US Veterans Denied Pain Medications Over Medical Marijuana Use

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UPDATE 3/10 – A revised policy has been issued. Read more.

3/6 – Dr. Skye McDougal has been snowed in in DC and is expected in California on Monday, March 9 to sign the new policy.

3/3 – The policy has been revised and is awaiting the director’s signature on Friday, March 6 before it is released.

2/26 – Andrea Phillips of VISN-22 wrote today, “They are working on revising the language and progress has been made. I will make sure I notify you as soon as it is completed. I’ll try to get a deadline in the meantime.”

2/9/2014 – We received this word today: “There is a clinical leadership group reviewing the policy this week. Any revisions to the policy will then have to get approved at a larger VISN group that will convene later this month.”

2/5/2015 – On February 4, 2015, Cal NORML and VMCA has received a communication from the Ethics lead of VISN-22 stating:

“VISN 22 established a network policy effective September 23, 2014 to establish guidance for safe and effective use of opioids in the management of non-malignant pain. The Veterans Health Administration (VHA) seeks to reduce harm from unsafe medications and/or excessive doses, or excessive duration of treatment, while optimizing pain management strategies. Each Veteran who is receiving opioids must sign an opioid agreement at the time they start the medication. That agreement requires that patients will not drink alcohol or use street drugs while they are on opioids. Both medications (opioids and medical marijuana) have the potential for sedation which may increase harm or lead to cognitive impairment. Simply put, we want to effectively manage the Veteran’s pain while trying to keep them safe from possible drug/drug interactions, overmedication and addiction.

“VHA policy does not prohibit Veterans who use medical marijuana from participating in VHA substance abuse programs, pain control programs, or other clinical programs where the use of marijuana may be considered inconsistent with treatment goals. Although patients participating in state medical marijuana programs must not be denied VHA services, modifications may need to be made in their treatment plans. Decisions to modify treatment plans in those situations are best made by individual providers in partnership with their patients.”

“VISN 22 is reviewing the language in our existing network policy to better reflect the provider-patient relationship and the Veteran’s choice. The provider and the patient will discuss the various options and information available. The patient will then make the choice as to what direction they want their non-malignant pain managed. The revised policy will define a pathway to manage these cases.”

UPDATE 2/3/2015 – Cal NORML has been informed that Jeffrey Gering is no longer acting head of VISN 22. No permanent director has yet been found; the new acting director is said to be Skye McDougall. We are attempting to reach her through several Congressional offices in the region.

Cal NORML is seeking input from California-based veterans who have been affected by VA policy around medical marijuana. Download a flyer for vets.

On January 17, 2015 the Veterans Democratic Club of San Diego County voted unanimously to oppose VISN-22 policy that denies prescription meds to vets who use medical marijuana.

November 10 – As the US prepares to honor its veterans on Veteran’s Day, California NORML has been receiving phone calls and emails from vets who are being told by their VA doctors that they must choose between their prescription pain medications or their medical marijuana.

A spate of complaints from Loma Linda and Long Beach have been received at the CalNORML office, following the rescheduling of hydrocodone to Schedule II and Tramadol to Schedule IV, which require stricter reporting requirements for doctors. That, and other factors, seems to have spurred a tightening up of policy at some VA facilities. In one case a prescription for Xanax has been jeopardized because of a patient’s medical marijuana use.

Doctors at the VA are prohibited from recommending medical marijuana, even for PTSD, and a federal amendment to allow them to do so failed in Congress this year. [Update 11/20:
Blumenauer, Rohrabacher Introduce Bipartisan Veterans Equal Access Act to Expand Medical Marijuana Access to our Nation’s Heroes

“Viet Nam vets have shown me that, in many cases, cannabis is the one medicine that has consistently helped their seriously disabling symptoms, allowing them to function, hold jobs, keep their relationships intact, and raise families for the past 30 or so years, when years of therapy and numerous medicines have not,” said Frank Lucido, a Berkeley-based MD who specializes in cannabis therapy.

But some vets require prescription pain meds, as well as cannabis. Studies estimate that 50% of veterans experience chronic pain, and nearly half of these patients receive prescription opioids. The VA issued a directive in January 2011 stating that “VHA policy does not administratively prohibit Veterans who participate in State marijuana programs from also participating in VHA substance abuse programs, pain control programs, or other clinical programs where the use of marijuana may be considered inconsistent with treatment goals. While patients participating in State marijuana programs must not be denied VHA services, the decisions to modify treatment plans in those situations need to be made by individual providers in partnership with their patients.”

This would seem to leave the matter to individual doctors; however many patients are reporting that their doctors are making them choose between their prescription drugs or their medical marijuana, claiming that this is VA policy.

An investigation found that on September 23, 2014 then-acting Desert Pacific Healthcare Network director Jeffrey Gering issued a VISN policy stating: “For safety reasons in patients receiving chronic opioid therapy for non-malignant pain, if UDS detects marijuana, opioid therapy will be tapered off and discontinued if patient continues to use any form of marijuana and opioids concurrently.”

Safety has been identified as a concern, with some doctors and administrators wrongly assuming that the use of marijuana along with opiates is unsafe. In fact the opposite is true. An article published in August 2014 in the Journal of the American Medical Association (JAMA) by Marcus A. Bachhuber, M.D., of the Philadelphia Veterans Affairs Medical Center and colleagues shows that the number of opiate overdoses is down in states with medical marijuana programs, and suicides in those states are also down, according to a study co-authored by San Diego State economics professor Joseph J. Sabia. Veterans are committing suicide at the rate of 22 every day.

Increasingly, patients everywhere are being told they must sign “pain agreements” before being prescribed opiates, as part of the FDA Opioid Risk Evaluation and Mitigation Strategy (REMS) mandates. Those requirements “can include” commitments to return for follow-up visits “to comply with appropriate monitoring (such as random drug testing).” Nothing says doctors must include such commitments, or that the “appropriate monitoring” must be drug testing.

The VA’s Clinical Practice Guideline calls for a urine drug test prior to initiating opioid therapy and a follow-up contact at least every 2–4 weeks after any change in medication regimen. A recent inspector general’s report found that in 2012, only 6.4 percent of the new patients received both a UDT prior to and a follow-up within 30 days. Reportedly, after that report hit, facilities stepped up their drug testing.

Drug testing for pain patients is being pushed by journals like Pain Medicine News, which run advertorials saying that marijuana should be tested for as a matter of course, even though the stated purpose of the drug tests is to confirm compliance with prescribed medications. [Update 3/15: PMN has now published an editorial calling for rescheduling of MMJ and research into its uses for pain.]

As far back as 1997, Dr. Sandra Welch from the University of Virginia has been studying the interaction of opioids and cannabinoids, with results in animal studies showing that the two have a synergistic effect. These findings were confirmed in a recent study of 21 individuals with chronic pain, which concluded that “vaporized cannabis augments the analgesic effects of opioids without significantly altering plasma opioid levels. The combination may allow for opioid treatment at lower doses with fewer side effects.” And a 2012 study from Vancouver found that increased access to medical marijuana reduced patients’ use of opiates and other addictive drugs.

In a 10-year survey published by O’Shaughnessy’s in 2006, Helen Nunberg, MD reviewed patient files at nine different medical marijuana clinics. She found that 51% of the 1800 patients in the study reported using cannabis as a substitute for prescription medications; 48% reported using cannabis to prevent prescription medication side effects; 67% reported using cannabis to reduce dosage of prescription medication; and 49% of patients using cannabis for chronic pain were previously prescribed an opiate.

The California Center
 for Medicinal Cannabis Research, established by the state legislature at University of California in 2000 to conduct controlled
 scientific studies of medical marijuana, reported positive results in six different human clinical trials regarding chronic pain and spasticity, using vaporized whole-plant cannabis. CMCR director Prof. Igor Grant concluded in a report to the legislature, “There is good evidence now that cannabinoids may be a good adjunct or even first line treatment” for neuropathic pain.” Cannabis has also been found helpful in treating intractable pain.

Michael Krawitz, Executive Director of Veterans For Medical Cannabis Access is himself a longterm pain sufferer and has seen his own share of difficulties in integrating his use of cannabis as an adjunct therapy inside the VA system. Krawitz said, “It is sad that over the years my medical needs have been best met when I was outside of the United States under the care of doctors in Europe. Here in the country where I was born and honorably served in the military, I am denied basic medical needs as well as the ability to discuss my medical options with my VA doctor — and have them make their medical advice based upon evidence instead of doctrine.”

Cal NORML and Veterans for Medical Cannabis Access are calling for:

-the reintroduction and passage of a congressional bill or amendment to grant doctors at the VA the same first-amendment rights as other doctors to discuss medical marijuana,

-the descheduling of cannabis from DEA’s Schedule I, allowing it to be researched and prescribed,

-a safety study on the use of cannabis with opiates, and

-an education program for VA doctors, informing them of VA’s policy on medical marijuana, and its beneficial effects including its use as an adjunct to prescription pain medications.

UPDATE 1/17/2014 – The Veterans Democratic Club of San Diego County voted unanimously to oppose VISN22 policy that denies prescription meds to vets who use MMJ.

1/11/15: Despite numerous requests, Cal NORML has not been able to see a change of regional VA policy in writing. Instead, we’ve had more complaints from vets who are being told that the policy denying them their prescription meds is still in effect. On Christmas Eve a paratrooper injured in service was told he would still be denied his meds.

UPDATE 11/26/2014: Just in time for Thanksgiving, the VA leadership in Southern California has reportedly agreed to amend their policy toward medical marijuana patients with opioid prescriptions.

According to correspondence forwarded from Michael Krawitz of Veterans For Medical Cannabis Access, the national VA ethics committee contracted the regional VISN 22 office and informed them that:

“Opioids are among the many treatments that may be clinically indicated in managing a Veteran’s pain, including those Veterans participating in state approved medical marijuana programs.

“Providers should use their clinical judgment and knowledge of professional standards in determining whether or not the benefits of long-term opioid therapy for patients using medical marijuana outweigh the risks. These decisions should be part of a shared decision making discussion with the patient and should be based on available medical evidence.”

They report:

“The VISN 22 pain leadership expressed concerns that providers hold regarding the risks of treating patients with long term opioids who also use marijuana but by the end of the conversation had agreed to revise their policy in light of our discussion and VHA guidelines for treating patients using marijuana.”

If others have problems in this area, please write here.

Also see:
Also see: Two Veterans Tell Their Story: VA Hospitals in Southern California Deny Medical Marijuana Patients Their Prescription Meds

Legal and Clinical Evolution of Veterans Health Administration Policy on Medical Marijuana

Pain Doctors Discriminate Against Medical Marijuana Patients

VA Allows Medical Marijuana for Pain

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