Oklahoma doctors, pain patients search for clarity on marijuana
Oklahoma City — Without clear guidance from the state, Oklahoma pain doctors are on their own to figure out how to care for patients who want to use medical marijuana, and advocates say a significant number have decided not to try.
Medical marijuana supporters estimate about 50 pain management doctors around the state have decided to discharge patients who want to use marijuana. Others have kept their patients on, but declined to continue prescribing them opioids.
Chris Moe, an activist, said he and his doctor had an understanding for years that the doctor would continue to prescribe opioids he needed to manage his back and nerve pain, so long as Moe didn't test positive for anything other than the marijuana he used to control other symptoms. He didn't expect anything to change when Oklahoma voters legalized medical marijuana through State Question 788, and was surprised when his doctor discharged him.
Moe said his doctor was afraid for his license if he kept prescribing opioids to a patient using medical marijuana. Other people who contact him through his Facebook page for chronic pain patients have told similar stories, and Moe worries some of them could turn to street drugs if cut off from their medications.
“I'm getting calls from people who are ready to kill themselves because they've lost all hope,” he said.
A 2016 report from the National Academies of Science found “substantial” evidence that marijuana smoking can reduce chronic pain, but equally compelling evidence linking it to an increased risk of car crashes, chronic bronchitis and some mental illnesses — particularly in people with a family history of psychosis. Some groups have put out guidelines for doctors to weigh the potential risks and benefits, but what's good practice remains up for debate.
No simple answer
At first blush, discharging patients may look like the safe option. But it's not so simple. SQ 788 includes a provision forbidding discrimination against medical marijuana users, including refusal to provide health care.
Tom Bates, interim commissioner of the Oklahoma State Department of Health, told doctors at an event in Oklahoma City on Friday that they still can exercise clinical judgment but can't deny care solely because a patient uses medical marijuana. He wasn't sure whether denying patients opioids because they used medical marijuana would be illegal.
“That's the language of the state question, and we'll just have to see how that plays out,” Bates said. “That's something for the medical profession to sort out.”
The Health Department can't step in because of its limited authority under SQ 788, the Legislature won't be able to settle any questions until it returns in February and the two state licensing boards overseeing medical doctors and osteopathic physicians are waiting for clarity before issuing guidance.
The Oklahoma Pain Society, a trade group, issued a statement saying its member physicians can decide whether to use marijuana to treat chronic pain, so long as they monitor patients carefully and discuss benefits and risk with them. Its guidance doesn't have the force of law, though.
The greatest concern when allowing patients to use other drugs with opioids is whether the combination would increase the risk of overdose, as happens when patients mix opioids with some drugs for anxiety or insomnia.
Marijuana and opioids act on the same pathways in the brain, but marijuana doesn't increase the risk of overdose, said Dr. Sunil Aggarwal, who studies cannabis at Advanced Integrative Medicine of Seattle Institute. Patients who use medical marijuana often can reduce their use of opioids, putting them at a lower risk of overdose, he said.
Dr. Ajay Wasan, vice president of scientific affairs for the American Academy of Pain Medicine, countered it isn't clear that combining marijuana and opioids is risk-free. Until more evidence emerges, doctors should probably err on the side of reducing patients' use of opioids if they want to use marijuana, he said.
“There's still a lot of controversy in this field,” he said.