Struggling with stimulants and cannabis

[Attending1985]

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Anyone struggling with decisions regarding cannabis and stimulant co-prescribing? With cannabis being legal most everywhere and the ease of getting a medical card it’s becoming more and more of issue. What I see really commonly are people coming in with testing from a psychologist who has not questioned them at all regarding cannabis use saying they have adhd. I’m also inheriting a bunch of patients from an np who left who didn’t screen for cannabis use and liberally diagnosed and treated adhd which is a real headache.
Seems like others are all over the board with this from I have no issue to absolutely no cannabis and stimulants together.
I think uniform policy would be most fair to patients. I think Kaiser does this. My employer leaves it up to our discretion. I’m leaning towards a black and white policy because it doesn’t feel right to allow some to use while saying no to others based on their reports since our uds doesn’t quantify.

 

[Taddy Mason]

I’ve always said no to stimulants in people using cannabis unless I was strong armed by an attending in residency and fellowship. It’s one of the few instances I’ll use random Utoxes for periodic monitoring when prescribing stimulants.

 

[hamstergang]

I think uniform policy would be most fair to patients. I think Kaiser does this. My employer leaves it up to our discretion. I’m leaning towards a black and white policy because it doesn’t feel right to allow some to use while saying no to others based on their reports since our uds doesn’t quantify.

What is your reasoning for not prescribing stimulants to patients who use any marijuana?

 

[comp1]

Because how can you know whether their focus issues are solely THC induced or their symptoms are subthreshold unless worsened by THC? Here is Kaiser's policy: https://mydoctor.kaiserpermanente.org/ncal/Images/OAK ADHD CLINIC CANNABIS POLICY_tcm75-1588781.pdf

I'm not sure it's good clinic policy to allow individual clinician decision making on controlled substances within a clinic. It could rapidly lead to doctor shopping which is harmful to everyone. If something needs to vary from a clinic policy for a given patient, it probably should be discussed at a clinic meeting.

 

[Stagg737]

What is your reasoning for not prescribing stimulants to patients who use any marijuana?

How do you know a patient is being honest about how much they use? If they say "socially every couple of weeks" or something like that, how do you know it's not more frequently? Are you suggesting quantitative testing on a semi-regular basis? It's not like we can follow them around and monitor their use. Also, if it's with any regular frequency, even a couple times per week, that can certainly lead to symptoms that many people are now diagnosing as "ADHD". How do you know you're not just giving stimulants to counteract an effect of the cannabis like some docs do for benzos ("I need benzos for my anxiety but they make me tired, so my doc started me on stimulants so I can function during the day")?

Not saying the solution is to completely avoid stimulants if there's *any* mj use. I'm sure there's plenty of people with many psych disorders who use it casually where it doesn't cause or significantly contribute to their problems. Just playing devil's advocate regarding the lack of objectivity and hard evidence for both diagnoses and symptoms in our field and our inability to identify who mj may be a problem for in a concrete or consistent manor.

 

[mistafab]

I think a fair point to bring up is cannabis use vs cannabis use disorder.

May be helpful to frame your thinking around that.

 

[Sushirolls]

No cannabis / stimulants together.
Hard policy for me from day one.
Any controlled substance I might prescribe gets UDS testing at minimum Q3 months.
Pop positive on cannabis with stimulant? No refill until clear.
Psychologist did testing? Higher rate of garbage report, compared to Neuropsychologists who know what they are doing and explore/report with quality. I've yet to see a neuropsychologist drop the ball there, compared to psychologists who decided to start testing...

I've run into this issue and told patients their psycholigst report is not valid in my eyes, and cannabis must stop. Will review symptoms again at that point, and if mixed clinical history will refer to board certified neuropsychologist.

As you can imagine, my google reviews online are lit up with patients upset about cannabis / stimulants.

 

[Attending1985]

I wish we would adopt a clinic policy with nursing administering the UDS at intervals and clear guidelines for people but people have voted against. Seems a lot of people really don’t care if people use thc and stimulants together at all.

 

[Attending1985]

I think a fair point to bring up is cannabis use vs cannabis use disorder.

May be helpful to frame your thinking around that.

I find that people using cannabis heavily will deny any of the criteria and in general have a lot of resistance to considering any negative psychiatric effects. They will tell me how wonderful it is but at the same time they’re doing poorly.

 

[Stagg737]

I find that people using cannabis heavily will deny any of the criteria and in general have a lot of resistance to considering any negative psychiatric effects. They will tell me how wonderful it is but at the same time they’re doing poorly.

"The marijuana is great, it's the only thing that helps the anxiety and ADHD because you won't give me the meds I need."

 

[FatherPsychiatry]

I wish we would adopt a clinic policy with nursing administering the UDS at intervals and clear guidelines for people but people have voted against. Seems a lot of people really don’t care if people use thc and stimulants together at all.

So long as the money keeps flowing in. Good to "check in" with the Adderall patients q30d right?

 

[clozareal]

It's not just that the marijuana is causing issues with concentration, it's that even if you use ADHD medications to treat their focus, their treatment response and side effect profile is often worse in my experience. Same with treating anxiety/depression/insomnia with medications in those who are also on cannabis.

People will say that their cannabis use isn't impairing them in any way but then say they have attention/motivation issues because of ADHD. How are they attributing one symptom to one cause and not the other?

ADHD does increase risk of substance use though and I often have people who lower/quit using cannabis or other substances when their impulsivity and ADHD is more under control. I will lean more toward a non-stimulant or a long-acting stimulant if they do have substance use though and will monitor closely for misuse/diversion (e.g., early refills, using differently than prescribed without telling me first, UDS) although I don't usually do a pill count.

My policy isn't as strict as others it seems. For active substance use disorder, I treat that first and will use a non-stimulant for those who have had symptoms of ADHD from a young age. For recreational use but still working, going to school, overall functioning, I will proceed with caution and stipulations. I'm not convinced in the literature on adult-onset ADHD and actually, the studies I've seen have made me more skeptical of it as a clinical entity. However, I do see adult diagnoses of ADHD with good reasons why they didn't get diagnosed as a kid rather than the symptoms starting from adulthood.

 

[Attending1985]

It's not just that the marijuana is causing issues with concentration, it's that even if you use ADHD medications to treat their focus, their treatment response and side effect profile is often worse in my experience. Same with treating anxiety/depression/insomnia with medications in those who are also on cannabis.

People will say that their cannabis use isn't impairing them in any way but then say they have attention/motivation issues because of ADHD. How are they attributing one symptom to one cause and not the other?

ADHD does increase risk of substance use though and I often have people who lower/quit using cannabis or other substances when their impulsivity and ADHD is more under control. I will lean more toward a non-stimulant or a long-acting stimulant if they do have substance use though and will monitor closely for misuse/diversion (e.g., early refills, using differently than prescribed without telling me first, UDS) although I don't usually do a pill count.

My policy isn't as strict as others it seems. For active substance use disorder, I treat that first and will use a non-stimulant for those who have had symptoms of ADHD from a young age. For recreational use but still working, going to school, overall functioning, I will proceed with caution and stipulations. I'm not convinced in the literature on adult-onset ADHD and actually, the studies I've seen have made me more skeptical of it as a clinical entity. However, I do see adult diagnoses of ADHD with good reasons why they didn't get diagnosed as a kid rather than the symptoms starting from adulthood.

One reason why I’m hesitant to treat is ime those patients don’t get better in the long term and there’s an escalating pattern of messages and calls regarding worsening symptoms and a lot of frustration on both sides.
I usually just tell people that these two medications interact and have opposing effects so I ask you to pick the one that’s more important to you. I find in heavy users with likely sud most pick the cannabis and some just drop off and I’m find someone who will prescribe.

 

[Stagg737]

One reason why I’m hesitant to treat is ime those patients don’t get better in the long term and there’s an escalating pattern of messages and calls regarding worsening symptoms and a lot of frustration on both sides.
I usually just tell people that these two medications interact and have opposing effects so I ask you to pick the one that’s more important to you. I find in heavy users with likely sud most pick the cannabis and some just drop off and I’m find someone who will prescribe.

One of my former attendings who was one of our clinical line directors as well as the pain specialist at a large academic center for 20+ years used to do the same thing for patients who were simultaneously on benzos and opiates. She'd talk to them about their pain and anxiety and let them know that they would work together to taper off at least one of those med classes (ideally both if possible), but that the long-term risks of both and the interactions wasn't something we would enable. In the 2-3 months I rotated with her, almost every patient agreed with that plan, was thankful for the care, and actually did better clinically and functionally with decreasing the polypharmacy. I also have a similar stance with benzos and stimulants except for very rare circumstances.

I agree that it's a similar concept with cannabis and several drug classes and I don't acquiesce patients who want me to just keep throwing more meds at their symptoms so that side effects just keep getting added or exacerbated when we could stop the problem substance and eliminate the issue altogether.

 

[wellbutrin.girlfriend]

Sounds like an excellent opportunity for some motivational interviewing! Just read a nice paper on this, will share here

 

[clozareal]

One reason why I’m hesitant to treat is ime those patients don’t get better in the long term and there’s an escalating pattern of messages and calls regarding worsening symptoms and a lot of frustration on both sides.
I usually just tell people that these two medications interact and have opposing effects so I ask you to pick the one that’s more important to you. I find in heavy users with likely sud most pick the cannabis and some just drop off and I’m find someone who will prescribe.

Sounds like you're not struggling then and have a clear strategy. If you've inherited a bunch of people on it then you can tell them your policy.

 

[clozareal]

I agree that it's a similar concept with cannabis and several drug classes and I don't acquiesce patients who want me to just keep throwing more meds at their symptoms so that side effects just keep getting added or exacerbated when we could stop the problem substance and eliminate the issue altogether.

Yep. I'll tell them my evaluation that their alcohol/cannabis use is leading to worsening in attention/mood/motivation. In my practice, most will agree and they want to cut down but have difficulty in doing so without support. I'll let them know that we can do this first and see for a few months how they do off of substances and re-evaluate for ADHD. If they agree, then it's a win-win because it gives me clinical clarity and it helps the patient out.

If they don't agree with the substance use issues, then I try to work with their ambivalence with motivational interviewing until they either drop off my patient panel or work toward reducing their intake.

The big problem is the acquiescence, that they try to convince me that their substance use isn't problematic. The ones who smoke the most (e.g., spending all day high, waking up at night and taking a hit, using 90+% THC, often smoke alone, can't drive or be in social situations where they aren't vaping) are the ones who are the most convinced of this, but I won't be convinced otherwise.

 

[mistafab]

I love to have these conversations with patients. I teach them that if they are seeing me and using cannabis regularly, then it is definitely worsening a psychological/psychiatric problem. In addition, they are experiencing withdrawal if it helps with their anxiety, sleep, etc.

It is one of my favorite points that if they are using marijuana for anything other than having a good time - it is more problematic, not less problematic. They think that because they "use it for sleep" that somehow that is more responsible and less of an issue. Buddy, if you are using recreational drugs for sleep, you have a problem.

I find that people using cannabis heavily will deny any of the criteria and in general have a lot of resistance to considering any negative psychiatric effects. They will tell me how wonderful it is but at the same time they’re doing poorly.

 

[FlowRate]

Our region's policy is very similar to the one linked. We require that people prove they don't have a use disorder (that they're able to stop THC use) by requiring a negative UDS. The letter of our policy is no THC use / minimal THC use while using a stimulant, but the actual bar is negative UDS. It's up to the clinician how much they want to emphasize no/minimal use while they prescribe a stimulant. FWIW IIRC some research studies define "heavy" THC use as at least once a week.

I've had several patients where I almost believe they had stopped use--who test positive for multiple weeks in a row. They're not even obese. The normalization of very heavy use around here is crazy. Common for me to hear $200-300 per month THC habits.

 

[Attending1985]

Sounds like you're not struggling then and have a clear strategy. If you've inherited a bunch of people on it then you can tell them your policy.

I’m struggling because there is some nuance with frequency of use and just the fact that cannabis use is so overwhelmingly common now. unlike alcohol where people generally know it’s not a good idea to overuse the general consensus seems to be cannabis is ok to overuse. On top of that there does seem to be a sect of people that respond positively to chronic cannabis use so there’s that too.

 

[comp1]

This is not some moral judgement about what is "good" or what is "overuse." You seriously have to take any moral judgement out of this. This is about the well established fact that cannabis use worsens cognition in general. I'm sure there's someone somewhere that has some sort of improvement on cannabis, but statistically, they are definitely not your patient. At the very least, your patients need to try being off cannabis for a couple of months (as shown by UDS) to see what happens with their symptoms. If they can't do that, then perhaps there really is a different problem than ADHD going on. I still think more frustrating for me than individual decisions you make is that your clinic doesn't have a policy about this. You all need to have a staff meeting. You shouldn't be alone in this, for a lot of reasons.

 

[clozareal]

I’m struggling because there is some nuance with frequency of use and just the fact that cannabis use is so overwhelmingly common now. unlike alcohol where people generally know it’s not a good idea to overuse the general consensus seems to be cannabis is ok to overuse. On top of that there does seem to be a sect of people that respond positively to chronic cannabis use so there’s that too.

So you're struggling with providing psychoeducation on this frequently to patients?

I explore this concept more with them: that cannabis use results in a positive response. This means they have a positive attitude toward it but my goal is to untangle the nuance around this. I often see that people say it helps with sleep because they get anxious when they go to bed or that it helps them relax, when in actuality they are chasing/treating cannabis withdrawal that they're confusing for mood/anxiety/sleep issues. It's a short term fix that creates a long-term problem.

I also have people who tell me that there's no such thing as cannabis addiction, that there's no harmful effects on sleep, that there are no long-term harmful effects. I then have to communicate with them the research on:

1. How we make a diagnosis of cannabis use disorder (i.e., addiction) and the impairment that it can cause
2. Increased risk of psychosis and schizophrenia
3. Increased risk of major depressive disorder and anxiety disorders
4. Increased risk of mania
5. Decreased IQ, decreased hippocampal volume, decreased motivation, impairments in learning and memory, impairments in attention and processing speed
6. Increased cardiovascular risks: arrhythmias, orthostatic hypotension, heart attacks, strokes
7. Impaired pulmonary functioning and chronic bronchitis (this is probably the most straightforward for patients who are smoking)
8. Increased risk of GI disorders developing like cannabinoid hyperemesis syndrome
9. Increased risk of motor vehicle accidents, especially if they are smoking while driving
10. Possibly increased risk of testicular cancer
11. Adverse effects in neonatal outcomes when using cannabis while pregnant

I don't tell them about all of these risks but it's in the back of my mind and I tailor it for the chief complaint and demographic of each patient (particularly adolescents). I'm careful to monitor for shame around this especially when it comes to their attitudes and feelings around coming to see a psychiatrist and potentially problematic use that they may have already received messages about. I try to reassure them that I'm helping them reach their goals that they came to me for. I'd rather have them engaged in care and do better if we can make some headway on this. The research seems favorable in that if you quit smoking, then some of these may be reversible like the cognitive impairment from cannabis use.

 

[Celexa]

Generally speaking, I dont prescribe stimulants to pts also using marijuana. I used to make it a hard line. However, as I have seen more patients, I have started to have a small handful where I am prescribing a stimulant and they use marijuana. Emphasis on SMALL. Can count them on a hand with a finger or two missing. Many/most of the below factors need to be true:

-they have no history of psychosis
-the history of ADHD is very solid--childhood diagnosis, family member can confirm the hx, and predates marijuana use
-my evaluation, their description of the current symptoms, and their report of what the stimulant does align with the diagnosis
-the dose of the stimulant is rational and standard. No pushing dose limits.
-mood and anxiety comorbidities are controlled, OR they are ok holding their stimulant dose steady while we treat the comorbid conditions and they engage with me on recommendations for those conditions--including if that's working on decreasing marijuana use
-they aren't on other controlled substances with the possible exception of genuinely rare prn benzo (ie for the dentist).
-sleep apnea has been assessed and, if present confirmed treated/compliant with the cpap--objectively
-they understand that no adhd regimen provides perfect 24/7 coverage and they WILL also need to use behavioral strategies.

Or, to make the above a lot shorter: I prescribe stimulants to patients using marijuana when after careful assessment, I believe that the stimulant is providing more benefit than harm. Isn't that ultimately the reason for anything we do?

 

[Celexa]

I’m struggling because there is some nuance with frequency of use and just the fact that cannabis use is so overwhelmingly common now. unlike alcohol where people generally know it’s not a good idea to overuse the general consensus seems to be cannabis is ok to overuse. On top of that there does seem to be a sect of people that respond positively to chronic cannabis use so there’s that too.

There are people who use cannabis recreationally without issues, and there are patients who benefit from medical marijuana on physical symptoms, but I wouldn't say that there are people who benefit psychiatrically from chronic cannabis use. Thats something I tell my patients almost word for word. Most appreciate the nuance, or at least respect me enough not to be rude.

It sounds like you are having trouble trusting your own clinical intuition. You dont have to prove that the patient has a problem with marijuana beyond reasonable doubt to deny them a stimualnt. You need to believe as their physician they would potentially benefit to prescribe one. And then you get to observe and see if they do actually benefit. It isnt a bell that cant be unrung. Thats something else I tell my patients--if I as your doctor have reason to believe this medication (or any other!) Is doing you more harm then good, I will stop prescribing it. Overwhelmingly I have found patients to appreciate the point.

 

[Candidate2017]

Anyone struggling with decisions regarding cannabis and stimulant co-prescribing? With cannabis being legal most everywhere and the ease of getting a medical card it’s becoming more and more of issue. What I see really commonly are people coming in with testing from a psychologist who has not questioned them at all regarding cannabis use saying they have adhd. I’m also inheriting a bunch of patients from an np who left who didn’t screen for cannabis use and liberally diagnosed and treated adhd which is a real headache.

Nah, you're not struggling with weed and stimulant co-prescribing. You're struggling with psych NPs who hand out candy to everyone and then leave for greener specialty pastures (derm, cards, GI, other procedural specialties) once the wave of feces they created reaches tsunami proportions. Of course, the practice habits of psych NPs are the direct result of the organization going for the cash grab. So yeah, when everyone is dumping on psychiatry you gotta try to stay afloat on top of the brown stuff and ride the wave.

 

[comp1]

I haven't really seen psych NPs leave psych all that often. It's pretty sweet for both MDs and NPs. That said, at the very least there should be a standard within clinic or system expectation for both NPs and MDs regarding this sort of prescribing.

 

[Stagg737]

I haven't really seen psych NPs leave psych all that often. It's pretty sweet for both MDs and NPs. That said, at the very least there should be a standard within clinic or system expectation for both NPs and MDs regarding this sort of prescribing.

Where I’m at quite a few psych NPs have gone back to practicing as RNs because the pay bump for NP wasn’t worth the responsibility and burn and churn that their employers expected to deal with PD patients and doctor shoppers. Our academic center pays them enough that they’re happier to just pick up RN shifts.