The opioid crisis is prompting a reexamination of cannabis, once a tool in the physician’s toolbox for pain management, for its medical benefits.
In response to the opioid crisis, last year, the Oklahoma Legislature passed Senate Bill 1446 and implemented guidelines that affected the way physicians can prescribe opiate medications for the treatment of acute and chronic pain. Along with limiting the duration and amount of medications given for acute pain, other limitations were enacted for chronic pain. One of these was a guideline that physicians should consider specialty consultation for patients with complex pain conditions, other serious illnesses, mental illness or a history or evidence of current drug addiction or abuse. This broad guideline would encompass many if not most patients with chronic pain and make it difficult for primary care doctors to feel comfortable managing these cases. It is now commonplace for primary care doctors to refer nearly all chronic pain patients who need or are considered for opiate therapy to pain management.
Pain management is a medical subspecialty branching from several medical specialties. These specialists in pain relief sometimes are able, with specific procedures and therapies, to get people with severe chronic pain functioning again without pain or more commonly with well controlled pain. Most fellowship programs are associated with anesthesiology, but there are also programs in neurology or physical medicine and rehabilitation. Different types of pain management specialists have more experience in specific pain conditions and vary on what types of treatments they offer. Some only perform procedures designed to decrease pain. Others use a multidisciplinary approach to pain management, combining their own use of procedures with medications and/or referrals to other providers such as physical therapy, psychological therapy and rehabilitation. A few will include alternative therapies such as chiropractic, acupuncture or massage. Very few include referral to a cannabis physician. Many will not even allow cannabis therapy during the physician-patient relationship. We will explore the reasons for this.
Many patients I see in our cannabis clinic are understandably frustrated with their pain management and their pain management physician. Chronic pain management is difficult under the best of circumstances. The changes caused by the opioid crisis have added another layer of complexity. Patients who have been stable on opiate therapy for non-cancer pain are being required to change from opiates. Others have concerns about the long-term harms of opiates and desire to change but find few non-cannabis alternatives that are helpful. These patients often are forced to seek medical cannabis either against the advice of the pain management specialist or without telling them. This is typically not an ideal situation. Having two doctors treating an issue with conflicting opinions and treatments is not patient-friendly or particularly therapeutic.
From the perspective of the cannabis patient or cannabis physician, the easy way is to just blame the pain specialist for not keeping up with progress or claim that they have ulterior motives or intent. But the reality is that there are many factors that somewhat tie the hands of a pain management doctor regarding cannabis therapy. Sure, some doctors are just obstinate and do not want to change their practice and beliefs. It appears that history, current training and federal regulation all play a significant part in the divide between pain management and cannabis.
First and likely foremost is the insanity of our nation’s current laws and regulations regarding cannabis. While medical cannabis is legal under the laws of Oklahoma, it is still illegal under federal law. Despite this, the federal government has at least temporarily agreed not to enforce federal law against the users and producers of cannabis who are following state laws. Unfortunately, that applies to federal law enforcement. It does not apply to all federal agencies.
This puts the pain management specialist in a quandary. While medical licensure is from the state, all doctors that prescribe scheduled medications (opiates, benzodiazepines and many others) are required to have a Drug Enforcement Administration (DEA) diversion control registration. This is a federal program. Without this registration certificate, the doctor cannot prescribe any scheduled medications. This would effectively end the medical practice of a pain physician. The federal government wanted to revoke the registration of physicians who recommended cannabis. This went all the way to the United States 9th Circuit Court of Appeals in 2002, where a verdict was given that a cannabis recommendation is free speech and therefore cannot be regulated by the DEA or Department of Justice. An actual prescription, however, is not protected and is illegal. This is the reason that cannabis physicians recommend and do not prescribe. This tenuous legal status currently appears to protect physicians from federal prosecution or revocation of licensure. Still, the complexity and career risk are significant hindrances to pain physician involvement in cannabis therapy.
Second, a large part of the training of pain specialists is detection and prevention of abuse or diversion of the medications given. A long-term fundamental part of that has been the use of drug screening to ensure that the patient is taking the prescribed medications and the patient is not taking other potentially abused medications that have not been prescribed. Cannabis use is part of that screening. For many years, any positive cannabis screen was an exclusion for treatment under pain management, certainly with scheduled medications. Some pain management doctors are changing on this, as there are some studies that show that cannabis augments the pain relief of opioids. However, if the DEA were able to find out that scheduled medications were being given to a known user of a federally illegal substance, the doctor would again be at risk of revocation of registration. Fortunately, HIPAA privacy protections will generally prevent this. In addition, no high-quality studies have been completed showing safety for the ongoing use of cannabis and opioids. For these reasons, most pain management specialists refuse to prescribe opiates for patients using cannabis therapy. Ideally, when patients are changing from opiates to cannabis for chronic pain management, the doctor will at least continue to prescribe opiates to allow for a weaning process to avoid opiate withdrawal. Unfortunately, that has not always been the case for all of my patients.
While my anecdotal experience is that most patients get relief of pain, improved sleep and improved quality of life with cannabis, the medical literature does not yet fully support this. Most reviews find that there is a lack of high-quality evidence. The myriad ways cannabis can be taken, multiple varieties of products under the umbrella of cannabis and difficulty posed by legal issues have made it very difficult to scientifically assess cannabis in the same manner that pharmaceutical agents are tested. Some studies appear to be completed in a poor manner with the motive of finding lack of efficacy. On the good side, there has been progress in the research area. Even the federal government is relaxing the rules somewhat regarding cannabis research. Better quality research is coming from overseas, particularly Israel. In the future, more studies will become available that assess the areas in which cannabis likely has the most beneficial effects.
Finally, practicing physicians have been trained that cannabis is an illegal drug without medical indications. In the distant past, American Medical Association opposed the Marijuana Tax Act of 1937 because it effectively made cannabis illegal and took away a commonly prescribed medication from the armamentarium of physicians in that era. However, in the years since, medical training has evolved to not look at cannabis as medication. As the experts in pain management, pain management specialists generally follow strict standards and guidelines. These guidelines do not include cannabis. Interestingly, there are no high-quality studies showing good long-term outcomes for pain, quality of life or function for opioid therapy in chronic pain either. It appears the primary reason one therapy (opiates) is in the guidelines for chronic pain and the other (cannabis) is excluded is social acceptance, not proven medical benefit. That social acceptance, of course, is changing right in front of our eyes.
I foresee over the coming years a change in medicine, including pain management. At some point when the federal government finally grants its blessing to the will of the majority of Americans and stops calling cannabis illegal, there will be very few or no “cannabis physicians” like myself. Cannabis as a therapy will again be included in physician training and will be part of the toolbox of all physicians, including pain management specialists. I suspect recreational use will be legal also, which will create a somewhat unique situation with this atypical medication, but blazing new pathways of health care is already something that cannabis is doing, and the future will be even more exciting for this transformative plant.
Dr. Steven Ross, MD
Dr. Steven Ross is a physician who has practiced and taught medicine in several countries worldwide and is now a practicing cannabis clinician and founder of MMDOKC in Oklahoma City. He has a passion for assisting patients with cannabis recommendations and guidance for medical use.