I am a pro-marijuana pediatrician ― not because available treatments are inadequate, but because it can remove me from the liability of prescribing opioids.
My youngest patient using medical marijuana is 3 years old.
I have been a pediatric oncologist for 15 years. I have no concerns prescribing opioids for my patients with real and acute pain that is limited in duration or associated with a defined event. But I worry when prescribing to patients whose parents have persistent prescription requests for children with no solid signs of or reasons for pain.
More parents now struggle with opioids than they did when I began working in my field. To feed their addiction, some parents report their child’s pain responds only to opioids and then take their child’s prescription themselves. If the pain lingers longer than expected or occurs without a definitive event like major surgery or a destructive tumor, the opioid charade begins. First we recommend rest, hot packs, cold packs, acetaminophen, ibuprofen, physical therapy and counseling. A non-addictive neuromodulator might be added. The charade can escalate to mushrooming doses of oxycodone, morphine or Dilaudid, and interchanging them.
This game scares me. I am not a chronic pain or addiction specialist. As a pediatrician, I have no guidelines or protections in managing parental addiction. There are almost no pediatric chronic pain specialists. It is for these patients who claim chronic pain that I recommend marijuana. Medical marijuana comes with checks and balances I don’t otherwise have.
“A mother once threatened to punch me for refusing to prescribe more Dilaudid for her child. She later threatened to get a gun from her car.”
Anytime I prescribe an opioid, I worry about who is taking it. I worry about my practice because I have few legal protections and much legal risk. I cannot guarantee who takes the child’s medications. One of my patients obtained 200 tablets of Dilaudid prescribed under his name by four different doctors in four weeks. He slipped through the registry and its automated warnings because his cancer diagnosis exempts him from mandated prescription limits. I suspect his mother took some of those medications.
I have no counseling guidelines and no opioid contracts to address parental diversion. I have no recourse if a parent abuses their child’s prescription. I also fear for my safety. A mother once threatened to punch me for refusing to prescribe more Dilaudid for her child. She later threatened to get a gun from her car. Because of our isolated location in New Hampshire, her child cannot get cancer treatment elsewhere. I still care for him. For these individuals and for myself, medical marijuana is a safer distraction.
We need better language about medical marijuana. We should differentiate tetrahydrocannabinol (THC), the component that gets one high, from cannabidiol (CBD) which is not psychoactive and is of medical interest and value. Without this distinction, marijuana’s continued stigmatization prevents allocation of funding to research the components and optimal medical use.
But even if my patients and their parents had only the psychotropic fraction, my worries are minimal compared with prescribing opioids. Getting stoned and munching through a family-size bag of potato chips, even for someone on a sodium-restricted diet, is much less catastrophic than dying from an oxycodone overdose. And, I have no responsibility or liability with medical marijuana. I wish opioids were regulated similarly.
So when my attempts to control a patient’s or parent’s opioid requests are unsuccessful and I suspect abuse, I recommend medical marijuana. People are usually surprised. I play it up. “Perhaps we should consider marijuana. It’s controversial so I would not try it unless you agree the opioids are not working,” I tell them.
Marijuana has its allure. So far no one has declined it. Maybe parents think they will get marijuana in addition to the opioids. But once they agree that opioids are inadequate, I quickly spin that response. My prescriptions are insufficient, so by default, further prescriptions are useless. And for parents who are addicted, my prescriptions are the treatment they “need.”
I often feel guilty after a parent agrees to try medical marijuana for their child in situations where I believe opioid abuse by said parent is present. Parents don’t immediately realize they are being tricked into giving up the opioids I prescribed. Instead of addressing the parents’ underlying addiction and mental health issues, I replace their trouble with another while alleviating my own anxieties.
“I often feel guilty after a parent agrees to try medical marijuana for their child in situations where I believe opioid abuse by said parent is present. Instead of addressing the parents’ underlying addiction and mental health issues, I replace their trouble with another while alleviating my own anxieties.”
My role shifts to omission of details. I don’t tell them doctors cannot prescribe marijuana. Physicians only make a recommendation that marijuana be tried, but our recommendation is not a guarantee they will get it. We only certify their child’s diagnosis and treatment length. The state is then responsible for criminal background checks, screening and counseling. If approved, the state determines the product to be administered, decides how much is given, and assigns a single dispensary, which is the only location the patient can use.
I don’t tell them that it is expensive, that insurance won’t pay for it, or that in New Hampshire, you must pay upfront and in cash. I don’t tell them they are less likely to get high. The conversation is a fast one. I don’t tell them anything about these particular downsides because I don’t want them to realize they are being duped and then change their mind and ask for another opioid prescription.
Despite my guilt, I am relieved at my extrication. Medical marijuana provides some relief for my patients and liberates me. When parents and patients realize I am powerless in their obtaining marijuana, they redirect their demands and anger elsewhere. Because they have conceded that opioids did not work before, they are unlikely to ask for them again. By ending the deception, parents, patients and I can recenter our relationship and refocus our efforts on the patient’s cancer without distractions.
State governments tightly regulate cannabinoids. I wish governments did the same for opioids. My expertise is in treating pediatric cancers. I am untrained and unsupported in managing the chronic pain or addiction issues surrounding my patients.
I am pro-marijuana, because I want out of the opioid business. Medical marijuana gives me that way out so I can get back to healing children. Governments should manage opioids the way they manage medical marijuana so all providers can get back to caring for patients.
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