Tuesday, May 21, 2013

Is It OK For Pain Management Doctors To Fire Patients Using Medical Marijuana?

When a patient sees a pain management doctor, the patient may receive narcotic medications. Especially if the person has a chronic pain issue and there is no surgical answer, opiates may be part of the plan for a long time.

There are significant potential side effects with opiate medications. This may include constipation, depression, sedation, euphoria, dizziness, fatigue, anxiousness, clammy skin, confusion, respiratory depression, and a slew of others.

One of the biggest issues seen is tolerance and/or addiction with opiates. Tolerance is when the patient's chronic pain condition doesn't change, but the same amount of pain medication doesn't quite provide adequate pain relief any longer.

One of the newer options in 16 states plus the District of Columbia is medicinal marijuana. Treatment with marijuana may offer substantial relief that may decrease the need for high doses of opiates or in some cases provide relief where opiates do not work well.

For instance, opiate medications are not a great choice for peripheral neuropathies. They just don't modulate the pain well, whereas, medical marijuana works very well for these issues.

Medical marijuana does not preclude the need for interventional pain management. With a disc herniation or a focal problem where a pain management injection would help, medical marijuana is not the answer.

When patients are on chronic pain medications with a pain doctor, typically a pain contract is signed. The "contract" usually states that while a patient is under his or her care, the patient will not use illicit drugs.

Unfortunately, marijuana is still federally illegal despite the fact it is now legal in 16 states. And most pain doctors perform drug screening on their patients. So if a patient is under a contract, gets tested, and turns up positive for THC (the active component of marijuana), is it appropriate for the pain doctor to terminate the patient?

It's a simple answer as to whether or not the pain doctor has the right to terminate the patient, but not a simple answer as to whether it's appropriate. If the pain agreement states that the doctor has the right to terminate a patient if the drug test turns up positive for narcotics not being prescribed, then that is difficult to refute. If the patient is given the opportunity to rectify their termination by ceasing the marijuana use and re-testing in a few weeks, once again that is the doctor's prerogative.

Ethically, the situation is not so simple. Patients deserve effective pain management, and there is a big push in American not to undertreat. Medical marijuana has shown effectiveness in a number of chronic pain conditions and numerous other conditions such as severe nausea/vomiting and cancer.

Having marijuana continue to be federally illegal and placed into the illicit category puts pain doctors in a very difficult situation. If they test patients for THC and then don't terminate patients who test positive, is it showing bias with regard to other illicit substances?

Some pain doctors do not view marijuana as an illicit substance due to its medicinal value, therefore, they do not test for it with screening. If a patient discloses the use of marijuana to the doctor, the issue becomes the same.

The point here is there really is no clear cut right and wrong answer for the pain doctor to follow. Guidelines need to be individualized. Hopefully once federal views on marijuana change then these ethical issues will become moot.

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