Stimulants in marijuana users

[neopsych12]

How do you handle treatment of ADHD in cannabis users? Do you withhold stimulant treatment if a patient choses not to abstain from marijuana? I have had great difficulty in using motivational interviewing to facilitate cannabis cessation in most of my younger ADHD adults. I would like to hear about how other providers are handling this issue in their practices.

We don't deny appropriate medical treatment for cirrhosis in active drinkers or those with CHF who continue to eat at McDonalds daily.

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[Attending1985]

Yes I withhold. I am skeptical of treating “adult adhd” in the first place so it’s a good reason not to use stimulants.

 

[SilverHawk]

I also withhold. Proper medical treatment includes minimizing psycho-active substances or anything that could interfere with mental processes. If patients are able to "focus" enough to get cannabis, perhaps the emphasis should be that active substance usage can complicate ANY psychiatric illness

 

[Amygdarya]

Also, couldn't ADHD-like symptoms be caused by smoking MJ in the first place?

 

[AcronymAllergy]

Also, couldn't ADHD-like symptoms be caused by smoking MJ in the first place?

To an extent, sure. As we've all probably seen, most ADHD symptoms are pretty ridiculously non-specific, particularly in isolation. That's where a thorough interview and some collateral report can be helpful. Theoretically. Unless the MJ use started in elementary school. In which case I got nothing, and there are probably bigger issues at play.

Although I wonder if some folks would start a med trial with the goal that the stimulant might result in reduced MJ use...?

 

[SpinDktr]

Although I wonder if some folks would start a med trial with the goal that the stimulant might result in reduced MJ use...?

I would hope no practicing psychiatrists would have this view, but I'm sure there are some out there. I also never prescribe stimulants in the setting of active cannabis use.

 

[witzelsucht]

just to stir the pot a bit, do y'all withhold stims if someone is on nicotine? coffee fiend? drinks 2 beers per night? all of the above?

 

[futuredo32]

Do those of you who withhold live in a state where "medical marijuana" is legal?

 

[thoffen]

If a simulant is indicated for ADHD, I'm having a hard time figuring how marijuana figures into the equation unless they have a clear use disorder, but I wouldn't by any stretch consider that an absolute contraindication.

 

[VA Hopeful Dr]

If a simulant is indicated for ADHD, I'm having a hard time figuring how marijuana figures into the equation unless they have a clear use disorder, but I wouldn't by any stretch consider that an absolute contraindication.

Did the DEA reclassify marijuana out of being a schedule 1 substance and I not notice?

 

[thoffen]

Did the DEA reclassify marijuana out of being a schedule 1 substance and I not notice?

Do you withhold antidepressant treatment in a marijuana user? Do you withhold treatment for someone because they drive over the speed limit? Etc. My post is no advocacy for marijuana use. I'm merely saying that there would need to be a clinical reason where marijuana use affects someone's treatment response or risks of treatment for it to have bearing. Please at least pose a hypothesis to how that works. Then we can give it consideration.

 

[NickNaylor]

If someone has a clear, documented history of long-term stimulant treatment, I will typically continue a stimulant even if they are using cannabis occasionally. It takes more than cannabis to get me excited though I do obviously counsel them about the fact that smoking cannabis on the regular may be counterproductive.

I have never started a treatment-naive adult with "ADHD" on a stimulant and do not intend to do so. Often these patients say that have "ADD" and have chronically impaired concentration in the setting of depression, in which case bupropion moves up on the list of recommendations.

 

[VA Hopeful Dr]

Do you withhold antidepressant treatment in a marijuana user? Do you withhold treatment for someone because they drive over the speed limit? Etc. My post is no advocacy for marijuana use. I'm merely saying that there would need to be a clinical reason where marijuana use affects someone's treatment response or risks of treatment for it to have bearing. Please at least pose a hypothesis to how that works. Then we can give it consideration.

Is Lexapro a Scheduled drug?

I'm not commenting on whether or not stimulants work with a patient using marijuana at the same time. I'm commenting on how unimpressed the DEA will be if they find out you're giving a Schedule 2 drug to someone using a (Federally) illegal drug at the same time.

My argument is 100% legal, 0% medical.

 

[hamstergang]

I'm commenting on how unimpressed the DEA will be if they find out you're giving a Schedule 2 drug to someone using a (Federally) illegal drug at the same time.

My argument is 100% legal, 0% medical.

But what is the legal argument? Does the DEA actually care about this? I'm not worried about impressing them.

 

[Bartelby]

For a regular cannabis user I would avoid the combination. If someone occasionally uses I would consider a stimulant in the right context. I feel similarly about alcohol.

 

[Armadillos]

I would never start a stimulant for the first time in someone using MJ, but in someone with a childhood ADHD diagnosis and long term stimulant use I don’t really see a compelling reason to stop it bc they use MJ. ADHD has significant associated impairment and genuine risks such as traffic fatalities, so I wouldn’t want to intentionally leave it untreated.

 

[VA Hopeful Dr]

But what is the legal argument? Does the DEA actually care about this? I'm not worried about impressing them.

They do for opioids. As stimulants are also Schedule 2, I will not risk my DEA license or anything else on the off chance the DEA does care.

 

[Armadillos]

They do for opioids. As stimulants are also Schedule 2, I will not risk my DEA license or anything else on the off chance the DEA does care.

Is it illegal to prescribe a controlled substance to someone using a substance of abuse?

Is Lexapro a Scheduled drug?

I'm not commenting on whether or not stimulants work with a patient using marijuana at the same time. I'm commenting on how unimpressed the DEA will be if they find out you're giving a Schedule 2 drug to someone using a (Federally) illegal drug at the same time.

My argument is 100% legal, 0% medical.

This seems incredibly paranoid, you always bring up the DEA, have you actually seen MDs practicing in good faith have DEA issues?? The only doctors I hear about having issues with the DEA are straight up drug lords responsible for writing millions of dollars worth of opioid prescriptions. The DEA isn’t in the business of arresting people engaged in the honest practice of medicine.

 

[VA Hopeful Dr]

Is it illegal to prescribe a controlled substance to someone using a substance of abuse?



This seems incredibly paranoid, you always bring up the DEA, have you actually seen MDs practicing in good faith have DEA issues?? The only doctors I hear about having issues with the DEA are straight up drug lords responsible for writing millions of dollars worth of opioid prescriptions. The DEA isn’t in the business of arresting people engaged in the honest practice of medicine.

Yes, I have seen doctors that thought they were practicing in good faith get taken down by the DEA for not paying attention to the other substances their patients were on. This was 3 years ago in a doctor who worked one floor above me.

Am I being paranoid? Probably. But these days for us family doctors it is almost impossible to get a job with any restrictions on your DEA registration. So I will not take even the slightest risk of that because someone who wants to be treated for ADHD can't stop smoking marijuana.

 

[whopper]

From my own experience I only see the DEA or authorities really going after bad doctors in extreme cases. E.g. a guy who was literally the 2nd highest prescribing opioid provider in the country who gave barrels of pills to patients weekly and was of all things a pediatrician yet giving it out to adult patients. Another guy was giving out opioids that resulted in multiple deaths.

I mentioned this in other threads but a doctor around where I worked in Ohio lost his license but this was only after this guy sexually molested literally dozens of patients. Seriously the board didn't do anything until the complaints were in the dozens.

The only doctor I know of where someone in a position of authority got him taken out professionally over one case, it was an ER doctor who gave a patient a muscle paralyzer then raped the patient. It was all on video, and made the front-pages of the local news so a dashing prosecutor took the guy out. Later turned out that he had done the same thing to dozens of women but the authorities only knew of that one case. The other women who were assaulted didn't come out of the woodwork until that video was out cause they felt they couldn't prove their case so they never alerted the authorities.

I actually wish they went after more doctors cause so many out there are pill-pushers of Ambien, benzos, and opioids and have been for years and I see nothing being done against them. Heck Express Scripts tells docs to give out Ambien long-term even though it's against the FDA and manufacturer's recommendations and nothing's being done to them. I had a patient on Gabapentin for sleep and they told me to switch it to Ambien because it's on their "med preferred list" even for long-term use, and even went as far to tell me it's their #1 recommended medication.

 

[PikminOC]

Va hopeful is right on

 

[smalltownpsych]

Yes, I have seen doctors that thought they were practicing in good faith get taken down by the DEA for not paying attention to the other substances their patients were on. This was 3 years ago in a doctor who worked one floor above me.

Am I being paranoid? Probably. But these days for us family doctors it is almost impossible to get a job with any restrictions on your DEA registration. So I will not take even the slightest risk of that because someone who wants to be treated for ADHD can't stop smoking marijuana.

It's not paranoia when they really are out to get you. If someone doesn't think the DEA loves to get doctors in trouble and thinks that the government is a rational, fair, or compassionate system, then...
I would caution against the "we need to get rid of the bad doctors" slogan as it tends to justify treating all of us unfairly as we end up needing to prove that we are not "bad" .

 

[whopper]

Some marijuana users are using it to self-medicate ADHD.

Now completely avoiding stimulants in such a patient is avoiding treating their primary disorder (emphasis on "such a patient).

The problem becomes if you give a substance abuser a stimulant are you merely giving them a new substance abuse problem? What you could do is try Wellbutrin or Atomoxetine but these meds don't work as well. Another issue is some people really do need the stimulant.

Although I wonder if some folks would start a med trial with the goal that the stimulant might result in reduced MJ use...?

I've done that on few occasions. E.g. I had an alcoholic, (pretty severe too) and we tried him on Methylphenidate 5 mg, 1 pill, and his anxiety went significantly down. Also he drank to self-medicate anxiety, and that anxiety started as a small child.

But this is very risky with the obvious problems. Since he was homeless and because of the substance abuse I discharged him on Wellbutrin, and we only kept him for a few days cause more inpatient days wouldn't have really helped him more. The Wellbutrin certainly wasn't at a dosage or duration where it could take effect (and it might not even work) and I wasn't going to discharge him on stimulants.

I have noticed that ADHD patients with anxiety (from the ADHD, not a separate anxiety disorder) respond well sometimes to Guanfacine or Clonidine.

 

[Sushirolls]

Once the cannabis is stopped, will resume the stimulant.

 

[FoxMade]

I'm amazed at the lack of clinical reasoning stated by those saying they would not prescribe a stimulant to treat ADHD in an adult who uses cannibas. Legal arguments well noted, and up for debate.

Do any of you have an actual clinical or medical reason for MJ use being a reason you don't treat ADHD a stimulant?

 

[VA Hopeful Dr]

I'm amazed at the lack of clinical reasoning stated by those saying they would not prescribe a stimulant to treat ADHD in an adult who uses cannibas. Legal arguments well noted, and up for debate.

Do any of you have an actual clinical or medical reason for MJ use being a reason you don't treat ADHD a stimulant?

I also withhold. Proper medical treatment includes minimizing psycho-active substances or anything that could interfere with mental processes. If patients are able to "focus" enough to get cannabis, perhaps the emphasis should be that active substance usage can complicate ANY psychiatric illness

Also, couldn't ADHD-like symptoms be caused by smoking MJ in the first place?

 

[PikminOC]

All good points. And the legalities are important. NO patient is worth my license. NONE.

 

[shahseh22]

I'm pretty sure that a good chunk of my ADHD kids over the age of 12 have used some cannabis at some point or another, though not everyone is a daily user. I still prescribe it to help their symptoms.