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Management of Pain and Addictions:Broadening Our Perspectives

September 7‐10, 2011Tucson, AZ

To Test or Not to Test for Cannabis/Marijuana with Pain 

Contracts

To Test or Not to Test for Cannabis/Marijuana with Pain 

Contracts

• Mary Lynn Mathre, RN, MSN, CARN

• President and Co‐founder of Patients Out of Time

• www.MedicalCannabis.com

Drug testing business is huge

Pre 1980s:  Drug screening was used for emergencies or forensics.  

Now: Started random testing with the US Military in early 1980s

Drug testing by law enforcement: traffic stops/arrests; probation & parole

Pre‐employment and random drug testing common in the workplace 

Random testing in school systems and with sports programs 

Home screening kits for parents.  Used by health care providers with pain 

contracts when prescribing opioids

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Drug Testing Business is growing

• Screening and Confirmation tests 

• Individual tests or drug panels

• Home, Office or Laboratories

• New drugs to test (i.e. K2 or spice)

Drug tests only show past or recent use (depending on the type of test), not a sign of abuse, dependence or 

addiction

• Urine

• Blood

• Saliva

• Hair

• Sweat

Pain Contracts for Patients With Chronic Pain 

• It is becoming standard practice to initiate pain contracts with chronic pain patients who are prescribed opioids for pain

• Most use urine drug screens

• Only about 8% of family practitioners utilized UDT with chronic pain patients 

(Gourlay et al, 02)

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Why include Drug Screening with Pain Contracts?

• Monitoring: documentation of pain intensity and level of functioning, assessments of progress toward achieving therapeutic goals, presence of adverse events, and adherence to prescribed therapies.  Drug test those "at high risk or who have engaged in aberrant drug‐related behaviors."

• "Clinicians should consider a differential diagnosis for abnormal urine drug screen results, including drug abuse or addiction, self‐treatment of poorly controlled pain, psychological issues, or diversion (which may be suggested by absence of prescribed opioids)." 

(Chou et al, 2009)

Why include Drug Screening with Pain Contracts?

• Patient Compliance

• Safety

• Legal

Patient compliance 

• 75% of patients unlikely to take prescription pain meds as prescribed (Couto et al., 2009)

• Up to 50% of patients were nonadherent to their chronic medication regimens (Vermeireet al., 2001 )

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Abnormal UDT findings

• Absence of a prescribed opioid

• Presence of an additional nonprescribed controlled substance

• Detection of an illicit substance

• An adulterated urine sample

Opioid Testing

• Semisynthetic opioids: oxycodone and oxymorphone will not typically be detected at the 300ng/ml cutoff

• Synthetic opioids: Fentanyl, meperidine and methadone will not be detected by opiate immunoassays

Patient Safety

• Use of additional nonprescribed controlled substances  can be dangerous

Other opioidsBenzodiazepinesAmphetamines

• Illicit substances could be dangerousHeroinCocaineCannabis (Are you sure this is a problem?)

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Legal Reasons

• Is drug testing mandated by law or regulations?

• US Code of Federal Regulations allows for prescribing Schedule II drugs for the treatment of pain as long as it is not for maintenance or detox of a concurrent substance‐use disorder

Department of Veterans Affairs

• Letter for Under Secretary of Health

• Directive 2010‐035 

• Directive 2011 ‐

Medicinal cannabis use for chronic pain

• CA cannabis docs see a 50% reduction in opioid use when using cannabis

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Oregon’s Cannabis Stats

• As of July 1, 2011:

– Current registered patients  – 49, 220

–90% patients use cannabis for chronic pain

–Conditions* (may have more than one)

• Severe pain  – 44,756

• Persistent muscle spasms, including but not limited to those caused by MS – 12,170

New Mexico’s Cannabis Stats

• As of August 3, 2011

• Active patients – 4050

• Active Caregivers – 131 (total 184)

• Top 5 Conditions:– PTSD – 1649

– Chronic Pain – 1223

– Cancer – 559

– Painful Peripheral Neuropathy – 383

– HIV/AIDS ‐ 233

New Mexico’s Cannabis Stats

• Additional Pain Conditions Treated with Cannabis as of 8/3/11

– Multiple sclerosis – 192

– Spinal Cord Damage with Intractable Spasticity –172

– Inflammatory autoimmune‐mediated Arthritis –72

– Crohn’s disease – 64

– Severe chronic pain ‐ 6

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Medicinal cannabis use for chronic pain

• Synergy with opioids and cannabis (Welch, 2004)

• Clinical trials support this finding

Advantages of Cannabis

• Opioid sparing

• Decreased risk of constipation

• Anti‐emetic properties

• Anti‐depressant properties

• Won’t decrease sexual functioning

Why include cannabis in the UDT panel?

• Will this help or harm the patient?

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Study found 13% of chronic pain patients use cannabis (Pesce, 2010)

• "The suggested practice guidelines indicate that drug testing is an essential component of the care of chronic pain patient opioid therapy.  Treating physicians often rely on patient self‐reports and it has been shown that a significant proportion of pain patients regularly obfuscate the truth in their self‐reports which can confound physicians who have to make important treatment decisions.  Earlier reports indicate that marijuana use often precedes the use of other illegal drugs.

Study found 13% of chronic pain patients use cannabis (Pesce, 2010)

• That having been said, although it is understandable in today's more relaxed climate regarding the use of marijuana (punishment for which can be a simple ticket) that patients would be more likely to report to their physician that they are taking that drug than cocaine or methamphetamine, reporting marijuana use would likely result in their being denied health insurance.  This means that patients are unlikely to report use of this drug, and physicians are unlikely to test for this drug.“  (p. 286)

Study found 10% Chronic Pain Patients Used Illicit Drugs (Christo et al, 2011)

• "Illicit drugs are used by approximately 10% of patients in chronic pain management settings.  The possibilities of such a result include that the patient might have occasionally used or is a frequent user, or is addicted to the illicit drug.  It is well accepted that patients should be informed and advised that continued illicit drug usage is incompatible with opioid therapy." 

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Study found 10% Chronic Pain Patients Used Illicit Drugs (Christo et al, 2011)

• "The appropriate action would be to reiterate opioid agreement with the patient, to inform the patient that continued illicit drug use prohibits opioid therapy, to repeat UDT with confirmation test on a regular basis, and failure to comply with this would result in termination of opioid therapy."

• "However, there is a difference of thresholds held by different practices, which results in different practice philosophies that dictate the level of tolerance when faced with such actions, i.e., "one chance" or "zero tolerance.“  (p. 134‐5)

Question the Experts!

• "Passive smoke inhalation does not explain marijuana results at typical cutoffs (50ng/mL).  If a positive result occurs, counseling the patient about the use of marijuana and reinforcing the boundaries set out in the treatment agreement will be more useful than taking a confrontational approach.  Repeated positive results for marijuana should be viewed as evidence of ongoing substance misuse that requires further evaluation and possible treatment." (Gourlay et al., 2010, p. 13)

• (Continued)

Question the Experts!

• "Food Products and Coca Tea:  Legally obtained hemp food products are increasingly available in retail stores.  Although hemp products do not appear to be psychoactive, there have been concerns that ingestion of these food products, which contain traces of THC, may cause a positive UDT result for cannabinoids.  However, multiple studies have found that the THC concentrations typical in hemp products are sufficiently low to prevent a positive immunoassay result.  (cont.)

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Question the Experts!

• There was a recent report by the Centers for Disease Control and Prevention of inadvertent ingestion of marijuana among a group of preschool teachers who experienced nausea, dizziness, headache, and numbness/tingling of fingertips after consumption of brownies purchased from a sidewalk vendor.  Analysis detected cannabinoids in a recovered sample of the brownies and 1 of 2 patients who sought medical attention had a urine sample test positive for THC.  (cont.)

Question the Experts!

• “Patients should be advised not to ingest hemp products or coca tea." (Gourlay et al., 2010, p.14)

• How is that advice helpful to the patient?

Health Care vs. Law Enforcement

• Question your “pain contract” and UDT policies related to cannabis.

– Are they helpful or harmful to the patient?

– Are they based on science or fear of law?

– What happens to a patient with a +THC result?

– Can you omit cannabis from the UDT panel?

– Should you omit cannabis from the UDT panel?

– What about Marinol?

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Action Plan

• First:  Always assess the patient’s use of cannabis – don’t assume substance abuse

• Educate your peers about medicinal cannabis for chronic pain

• Advocate for patient access to legal cannabis as appropriate  (ANA resolution)

• Conduct research on cannabis use for chronic pain (if in a legal medical cannabis state)

Action Plan

• Learn more (ANA Resolution):

The Seventh National Clinical Conference on Cannabis Therapeutics 

Theme: The Endocannabinoid System: Clinical Implications for Health Care

– April 26‐28, 2012

– Loews Ventana Canyon Resort Hotel

– Tucson

www.medicalcannabis.com

To Test or Not to Test for Cannabis/Marijuana with Pain Contracts

Mary Lynn Mathre, RN, MSN, CARN

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www.MedicalCannabis.com for more information on the therapeutic use of cannabis.