Federal Government Advises Doctors Against Testing Patients For Marijuana

[Norby]

http://hightimes.com/read/federal-government-advises-doctors-against-testing-patients-marijuana

 

As part of its plan to change the healthcare community’s cavalier attitude towards the distribution of dangerous prescription painkillers, the federal government has advised physicians across the United States to stop testing their patients for marijuana.

Last week, the Centers for Disease Control and Prevention (CDC) released an updated set of guidelines for prescribing opioids to patients suffering from chronic pain. Buried inside the language of this attempt to put a leash on the prescription painkiller epidemic, the CDC urged doctors to modify their drug screening policies in an effort to prevent those testing positive for THC metabolites from being disqualified from treatment.

Although the agency wrote that it still believes urine testing is necessary to discover any “undisclosed use” of illicit substances, it specifically states that this rule no longer applies to THC.

“Clinicians should not test for substances for which results would not affect patient management or for which implications for patient management are unclear,” reads the statement. “For example, experts noted that there might be uncertainty about the clinical implications of a positive urine drug test for tetrahydrocannabinols (THC).” 

Although passing a drug test is not usually a prerequisite for an initial prescription to painkillers, patients who end up passing through the corridor from the family doctor to a pain management clinic are often held to a higher standard in order to continue receiving these medications. Typically, these patients are required to test free of any illegal substances, including medical marijuana, before being allowed to participate and/or continue in a pain treatment plan.

However, the latest CDC guidelines suggest that this old philosophy leads to “stigmatization” and “inappropriate termination of care,” which inevitably creates additional hardships for those patients in need of these types of treatment programs.

“Clinicians should not dismiss patients from care based on a urine drug test result because this could constitute patient abandonment and could have adverse consequences for patient safety, potentially including the patient obtaining opioids from alternative sources and the clinician missing opportunities to facilitate treatment for substance use disorder,” the CDC guidelines reads.

According to a report by the Pain News Network, which originally detected the pro-marijuana provision tucked inside the CDC’s new opioid prescribing guidelines, point-of-care urine drug screens are infamous for providing false positive and false negative results for a number of substances, including marijuana.

“False positive readings for marijuana, for example, were given over 21 percent of the time, while false negative results for marijuana also appeared about 21 percent of the time,” the article reads. 

Interestingly, the latest guidelines for prescribing painkillers come just a month after Senator Elizabeth Warren fired off a letter to CDC director Dr. Tom Frieden urging his agency to research the “effectiveness of medical marijuana as an alternative to opioids for pain treatment in states where it is legal.” The letter also asked the CDC to study “the impact of the legalization of medical and recreational marijuana on opioid overdose deaths.”

A 2014 report published in JAMA Internal Medicine provides some evidence that fewer people are dying from opioid overdoses in states that have legalized medical marijuana. The study found nearly a 25 percent reduction in prescription painkiller deaths in states where marijuana is a legal treatment option. However, this information was not cited in the CDC guidelines.

(Photo Courtesy of WJMed.com)

 

[Greg Rx]

This could be a BIG deal. I want to send the guideline to a local doc but the whole report is 37 single space pages. I haven't found the exact quote, yet. Checking the 2014 report, next.

[+Malamute]

Thanks.

 

This one slipped byme.

 

I will go read it up close.

[AmishRnot4ganja]

Yay Elizabeth Warren! The only person in Washington who still has a functioning brain.

[Dr. Bob]

Cannabis use in chronic pain reduces the need for narcotic pain medication by 60-75% in our experience.  Our experience also shows that pain physicians that accept the use of cannabis and narcotic pain medication become targets of medical boards and LEO.  They also have problems getting their prescriptions filled if they are known to be marijuana friendly.  The science is there already, the attitudes need some adjustment.  

 

This needs to be done on the legislature level (anyone come to mind?) and by civil action in the courts (we've seen some success with this as well).  When you punish a pharmacy as we did, they change their attitude.  But right now you have a very high standard of proof, well beyond them refusing to fill a reasonable prescription from a licensed physician.  We can make that easier for patients.

 

Dr. Bob

Edited March 24, 2016 by Dr. Bob

[cristinew]

http://mashable.com/2016/03/23/government-testing-patients-marijuana/#sDF7KvRk7uqm 

[Greg Rx]

  They also have problems getting their prescriptions filled if they are known to be marijuana friendly.  The science is there already, the attitudes need some adjustment.  

 

 

As a pharmacist, I don't think this is true. There are many reasons to avoid certain docs but that is not one of them. We are limited as to how many dosage units of hydrocodone we can order in a month and we could sell every single one of them. Just like doctors (and CG), we have many unwritten rules to follow to avoid attention. 

[Dr. Bob]

As a pharmacist, I don't think this is true. There are many reasons to avoid certain docs but that is not one of them. We are limited as to how many dosage units of hydrocodone we can order in a month and we could sell every single one of them. Just like doctors (and CG), we have many unwritten rules to follow to avoid attention. 

 

I'm glad it is not true in your pharmacy.  Point is, it is in others.  

 

Dr. Bob

[+Malamute]

Alright, I took the time to read the whole thing.... ick.

 

But I figured I would paste over the section on this topic.

 

 

10. When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs (recommendation category: B, evidence type: 4).

 

Concurrent use of opioid pain medications with other opioid pain medications, benzodiazepines, or heroin can increase patients’ risk for overdose. Urine drug tests can provide information about drug use that is not reported by the patient. In addition, urine drug tests can assist clinicians in identifying when patients are not taking opioids prescribed for them, which might in some cases indicate diversion or other clinically important issues such as difficulties with adverse effects. Urine drug tests do not provide accurate information about how much or what dose of opioids or other drugs a patient took. The clinical evidence review did not find studies evaluating the effectiveness of urine drug screening for risk mitigation during opioid prescribing for pain (KQ4). The contextual evidence review found that urine drug testing can provide useful information about patients assumed not to be using unreported drugs. Urine drug testing results can be subject to misinterpretation and might sometimes be associated with practices that might harm patients (e.g., stigmatization, inappropriate termination from care). Routine use of urine drug tests with standardized policies at the practice or clinic level might destigmatize their use. Although random drug testing also might destigmatize urine drug testing, experts thought that truly random testing was not feasible in clinical practice. Some clinics obtain a urine specimen at every visit, but only send it for testing on a random schedule. Experts noted that in addition to direct costs of urine drug testing, which often are not covered fully by insurance and can be a burden for patients, clinician time is needed to interpret, confirm, and communicate results.

 

Experts agreed that prior to starting opioids for chronic pain and periodically during opioid therapy, clinicians should use urine drug testing to assess for prescribed opioids as well as other controlled substances and illicit drugs that increase risk for overdose when combined with opioids, including nonprescribed opioids, benzodiazepines, and heroin. There was some difference of opinion among experts as to whether this recommendation should apply to all patients, or whether this recommendation should entail individual decision making with different choices for different patients based on values, preferences, and clinical situations. While experts agreed that clinicians should use urine drug testing before initiating opioid therapy for chronic pain, they disagreed on how frequently urine drug testing should be conducted during long-term opioid therapy. Most experts agreed that urine drug testing at least annually for all patients was reasonable. Some experts noted that this interval might be too long in some cases and too short in others, and that the follow-up interval should be left to the discretion of the clinician. Previous guidelines have recommended more frequent urine drug testing in patients thought to be at higher risk for substance use disorder (30). However, experts thought that predicting risk prior to urine drug testing is challenging and that currently available tools do not allow clinicians to reliably identify patients who are at low risk for substance use disorder.

 

In most situations, initial urine drug testing can be performed with a relatively inexpensive immunoassay panel for commonly prescribed opioids and illicit drugs. Patients prescribed less commonly used opioids might require specific testing for those agents. The use of confirmatory testing adds substantial costs and should be based on the need to detect specific opioids that cannot be identified on standard immunoassays or on the presence of unexpected urine drug test results. Clinicians should be familiar with the drugs included in urine drug testing panels used in their practice and should understand how to interpret results for these drugs. For example, a positive “opiates” immunoassay detects morphine, which might reflect patient use of morphine, codeine, or heroin, but this immunoassay does not detect synthetic opioids (e.g., fentanyl or methadone) and might not detect semisynthetic opioids (e.g., oxycodone). However, many laboratories use an oxycodone immunoassay that detects oxycodone and oxymorphone. In some cases, positive results for specific opioids might reflect metabolites from opioids the patient is taking and might not mean the patient is taking the specific opioid for which the test was positive. For example, hydromorphone is a metabolite of hydrocodone, and oxymorphone is a metabolite of oxycodone. Detailed guidance on interpretation of urine drug test results, including which tests to order and expected results, drug detection time in urine, drug metabolism, and other considerations has been published previously (30). Clinicians should not test for substances for which results would not affect patient management or for which implications for patient management are unclear. For example, experts noted that there might be uncertainty about the clinical implications of a positive urine drug test for tetrahyrdocannabinol (THC). In addition, restricting confirmatory testing to situations and substances for which results can reasonably be expected to affect patient management can reduce costs of urine drug testing, given the substantial costs associated with confirmatory testing methods. Before ordering urine drug testing, clinicians should have a plan for responding to unexpected results. Clinicians should explain to patients that urine drug testing is intended to improve their safety and should also explain expected results (e.g., presence of prescribed medication and absence of drugs, including illicit drugs, not reported by the patient). Clinicians should ask patients about use of prescribed and other drugs and ask whether there might be unexpected results. This will provide an opportunity for patients to provide information about changes in their use of prescribed opioids or other drugs. Clinicians should discuss unexpected results with the local laboratory or toxicologist and with the patient. Discussion with patients prior to specific confirmatory testing can sometimes yield a candid explanation of why a particular substance is present or absent and obviate the need for expensive confirmatory testing on that visit. For example, a patient might explain that the test is negative for prescribed opioids because she felt opioids were no longer helping and discontinued them. If unexpected results are not explained, a confirmatory test using a method selective enough to differentiate specific opioids and metabolites (e.g., gas or liquid chromatography/mass spectrometry) might be warranted to clarify the situation.

 

Clinicians should use unexpected results to improve patient safety (e.g., change in pain management strategy [see Recommendation 1], tapering or discontinuation of opioids [see Recommendation 7], more frequent re-evaluation [see Recommendation 7], offering naloxone [see Recommendation 8], or referral for treatment for substance use disorder [see Recommendation 12], all as appropriate). If tests for prescribed opioids are repeatedly negative, confirming that the patient is not taking the prescribed opioid, clinicians can discontinue the prescription without a taper. Clinicians should not dismiss patients from care based on a urine drug test result because this could constitute patient abandonment and could have adverse consequences for patient safety, potentially including the patient obtaining opioids from alternative sources and the clinician missing opportunities to facilitate treatment for substance use disorder.

[Dr. Bob]

I'm glad it is not true in your pharmacy.  Point is, it is in others.  

 

Dr. Bob

 

Prime example.  I am personally aware of one pharmacy in Muskegon that refused a prescription for 40 soma for one of my patients (acute issue, one month only script, on very low dose medication) that was giving another patient 270 10mg Methadone tabs for back pain every TWO WEEKS.  Note, these were not the same patient, the patient with the soma was very low dose pain control as noted (NSAID and 45 norco a month, stable dose for a year under my care).  The high dose methadone patient was obviously not under MY care, but I was aware of it.

 

I sent them into that pharmacy, which the patient previously used for years before switching to another when he started seeing me, to see if they would fill it. They refused- and did so on tape because the patient was wearing a wire for me to document this for a lawsuit against the pharmacies.  We won the suit because they were refusing to work with me due to an email sent out by one of the pharmacies making a big deal of the fact I did medical marijuana certifications- even calling me a 'pot doctor'.

 

This method of holding pharmacies accountable financially for refusing to work with pain and addiction patients is needed- not because they don't have a right to refuse to fill a script, but because if they refuse to fill a script they should risk the possibility of having to justify that decision in court with a punishing financial penalty on the line.  The pharmacy that called me a pot doctor and encouraged the other 60 pharmacies on the mailing list not to fill my scripts WAS financially punished by my suit.

 

That said, the VAST majority of pharmacies we worked with had no problems with our scripts and viewed us as conservative and appropriate with our prescribing.  But it was bad enough there to prompt a suit, and an article on my website.  And it was bad enough to force them to write me a check.

 

Dr. Bob 

Edited March 24, 2016 by Dr. Bob

[imiubu]

...

[Greg Rx]

Thanks Mal, I gave up trying to find it.