Cdc says pain drs do not test for cbd oil

Why Pain Clinics Should Stop Testing for Marijuana

High-quality evidence supports the use of medical marijuana for chronic pain, neuropathic pain, and other conditions. Yet, patients who live in some states can’t legally use it — and are threatened with loss of access to their prescribed pain medications if they do.

I know this because a close family member of mine has chronic pain. She has fibromyalgia, migraines, neuropathic pain, rheumatoid arthritis, and numerous other health issues, resulting in 21 surgeries. She has been taking prescription opioids for 15 years.

She wishes she could use marijuana for her pain, because she knows from experience that it works — and with minimal side effects, unlike opioids. Marijuana reduces migraine frequency, reduces pain, and improves her functionality and quality of life. But she can’t use medical marijuana legally, because she lives in North Carolina. North Carolina does not allow medical usage for any of her conditions – only epilepsy.

Even worse, her pain clinic tests her urine twice a year, and marijuana is one of the drugs they test for. Her pain clinic will cut her off if she tests positive. In this threat, they are consistent with North Carolina’s Medical Board guidelines to doctors who prescribe opiates [PDF]. If a patient smells like marijuana or has a positive urine screen, the guidelines suggest this “should raise the physician’s awareness about the possibility that a patient is seeking opioid medications for reasons other than legitimate pain relief.”

My relative is, in her own words, a “disabled senior citizen,” hardly a candidate to be selling her medications. She is trying to cope with the burden of multiple painful conditions, with little respite. In her own words:

One of my issues is the tolerance that has developed for my pain medication and the limitation put on the strength. I have been on 30mg of extended release MSIR [morphine] for 3 years … and I would have to say on a scale of 1-10 [my pain is still a] 6 every day. This in turn reduces my motivation to exercise and move because I know it will increase my pain…

Her daily pain medication regimen is associated with side effects ranging from chronic constipation to sleep apnea and respiratory depression, not to mention opioid-induced hyperalgesia. And still her pain is insufficiently managed.

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In March, 2016, the CDC published guidelines for opioid prescribers: stop testing for marijuana:

Clinicians should not test for substances for which results would not affect patient management or for which implications for patient management are unclear. For example, experts noted that there might be uncertainty about the clinical implications of a positive urine drug test for tetrahyrdocannabinol (THC).

This is just one battle in the ongoing civil war in the medical community over pain. And there remain many questions about how cannabis should be used in practice. But in my view, it is time for prescribers to change their drug-testing policies. There is little evidence that testing for marijuana prevents opioid diversion. However, testing for THC — and dumping patients that test positive — presents plenty of risks for patients: barriers to access to care, lack of adequate pain management, and disruption in care continuity, for starters.

Time will tell whether the ongoing global marijuana legalization experiment will ultimately be a boon, a bane, or both. There are encouraging signs; for example, states that have medical marijuana dispensaries have seen a relative decrease in opioid addictions and opioid overdose deaths [PDF]. Regardless, there is little continued justification for drug-testing for marijuana in pain clinics. Instead, doctors should consider the evidence for marijuana as a potential therapeutic partner in treating pain.

Lisa M. Lines, PhD, MPH is a health services researcher at RTI International, an independent, non-profit research institute. She is also an Instructor in Quantitative Health Sciences at the University of Massachusetts Medical School. Her research focuses on quality of care, care experiences, and health outcomes among people with chronic illnesses; emergency department utilization; and person-centered care and patient-centered medical homes, among other topics. She is co-editor of TheMedicalCareBlog.com and serves on the Medical Care Editorial Board.

CDC Guidelines Instruct Pain Doctors Not to Test for THC

March 18, 2016 – The Centers for Disease Control and Prevention, in long-awaited guidelines on prescribing opioid medications for pain, gives tepid endorsement for the use of urine testing before and during opioid therapy for pain, despite its statements that, “Urine drug tests do not provide accurate information about how much or what dose of opioids or other drugs a patient took,” and “The clinical evidence review did not find studies evaluating the effectiveness of urine drug screening for risk mitigation during opioid prescribing for pain.”

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“Urine drug testing results can be subject to misinterpretation and might sometimes be associated with practices that might harm patients (e.g., stigmatization, inappropriate termination from care),” the guidelines state. Indeed, Cal NORML regularly hears from patients who are terminated from pain management medications because of their use of medical marijuana.

“Clinicians should not test for substances for which results would not affect patient management or for which implications for patient management are unclear,” the CDC states. “For example, experts noted that there might be uncertainty about the clinical implications of a positive urine drug test for tetrahyrdocannabinol (THC)…Clinicians should not dismiss patients from care based on a urine drug test result because this could constitute patient abandonment and could have adverse consequences for patient safety.”

“We applaud the CDC’s reasoned approach to the use of urine testing and its drawbacks when used on pain patients,” said Ellen Komp, Deputy Director of California NORML. “Considering that opioid overdose deaths are significantly lower in states with medical marijuana programs, we are sorry the agency apparently didn’t read the letter Elizabeth Warren recently sent to its chief calling for marijuana legalization as a means of dealing with the problem of opiate overdose.”

Also from the guidelines:

“Experts agreed that prior to starting opioids for chronic pain and periodically during opioid therapy, clinicians should use urine drug testing to assess for prescribed opioids as well as other controlled substances and illicit drugs that increase risk for overdose when combined with opioids, including nonprescribed opioids, benzodiazepines, and heroin [notice THC is not included.]” The use of “a relatively inexpensive immunoassay panel for commonly prescribed opioids and illicit drugs” was acknowledged but its drawbacks were noted (does not detect synthetic opioids (e.g., fentanyl or methadone) and might not detect semisynthetic opioids (e.g., oxycodone). These panels are often where THC is detected.

“Most experts agreed that urine drug testing at least annually for all patients was reasonable. Some experts noted that this interval might be too long in some cases and too short in others, and that the follow-up interval should be left to the discretion of the clinician. Previous guidelines have recommended more frequent urine drug testing in patients thought to be at higher risk for substance use disorder. However, experts thought that predicting risk prior to urine drug testing is challenging and that currently available tools do not allow clinicians to reliably identify patients who are at low risk for substance use disorder.”

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“Some clinics obtain a urine specimen at every visit, but only send it for testing on a random schedule. Experts noted that in addition to direct costs of urine drug testing, which often are not covered fully by insurance and can be a burden for patients, clinician time is needed to interpret, confirm, and communicate results.”

Called “the nation’s top federal health agency,” CDC sought the input of experts to assist in reviewing the evidence and providing perspective on how CDC used the evidence to develop the draft recommendations.

UPDATE 2/26 PM: This response was received from CDC spokesperson Courtney Lenard:

It is prudent for clinicians to restrict use of any medical test to situations when results of the test would be helpful in decisions about patient management. This is particularly important when testing or test results might have unintended negative consequences for patients. Some experts noted that in some cases, positive THC results might have legal or other consequences for patients but might not inform patient care decisions. While CDC is not stating that urine tests for THC should never be used, the guideline recommends that clinicians should only test for substances (including THC) if the clinician knows how he or she would use the results to inform patient management.

Regarding the statement “However, experts thought that predicting risk prior to urine drug testing is challenging and that currently available tools do not allow clinicians to reliably identify patients who are at low risk for substance use disorder.”: this statement refers to the difficulty in risk-stratifying patients for urine drug testing, given that most other available tools would not allow clinicians to accurately predict which patients are at low enough risk for substance use disorder that urine drug testing would not be needed.