Clinical Dilemmas: Prescribing Opioids Concurrently With Medical Cannabis

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Given the rise in the legalization of medical cannabis, pain clinics may be confronted with this issue more frequently as patients seek alternative modalities for treating their pain.
Given the rise in the legalization of medical cannabis, pain clinics may be confronted with this issue more frequently as patients seek alternative modalities for treating their pain.

AC is a 57-year-old female patient who is seen in our clinic for chronic low back pain. She has lumbar disc disease, which causes radicular pain down both lower extremities. She has been prescribed oxycodone, which has been reported to be helpful.  Antiepileptic agents and tricyclic antidepressants have not been effective at controlling her radicular symptoms, although she does report some relief with baclofen. 

Recently the patient began experimenting with topical agents (OTC gels, creams, tinctures) for pain relief and was provided with a homemade compound by a close friend. This treatment worked well for her. During one of her routine monthly follow-up visits, we asked her to find out more about the ingredients used to create this particular compound, as she was not aware of what it contained. 

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AC was surprised to learn that a cannabis extract was the main ingredient in the topical product. The policy of this clinic does not allow for chronic cannabis use, regardless of the vehicle, if opioid medication is prescribed on a daily basis.  Until the American Medical Association (AMA) endorses the concurrent use of opioid with cannabis, this clinic will not allow for both to be used. Her last toxicology screen identified low tetrahydrocannabinol levels, which was attributed to the topical agent she had been using. 

The patient has since discontinued the topical agent due to the clinic's policy regarding cannabis use; however, the pain-relieving effect of this agent had been significant. Although the use of cannabis for medical purpose is allowed in the state where this patient resides, the clinic has made a decision not to prescribe opioid medication if this type of treatment is used. This is partly due to the lack of endorsement from the AMA until further research has been completed.  

At least 23 states and the District of Columbia have already approved programs that allow for medical cannabis use in their regions, with more states to approve such laws in the near future. Given the rise in the legalization of medical cannabis, pain clinics may be confronted with this issue more frequently as patients seek alternative modalities for treating their pain

Does your pain clinic currently allow the use of cannabis in combination with opioid medication? If so, has a maximum THC threshold been identified? How have your patients responded to such treatment?  Share your experience in the Comments section below. Mr Pacheco will be available to provide insight and feedback to your comments in this moderated forum.

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