into many peoples' idea of "doesn't matter much" and so one might "safely" lie to their doctor about it, at least from their perspective of how "unsafe" it is to lie about it.

I very rarely talk to anyone who is aware that marijuana can even cause or worsen mental illness, period. Everyone is under the impression that it has like zero interactions with anything, it's safe to mix with any Rx's, etc etc etc etc etc. So many etc because as far as most people are concerned, it's safer than rolling in the grass, medically speaking (people have grass allergies, you know). For anyone that I talk to, they only seem marginally aware of the issue with sedation, and even fewer understand one huge risk of sedation isn't just not driving when you don't feel like it (duh) but aspiration.

In any case, I frequently find that patients confide in me things they haven't confided elsewhere. I'm sure despite all my assurances, plenty are still lying to me. I find they lie less when you at least give them the impression of what sloop said - that truthful revelations of their recreational substance use isn't likely to lead to a major change in current medications that are helping them. Or other "negative" consequences in their views. Of course, that only works if you aren't in the category of prescribers that only prescribe to monk-like patients. And as one poster mentioned, patients are only going to tell you the truth if they think the truth - by their estimation - isn't going to hurt them. This is where some degree of reassurance from the provider can help, but only to a degree. Obviously you can only make so many assurances, as well (safety).

Some lies make "rational" sense to us - you lie to your doctor about smoking an ounce of MJ daily. Other lies, like the fact they have one single drink with dinner daily, after saying that might be appropriate for them specifically, possibly less so. Lying to your doctor is about more than "consequences" or assurances your doctor might offer.

In any case, lying to your doctor is extremely complex. I don't have to do an informal poll to establish what the evidence does, which is that it's exceedingly common. This might be why some of us don't get bent about patients lying, per se.

Devil's in the details.

I'd be more disappointed in this patient if I assured them that I wasn't going to change their current regimen unless the amount of recreational substances they were using was truly unsafe for what they were on, that the most important thing I ever see with a UDS isn't that it's clean, but that it reflects whatever they told me it would be, and they lied to me anyway.

My focus is on them being truthful, and us problem-solving all aspects of care for maximizing their mental wellness. They all interact but are discrete, as well. Ideally I'd like to get most people onto an aggressive therapy/medication/sobriety/sleep hygeine/exercise/stretching/PT/weight lifting/diet regimen, but I'm aware of any list of factors to optimize I may only get a handful. So this is why I like to discuss how much they are drinking/smoking/etc - not so I can judge, tell them to quit all their vices, or that I won't prescribe the "happy" pills to them. This is how I can get the full story from people.

I'm a patient too, and I've endeavoured to be honest with my doctors. That was hard when I was smoking cigarettes (legal) and I knew that getting into the details of just *how* much I was smoking was extremely unlikely to impact management. Same feelings when it came to caffeine (legal). Alcohol, too (legal). I can tell you right now, there are several physicians on SDN that could never be my physician. Not for anything illegal I'm doing, or any UDS that wouldn't come back 100% clean and truthful. Not even because telling them the truth would mean that they would impact my care in ways that would matter to anyone, myself or them. I just would find it too uncomfortable as far as feeling judged. And when you reflect on just how open I consider myself to be, I think that says a lot. Most people aren't anywhere near where I am with that. I think that means we should reconsider just how hard it can be for someone to tell their doctor the truth, even about things we think aren't a big deal for patients to be honest to us about.
 
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A doctor giving out controlled substances to a person that repeatedly uses illegal substances documented via UDS calls into question the credibility of such doctor. Have fun in court when the lawyer puts you up there and points out you are so negligent and give so little ****s about this patient that you continually give out potentially dangerous drugs ( benzos, stimulants, etc) to someone already “addicted” to an illegal drug. You’re gonna look very bad, but that’s the beauty of medicine everyone can do as they feel comfortable.
257009
 
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No one is denying that marijuana has pronounced negative effects on mood in many, if not most, people with habitual use.
Most people who also show up at the psychiatrist you mean? Aka not most people who habitually smoke marijuana?
 
I think this is more variable than you're implying. Yes, there are going to be those who largely have a pre-disposition to substance abuse which we treat directly. However, there are also people who use those substances as a means of coping with trauma or psychosocial stressors and whose best treatment courses are to address those factors. I think the best way to address this (at least initially) is with a strong social history which is unfortunately a highly variable practice from what I've seen thus far.

While a common clinical theory, the data does not support this idea.

What is supported is that there are people who are trait vulnerable to substance abuse, with some variations in substances. In those specific individuals who are already abusing substances, state anxiety can increase some forms of substance abuse. Which in most substances increase anxiety in the long run. This is very different that the anxiety causing substance abuse, which had never existed prior. The data does not support that treatment of the psychiatric disorder alone results in significant changes in substances abuse.

This may sound very technical, but there are significant treatment and social implications.
 
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While a common clinical theory, the data does not support this idea.

What is supported is that there are people who are trait vulnerable to substance abuse, with some variations in substances. In those specific individuals who are already abusing substances, state anxiety can increase some forms of substance abuse. Which in most substances increase anxiety in the long run. This is very different that the anxiety causing substance abuse, which had never existed prior. The data does not support that treatment of the psychiatric disorder alone results in significant changes in substances abuse.

This may sound very technical, but there are significant treatment and social implications.

If you're telling me that all people with substance abuse problems associated with mood disorders have trait variability and that treating the underlying mood disorder can never lead to resolution of the substance abuse (which sounds like what you're implying), then I'll say your theory is either missing something or there's not enough data. As I don't believe for a second that every single individual with substance abuse issues related with mood disorders are due to trait variability.
 
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Except the substance use is relevant if it's causing dysphoria and interfering with the prescribed medication's effectiveness. These are not always independent of one another and it is certainly. If the medication is ineffective independent of pot use, then it obviously shouldn't be used anyway, but that's not really the point of this thread.

You’re the one bringing up things that were not specifically part of the topic of this conversation. I was never talking about people in whom the medication wasn’t working because of the substance use. Additionally, the case that a medication that has never worked for someone is only not working because of the substance use is usually an entirely speculative one. In my experience, this is usually an argument made for affective illness (i.e. the antidepressant never had a chance because they’re continuing to abuse crack). If one is being really honest about such cases, though, they would admit that they don’t really know this and actually have no idea. With limited exception, our mood drugs are not so predictable in generating response that someone can make this case with any degree of actual certainty.

You’re right that in such cases where the medication is not working and the person is using drugs, the medication should be stopped. But I don’t think the drugs are really relevant in that decision. The medication should be stopped either way because it was never noted to be effective. The substance use might be relevant later if you’re considering a repeat trial when the person stops using drugs but that’s not actually the decision we were talking about.

If you’re talking about a situation where a medication was initially effective but then lost its efficacy when someone started using drugs then an ultimatum might be appropriate. That said, this is a very specific circumstance and the appropriateness of the ultimatum has nothing to do with some stupid moralistic take on substance use and everything to do with the logical validity of the assertion that the person can either stop drugs and use the medication or continue using drugs and stop the medication because it makes no sense to continue to prescribe the medication in circumstances known to make the medication ineffective.

To the second bolded: it's not really pointless at all, and I'd argue that it should be something you follow up on. Are they lying to score more and divert? Are they lying because of general underlying trust issues which they should be seeking therapy for? Are they lying because they have a personality disorder that hasn't been addressed/documented? Are they lying because they have a true use disorder and would benefit from treatment? Obviously you can't force them to tell the truth, but I think ignoring it or failing to dig a little deeper is doing the patient a disservice.
When it becomes apparent that my patients are lying to me, I confront them about it and ask why. On the other hand, how can I expect patients to trust me if I’m just going to assume things about their motives?
 
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If you're telling me that all people with substance abuse problems associated with mood disorders have trait variability and that treating the underlying mood disorder can never lead to resolution of the substance abuse (which sounds like what you're implying), then I'll say your theory is either missing something or there's not enough data. As I don't believe for a second that every single individual with substance abuse issues related with mood disorders are due to trait variability.

It's not my theory, it's the current state of the literature.

And yours doesn't hold up. Unless you try to treat methamphetamine induced anxiety disorder by treating the anxiety alone.
 
You’re the one bringing up things that were not specifically part of the topic of this conversation. I was never talking about people in whom the medication wasn’t working because of the substance use. Additionally, the case that a medication that has never worked for someone is only not working because of the substance use is usually an entirely speculative one. In my experience, this is usually an argument made for affective illness (i.e. the antidepressant never had a chance because they’re continuing to abuse crack). If one is being really honest about such cases, though, they would admit that they don’t really know this and actually have no idea. With limited exception, our mood drugs are not so predictable in generating response that someone can make this case with any degree of actual certainty.

You’re right that in such cases where the medication is not working and the person is using drugs, the medication should be stopped. But I don’t think the drugs are really relevant in that decision. The medication should be stopped either way because it was never noted to be effective. The substance use might be relevant later if you’re considering a repeat trial when the person stops using drugs but that’s not actually the decision we were talking about.

If you’re talking about a situation where a medication was initially effective but then lost its efficacy when someone started using drugs then an ultimatum might be appropriate. That said, this is a very specific circumstance and the appropriateness of the ultimatum has nothing to do with some stupid moralistic take on substance use and everything to do with the logical validity of the assertion that the person can either stop drugs and use the medication or continue using drugs and stop the medication because it makes no sense to continue to prescribe the medication in circumstances known to make the medication ineffective.

I don't really disagree with any of this except the bolded. OP's post was basically just "my patient tested positive on a UDS after appearing guarded, would you continue meds", specifically benzos and stimulants. So it's a pretty broad topic and there are plenty of angles to look at it from.

It's not my theory, it's the current state of the literature.

And yours doesn't hold up. Unless you try to treat methamphetamine induced anxiety disorder by treating the anxiety alone.

Then I'd like to see the literature, because I've worked with several psychiatrists who specialized in addiction psychiatry who focus on psychosocial and not medication aspects in some patients who are high anxiety/depression for periods who also abuse alcohol. So again, if you're going to argue that every single patient with a substance use disorder and a mood disorder have a trait variation then I disagree and will say "prove it", as my experiences directly contradict that statement.
 
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You dramatically overestimate the legal risks here, at least wrt marijuana. Our early psychosis service would have have to close down that doesn't mean none of them get benzos in an appropriate fashion.

You need to be writing high volumes of controlled scripts for the DEA to care. Do read accounts of board or federal enforcement actions to get a better sense of the circumstances under which action is taken.

Someone getting 1 mg Klonopin daily who smokes weed a few times a day ain't it.
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Why does anyone get prescribed benzos long term anymore anyway?

While a common clinical theory, the data does not support this idea.

What is supported is that there are people who are trait vulnerable to substance abuse, with some variations in substances. In those specific individuals who are already abusing substances, state anxiety can increase some forms of substance abuse. Which in most substances increase anxiety in the long run. This is very different that the anxiety causing substance abuse, which had never existed prior. The data does not support that treatment of the psychiatric disorder alone results in significant changes in substances abuse.

This may sound very technical, but there are significant treatment and social implications.
Ok, but first you have to try the weed/cocaine/cigarette/meth/heroin etc. (leaving out caffeine and etoh since they are generally accepted ). Don’t you think there is a reason certain people are even willing to try something they know is harmful? I do realize that substance abuse can be generational and use can be started at a very young age, but That’s not always the case
 
Why does anyone get prescribed benzos long term anymore anyway?
Some practicing psychiatrists are in their 80s.

I had one about 15 years ago who seemed barely able to function. I had heard he moved to another country, presumably to retire.

Another doctor told me he was back and not even intending to tell a joke but because I was so surprised I said, "From the dead?"

I looked him up on the licensing site and he had a patient die in 2013. It was difficult to suss out exactly how he was liable and maybe it wasn't in a proximate way, but at the very least he prescribed two 6-month prescriptions of Ambien to a young girl when her parents were not present in the office.

He had to do a couple of hours of continuing education and he's still practicing. I just checked right now, and he's still practicing and licensed just a city away from me.

All the info I gave him on benzodiazepines from the Ashton Manual, etc., he thought was bunk. He said there was no such thing as a maximum dose of Ativan if it hadn't reached the therapeutic effect.

You also have to remember that the emphasis on benzos changed recently as the opioid epidemic worsened. For one thing, people conflate them. For a second, they're in the systems of a lot of people who overdose on opioids, even though one of the selling points of benzodiazepines was it was more difficult to overdose on them than the previous generation of anxiolytics (which is true when they aren't taken with a drug that has a synergistic effect like an opioid). But they've been sitting as a Class IV scheduled drug forever with no particular special attention until they became implicated in the opioid overdose cases.

I remember the first time I saw him he said as I was leaving, "Do you need anything else?" And I didn't know what he meant. He meant scripts. Did I need any other scripts. As if I could have asked for anything.

The new kids coming out of medical school are completely different. I've been witness to the changes since 1998.

My guess is that a certain worldview of medicine becomes cemented in from the time you graduate medical school and finish your residency. I know they have continuing education courses that are now mandatory, but I think all those "Don't confuse your Google search with my medical degree" signs in doctors' offices sort of speak to the gravitas with which older doctors hold new information compared to their medical degree. The medical literature on the harms and dependence/tolerance to benzodiazepines is so old that it doesn't make sense to ask why in 2019. You could have asked that in 1998 when I started on them. You could have asked it in the 1970s when the literature was available. There could have just as easily been doctors in the 1970s doling out indefinite benzo "therapy" with signs reading "Don't confuse the New England Journal of Medicine with My Medical Degree."
 
for many people, it's practically a cultural expectation for them to lie to their doctors, particularly about "certain" things and particularly if they think those things "won't matter that much."

For sure there is a cultural expectation to be secretive.
Usually an addicted feel guilty because of his beaviour, I think this is the main reason because all of uf abuser use
to lie. Drug use is something that happen in the shadow , hidden from society, so it's hard to be open about.
 
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