N.H. Doctor: Recommending Medical Marijuana Removes Liability Of Prescribing Opioids

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New Hampshire’s medical marijuana program more than doubled in size last year, and many see it as an alternative to using opioids for pain management.

Dartmouth-Hitchcock Pediatrician Julie Kim wrote an article for the Huffington Post about how she sometimes prefers to recommend medical marijuana to her patients. Morning Edition Host Rick Ganley spoke with her about how medical marijuana has helped her with concerns over prescribing opioids to certain patients.

In your article, you write you are a pro-marijuana pediatrician, not because available treatments are inadequate, but because it can remove you of the liability of prescribing opioids. What do you mean by that?

Yes, as a pediatrician we have no resources in managing chronic pain in the state of New Hampshire and Vermont. There is no chronic pain clinic that can take pediatric patients. So when we have a patient with chronic pain, that is not my specialty. I did not train to become a chronic pain specialist. I also have a hard time because the opioid epidemic has become so big that a lot of parents now are using their children’s opioid prescriptions. I don’t know if it’s addiction. I don’t know if it’s chronic pain. That is not my specialty. I don’t know the best way to treat that. I have no resources. However, if I use the medical marijuana, the government steps in, does a lot of the background checks, does the management, does the counseling. There’s a lot more resources from that and it completely removes me from the responsibility of having to figure that out.

So as a pediatrician, your goal here obviously is to manage the pain of your patients, but you’re not always aware if this pain is real or if parents are actually using their children’s prescriptions?

That is correct. Oftentimes most kids don’t have chronic pain, and most of the times when a chronic pain issue is happening, if there is no identifiable source for that chronic pain, I do become very concerned about opioid addiction, especially if I know that the parents have had problems with it in the past.

And you’re saying in other areas of the country, you would be able to send your patients to a chronic pain specialist or a pain management center?

I would like to think that’s the case. But even across the country, there are probably only about 30 places in the country that have chronic pain centers specifically for children. So this is a problem across the entire United States.

So you’ve talked to other pediatricians who are saying the same thing?

Yes.

When do you suspect when a parent is asking for a prescription for their own use? What are the signs?

When there is no identifiable cause for the pain. I have no problems prescribing for acute pain. So if my patient has had a major surgery or has a bone lesion that I can identify on an x ray or an MRI, then I know that child is in pain. Most of the time with kids the pain is acute and limited. So they only need opioids to get over the healing process for maybe three to five days, maybe even less. But if the request for prescriptions continue and this goes on for weeks and weeks without any source of identifiable pain, then I become concerned.

You’ve been in practice for a number of years now. How often are you seeing that parents are coming in and you’re getting the feeling that they’re looking for opioid prescriptions for themselves?

I’m seeing that more and more over time. So when I first started more than a decade ago, this was a rare problem. And probably we just weren’t aware of it at the time, but now with so much recognition of the problem, I see it a lot. I think on a weekly basis, I see at least maybe one to three patients a week where I’m concerned there’s an addiction issue either with the patient or the parents.

There’s still a stigma attached to medical marijuana. I know the program in New Hampshire is still fairly new. Have you had issues with parents not wanting their kids to be exposed to it?

No. So the parents that I end up referring there are the ones that have had chronic pain issues, at least that’s how they sell this to me. A lot of times the parents are looking for some other alternative. Again, I don’t think it’s the child often that needs the opioids. It’s sometimes the parents that need this. So I have had zero parents say no they’re not going to do this.

What do you feel are some of the drawbacks to recommending medical marijuana over prescribing opioids?

Yeah, so the hoops are much greater, and there’s a background check that occurs for the patient and the parents. So if a parent is going to be the caretaker and going to be the one to pick up the medications, then the parents also go through a background check. That takes time actually. So nothing is immediate. Parents and the patient [also] need to go to a single dispensary at a specific time. So they’re given instructions about you’re going to be using this one dispensary, meeting with this one person. It’s less convenient than just being able to pick which pharmacy you want to be using. Also, the cost of medical marijuana is expensive. It’s not cheap. Opioids are extremely cheap unfortunately so, because I think that leads to part of the problem.

And insurance of course would cover opioids where they would not medical marijuana.

Exactly.

You say state governments tightly regulate marijuana of course, and you wish they would do more regulation for opioids. How so?

I wish that the states would help us as providers look into people’s backgrounds to see if they’re actually at risk for addiction issues. Like if there’s a history of addiction in the past, that might not be the ideal patient to give opioids to. But we have no recourse to look into people’s arrest records or what their histories have been to recognize that risk even. If there’s a problem with multiple prescriptions going out at the same time, you have patients filling a prescription at one pharmacy, two pharmacies, three pharmacies, as providers we don’t always know that because they can’t just use a single dispensary option like they do for medical marijuana.

But with the patient registry, is that not helping? Is that not working?

It helps only somewhat. So when a provider writes a prescription for somebody who has cancer, we’re not required necessarily to look at that list. Though for providers who are writing for acute pain issues, you must look at the list. But there is an exemption if the patient has a diagnosis of cancer. So that’s not always so helpful for me.

So those exceptions are helping people fall through the cracks?

Yes.

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