Cannabis and OTP: What’s Next?
Not only is cannabis—marijuana—legalized for recreational use in many states; it’s also legal for medical use in even more states, and some states even suggest it can be used to treat opioid use disorders (despite the lack of scientific evidence to support it as indication). What should an opioid treatment program (OTP) do?
We spoke with an OTP facility in Colorado, the first state to legalize recreational use, and a representative of the American Society of Addiction Medicine (ASAM).
“I can really only share our experience in Colorado,” said Tina Beckley, MA, CACIII’s Colorado Regional Director for the Behavioral Health Group (BHG). Ms. Beckley was the recommended referral source by the American Association for the Treatment of Opioid Dependence (AATOD) as her early experience will be helpful.
State test requirement
For example, BHG initially did not test for tetrahydrocannabinol (THC), the psychoactive ingredient in marijuana, Ms. Beckley, whose office is based in Dallas (she is based and lives in Colorado), said. AT Forum. As a result, many patients used marijuana regularly, he said. However, once THC testing was implemented (Colorado required it in OTPs, beginning in 2006), many patients began missing take-home doses, one phase at a time. “Some of them decided to donate [marijuana] up, and others decided they would keep losing [take-home] phases and come into the clinic more often,” he said. “There were others who stopped treatment altogether.”
Cannabis was first legalized in Colorado, for medical use before recreational use, as is the typical trajectory. Legalization for medical use posed an “immediate challenge” for OTPs in the state, Ms Beckley said. “Patients who had been using THC for years thought that if they could get a medical marijuana card, they could earn medicine to take home if all the other requirements were met,” he said. But only very few patients were able to continue receiving at home while using medical marijuana, he explained: those without a history of illicit marijuana use, who also had a medical condition that was identified as treatable with marijuana and primary care of which providers accepted the use of medical marijuana. Only “a couple” of patients meet those criteria, he said.
But once recreational marijuana is legalized, the situation gets more complicated, Ms. Beckley said. “A lot of patients felt that because it was legal, they could continue using it. It’s been a real challenge for programs to explain that OTPs follow federal rules, so if a urine drug screen is positive for THC, it is considered a positive urine,” he said. “Many patients also believe that it is the rule of the clinic and that it can be changed,” he added, citing feedback that locations receive each year from patient satisfaction surveys.
And it pointed to a definite problem for OTPs in legalization states. “In the beginning, there were quite a few patients who moved here because of the marijuana industry,” he said. “They were pretty discouraged because they couldn’t earn home medicine if they used marijuana.” And patients who moved from states where OTPs didn’t test for marijuana were also discouraged when they learned they would be tested and lose their homes.
An anecdotal note from Ms. Beckley: Some of the patients who stopped using marijuana to stay at home said they felt “clearer” than they had in a long time.
Mood swings and altered mind
“Our treatment staff believe that THC is mood-altering and mind-altering, with addictive properties and not conducive to sobriety, so it’s a clinical and therapeutic struggle,” he said.
However, the programs would like to see state regulations revised, Ms. Beckley. “One of our programs recommended that THC be removed from the tested drugs and left to the discretion of the OTP to treat clinically,” he said. Another option would be to allow patients who use recreational marijuana and meet all other requirements for take-home medication to be allowed to take one home a week (in addition to Sunday). That second option would significantly decrease the number of patients who have to dose on Saturday, he said.
“We think it’s unfortunate that cannabis is still considered a Schedule I drug,” said Ms. Beckley, noting that several states allow recreational marijuana, and even more states allow medical marijuana. “Many of our patients, again anecdotally, report that THC helps with opioid withdrawal symptoms, but without the ability to facilitate medical marijuana research, the positive claims cannot be substantiated,” he said.
While ASAM opposes asking patients to leave treatment because they use marijuana, there are concerns that other substances, whether cannabis, alcohol, cocaine or any other drug, can negatively affect OTP patients, Yngvild said. Olsen, MD, Medical Director. of the Institutes for Behavior Resources Inc/REACH Health Services in Baltimore City and a board member of ASAM. Use of cannabis or other substances “needs to be identified and treated as a health condition,” he said ATForum.
What if the OTP patient, or for that matter an OBOT patient on buprenorphine, has a prescription for cannabis? “ASAM’s policy says that in those states where state law allows medical cannabis, the same type of clinical and health-related approaches should be used as for other drugs, such as benzodiazepines and opioids,” said Dr. Olsen. “Even if it’s recommended or prescribed, it can still have negative consequences” for patients on methadone or buprenorphine, he said.
And while the Substance Abuse and Mental Health Services Administration and the Joint Commission do not require OTPs to test for marijuana except at the time of admission, some states, such as Maryland and Colorado, do. said Dr. Olsen. “There are a number of OTP medical directors and other doctors who are questioning the value and benefit of marijuana testing,” he said. “But it’s similar to why we do breathalyzer testing and other substance testing: it’s not to discharge patients, it’s a marker for people who are at risk for other health conditions.”
Meanwhile, states continue to look at the idea of marijuana as a treatment for opioid use disorders, possibly replacing methadone and buprenorphine, despite a lack of evidence. “It’s frustrating,” Dr. Olsen said.