Pain Clinics Test Patients for Marijuana Use

  • by Allen St. Pierre, Former NORML Executive Director July 7, 2009

    By Dale Gieringer, Director, CA NORML

    Like many medical marijuana users, Kristin Redeen needed additional prescription medications for her severe chronic pain. For seven years she had been treated at a private pain clinic in the Central Valley, where a doctor maintained her on Percocet, a semi-synthetic opioid. One day Kristin was unexpectedly asked to submit a urine sample.  pot_civil_rights

    “They already knew about my medical marijuana use,” says Kristin, who contacted California NORML. “I didn’t think I was doing anything wrong.”

    When the test  came back, Kristin was informed that the clinic would no longer renew her prescription because she had tested positive for an illegal controlled substance. Her doctor at the clinic cited legal concerns, claiming –falsely– that DEA regulations forbid giving prescription narcotics to users of marijuana or other illegal drugs.

    Kristin was cut off from her Percocet and began suffering seizures. She finally found a physician who was willing to prescribe her another opioid, Vicodin, but only at low doses insufficient to relieve her constant pain.

    Kristin is one of a growing number of medical marijuana patients discriminated against by pain clinics. “I must have heard of 25 cases this year,” says Doug Hiatt, an attorney in Washington state. “It’s Jim Crow medicine.”

    NORML has received a surge of complaints within the last six months.  Many medical marijuana users report that they can’t find a clinic willing to take them on.  Others, like Kristin, have been abandoned by clinics that suddenly adopted aggressive drug-screening policies.

    Clinics say they are legally compelled to drug-test chronic pain patients so as to avoid liability for overdoses and diversion of prescription drugs, particularly opioids such as oxycontin –which have nothing to do with cannabis.

    Chronic pain patients have good reason to object to being denied medical access to cannabis. Chronic pain is the leading indication for medical cannabis use, accounting for 90% of the patients in Oregon’s medical marijuana program.   More than 60 studies have shown cannabinoids to be effective in pain relief, according to a compilation by the International Association of Cannabis Medicine which includes four controlled studies of smoked marijuana by California’s Center for Medicinal Cannabis Research.

    Studies indicate that cannabis interacts synergistically with opioids in such a way as to improve pain relief [1, 2].    California medical cannabis specialists consistently report that patients are able to reduce use of opioids –typically by 50%– when they add cannabis to their regimen.  Cannabis can therefore be seen as a gateway drug leading away from opioid addiction.  Nevertheless, patients are being pressured to stop using cannabis if they want to get prescription opioids.

    To their dismay, patients have to pay for the drug tests at their own (or their insurers’) expense.   Carol, a chronic pain patient who had been treated for seven years by the same clinic without any testing, reports that she was billed $325 for a urine screen. The balance of the bill, which totaled $1,601, was paid by her insurer.

    Carol says her doctor told her that “the DEA requires him to drug test all his clients, that he has no choice, it is the law.”

    In fact, there is no law requiring clinics to drug screen patients for marijuana.   “It’s BS,” says Hiatt.  Not a single case is known in which pain doctors have been sued or prosecuted for allowing medical marijuana use along with opiates.

    Prosecutors have argued that marijuana might be obtained on the illicit market in trade for  prescription drugs, though such a scenario seems implausible in medical cannabis states. “It’s unwarranted paranoia,” says Gregory Carter, MD, one of the few practicing pain experts who recommend marijuana in Washington.

    Given that cannabis is notably less toxic and addictive than other prescription narcotics,  it seems highly ironic that pain clinics are discouraging its use.  The prejudice against marijuana has nothing to do with medical science, but rather with political and legal pressures to crack down on prescription drug use. Non-medical use of prescription drugs has recently emerged as the nation’s number-one drug problem du jour.

    A new government report, ominously entitled the “National Prescription Drug Threat Assessment,” reported 8,500 deaths in 2005 from prescription pain relievers (mainly opioids), more than double the 2001 total. “Diversion and abuse of prescription drugs are a threat to our public health and safety – similar to the threat posed by illicit drugs such as heroin and cocaine,” warned Drug Czar Gil Kerlikowske.

    The Pain Specialists’ Meeting
    The 2009 American Pain Society Convention in San Diego included a panel on “Cannabinoids in Pain Management,” chaired by Dr. Mark Ware of McGill University. Dr. Andrea Hohmann, an expert on stress-level analgesia from the University of Georgia, presented evidence from rodent studies which showed that cannabinoids suppress nociceptive processing through both the CB1 and CB2 receptors, and that endocannabinoids, including 2-AG and anandamide, help suppress pain.

    Donald Abrams, MD, of the University of California at San Francisco, discussed his studies showing that inhaled marijuana significantly reduced neuropathic pain experienced by HIV patients.  Cannabinoids and opioids interact synergistically on separate but parallel pain receptors, Abrams said. He is conducting another study on combined use of cannabinoids and opioids, preliminary results of which appear promising.

    Dr. Ware discussed studies involving the variety of cannabinoid medicines available in Canada, which include dronabinol, Sativex, Nabilone, and herbal THC. All of them have demonstrated efficacy in pain relief.  Cannabis is now recognized as a “third line” agent for neuropathic pain in Canada.  Noting that that its adverse effects are mild to moderate, Ware concluded that “cannabinoid analgesia is the real thing.”

    During the question session, your correspondent asked why it was that, in light of evidence that cannabis was so useful in pain therapy, there appeared to be an upsurge in drug testing to prevent its use.  The panelists could offer no explanation.

    We moved on to the exhibition hall, where drug testing companies were conspicuously displaying their wares.  Their exhibits showed how well their products could monitor usage of opiates.  The exhibitors seemed surprised when we told them that their products were being used against medical marijuana.

    One of the more sophisticated exhibitors was Ameritox, which boasted panels for distinguishing a dozen different opioids plus numerous sedatives, tricyclic anti-depressants, barbiturates, and stimulants as well as “drugs of abuse,” among them marijuana.  Their saleswoman seemed surprised to hear that the Ameritox test was being used to screen out medical marijuana patients.  She said that clinics could easily order the screens without the marijuana if they wanted.
    Another company boasted how their test could be administered at the doctor’s office, thereby allowing the doctor rather than the lab to collect the bill.

    Finally, we spoke to a legal expert on pain medication, Ms. Jennifer Bolen, a former prosecutor turned defense attorney, who has a useful website devoted to the subject:

    Ms Bolen pointed to three recent developments that have increased the pressure to conduct drug screening of pain patients.  First,  pain doctors have suffered a string of stinging legal judgments for over-prescribing opioids to patients who subsequently overdosed. One notable example involved Dr. Thomas Merrill of Florida,  whose life sentence was sustained by the Eleventh Circuit Court of Appeals last year.

    This February, a prestigious panel of the American Pain Society issued “New Guidelines for Prescribing Opioid Pain Drugs” which counsels that “diligent monitoring of patients is essential. “ The report specifically recommends periodic drug screens for chronic opioid patients at risk for aberrant drug behavior, though it doesn’t mention cannabis.

    Lastly,  under  legislation that took effect this year, the FDA has new authority to require pharmaceutical companies to implement “risk management” programs to prevent consumer drug misuse.

    Medical cannabis patients have no easy remedy to the current drug testing onslaught. In the absence of dire bodily harm, malpractice suits are of no avail.  In general, pain clinics have no legal obligation to treat anyone.  They commonly require patients to sign contracts allowing them to conduct drug screening at will.  Nonetheless, patients may have good grounds to complain to their state medical boards.  This is particularly the case where they have been abandoned by their doctors after being made dependent on prescription narcotics.

    The ultimate recourse is to educate doctors, many of whom remain woefully ignorant of the literature on medical marijuana and chronic pain.  At the APS convention we encountered a distinguished pain specialist from San Diego, who joked about having enjoyed the marijuana muchies with his son,  but averred that he wouldn’t let his patients use it, on the grounds that it wouldn’t be useful, and anyway smoked medicine is bad for the lungs. Like most convention attendees, he had missed the panel on medical cannabis, where Dr. Abrams had discussed the use of smokeless vaporizers.

    Still,  good physicians should be open to persuasion from patients. Cynthia, a severe chronic pain patient. had frequented the same clinic for 10 years when she was confronted with a surprise urine test.  In addition to prescription opiates, she had been using medical marijuana, though her recommendation was four years out of date.   The test cost her $100  and her insurer $500 more.

    On finding her positive for marijuana, her doctor informed her that she would have to reduce her cannabinoid level to zero.  After a heart-to-heart  talk, in which she explained to him how she had been able to reduce her opiate use to minimal levels thanks to medical cannabis, her doctor relented. “I feel really lucky,’ says Cynthia,  “You have to feel out the doctor. We have a special relationship.  I don’t think he plans to do this with all his patients.”

    [1] Lynch and Clark, “Cannabis reduces opioid dose in the treatment of chronic non-cancer pain,” Journal Pain Symptom Management, (2003) 25(6) 496-8.

    [2[ Narang et al., 2008 Efficacy of dronabinol as an adjuvant treatment for chronic pain patients on opioid therapy, J Pain. Mar;9(3):254-64.

    From O’Shaughnessy’s, Summer 2009
    To order this 52-page, all-content, no-jive publication, send $5 to p.o. box 490, Alameda, CA 94501. O’S is available in bulk to physicians, collectives, cooperatives and reform groups for $1/copy for free distribution to patients and interested citizens.

    179 responses to “Pain Clinics Test Patients for Marijuana Use”

    1. David says:

      Un-fucking-believable. So this is what those crooks, the DEA, are sinking down to now? How fucking low can they go? Taking away the rights and medicine of doctors’ patients??



      • Beth PEDEN says:

        I totally agree. I have seen people who were taking opiods for many years tested and their medications taken away. My biggest concern is over half of those people are now upgrading to street drugs and are using meth or heroin. The street prices have doubled for those who can find the medications they were taking for many years. I have seen good working people chance into iv drug users and some just plain junkies. Our government may have had good intentions, but the reality has become a nightmare. Street dealers are thrilled however, and they won’t be seeing any tax money from them. I’m unsure who had this great idea, but they need a reality check up.

    2. Jacki says:

      I would like to add my 2 cents worth here also. I have been treated by a general practitioner for 5 years now to manage pain caused from an injury to my thoracic spine in which a disc has bulged into my spinal cord causing it to flatten which causes severe pain when using my arms. I have been with the same doctor for about 4 years now after losing my original doctor due to a failed ‘surprise’ urine test. When I secured my second doctor, I told him up front that I used cannibis and his response was he had found it helpful for many things, as he was a user during his own cancer treatment. I asked about problems with the govt. and he responded that he didn’t care about the govt.I had to sign a ‘contract’ that allowed for testing. He stated that he would not test me unless he had a reason. He had been prescribing MS Contin-30mg twice a day and up to 60mg of Vicodin per day along with 10mg of Valium per day to control muscle spasms. Since MMJ isn’t legal here in Wisconsin, even the best local smoke didn’t help as much as MMJ, but it did help with the spasms. The last time I saw him, about a month ago, he demanded a drug test. I told him that I would probably fail because of MJ. He said that he would ignore that part.
      Today, I received a phone call from his office stating that he was uncomfortable treating me anymore and has washed his hands of me and my problem. I have not received the results of my test as of this writing and I wonder if I have any recourse.
      Thanks for your thoughts,

      • Beth PEDEN says:

        Normal has lawyers listed for this type of issue. It would be your best bet. I don’t receive anything for my pain now, my Dr even took away somas. I will not take another urine test.

    3. Annie says:

      I have M.S. and the pain clinic threw my out with no medicane for testing postive and I cant get pack in one at all so I know the feeling. Pot helps me better than anything else I have tried my doctor knows this yet I cant get it, just not fair!!!

    4. JIm Bob says:

      Scary stuff. The seizures could have led to a fatality by choking or falling.

    5. R.O.E. says:

      This is just criminal!! They cant show that cannabis has EVER killed anyone. They cant show that cannabis is worse than any other drug onthe market(or blackmarket for that matter). Yet they work so very hard to make life difficult on cannabis users. I think the day will come when they will try and remove all rights from cannabis users. HOW THE HELL ARE CANNABIS USERS SUCH A DANGER THAT YOU(DEA AND GOVERNMENT LEADERS) THINK YOU HAVE THE RIGHT TO RUIN THE LIVES OF GOOD PEOPLE?!?!?!? AMERICA? I think not! The day will come when America will change for better or worse. It just depends on who wins…the people or the government. This is socialism !! Communism comes after that.

    6. MB says:

      Amazing how much the DEA and pharmaceutical companies really hate Cannabis.

    7. R.O.E. says:

      Just a side note: Its reasons like this that I havent used cannabis for a very long time. I wont be til we get it legal. It was my fathers death that really got me in this fight. Cancer. He could have dont much better without the the drugs they pumped into him. It was terrible what these man made drugs did to him.

    8. Delpart says:

      It goes beyond the simple pain management aspect. People on disability have been told testing positive means instant disqualification and the potential to be sued for damages to repay monies spent on their care. I was aghast when I saw that paperwork to be signed.

      What I think is another major flaw is that we are paying out tons in additional tax dollars to test for “illicit” drug use at a rate much higher than what is often quoted to the public. How many times have you been told that drug screens only cost about $50-100? Somehow the costs of administering these tests have escalated higher than the cost of buying a Tylenol in a hospital. It is not uncommon of late to see the actual bill show anywhere from $600-1000 for a simple urine drug screen.

      People wonder why we cannot afford to provide medical care? Simple corruption for a dipstick test is just one of many examples.

      The other problem is of course doctors basically getting out of the “pain management” business. I was no longer able to get a normal prescription for a non-narcotic migraine medication because it came under their “pain management” rules at my previous care provider. Needless to say I had my insurance company reverse the bill for that last visit. They also referred me to a “pain specialist” who had a contract that had to be signed stating I needed to submit to random drug testing and that results could be made available to law enforcement.

      Who knows. Maybe in a few more years we wont be able to even get a simple Tylenol for a headache over the counter without having to see a pain management specialist first.

    9. Manfor Mantis says:

      1 David says:

      “How fucking low can they go”

      David…A man must know his limitations. Evidently… they don’t have any limitations… let alone a conscience to guide them from those unconscionable acts, especially when they are sworn to do no harm.

      Let me ask you David…Would you go to a Doctor if you knew he was on the mortician’s payroll? If you knew the inner workings of medicine it would shock you. So let’s leave it at that. I don’t want to blow your mind. How can I say that…you ask. 35 years a healthcare consultant and mediator should be enough

      How low can they go? To new depths I’m sure!

    10. Jerry Moler says:

      I hope NORML can use this and Bob’s case to make the general public aware of what our government is doing to the sick people of this country in the name of prohibition. How can anyone with a heart do this to a person in severe pain. What a bunch of truly evil people. I hope someday the have the misfortune of being in pain with no relief insight so they can experience what they have done to these poor people. This is the most shameful thing I have seen in the name of medicine. What happened to first do no harm!!!