Thida M. Thant, MD

Twenty-eight states and Washington, DC, have legalized marijuana for treating certain medical conditions, but the United States Drug Enforcement Administration (DEA) still classifies marijuana as a Schedule I drug “with no currently accepted medical use and a high potential for abuse.”¹ In certain states, clinicians can recommend, but not prescribe, medical marijuana. There is limited guidance in caring for patients who use medical marijuana and request or use DEA-controlled prescription medications, such as benzodiazepines, stimulants, and/or opiates. Physicians can take the following steps to ensure safe care for patients who use medical marijuana and request or take a DEA-controlled prescription medication:

1. Understand your patients’ point of view. Talk with patients who use medical marijuana about the history, frequency, and method of use, and reasons for using medical marijuana. Assess for psychiatric illnesses and any past or active treatment with DEA-controlled prescription medications.

2. Perform screens. Screen for risk factors, past psychiatric history, and prior or current substance use disorders. Treat any existing substance use disorders as appropriate.

3. Provide education. Discuss the risks of marijuana use and its potential adverse effects on the patient’s illness. Explain that marijuana is not currently an FDA-approved treatment and that there often are safer, efficacious alternatives.

4. Set clear boundaries. Be upfront about what is safe clinical practice or the usual standard of medical care and practice within the scope of state and federal laws. Document treatment agreements, utilize prescription drug monitoring programs, and use blood and/or urine toxicology screens as needed. Be aware that a routine drug screen can detect marijuana exposure but may vary in detecting the quantity or length of marijuana use.²

5. Try harm reduction. Any marijuana use, including use that falls short of a Cannabis use disorder, may adversely impact cognition, mood, and/or anxiety.³ Reducing use or abstaining from marijuana use for at least 4 weeks^4,5 or reducing or discontinuing the DEA-controlled medication if a patient continues marijuana use are reasonable interventions to see if psychiatric symptoms improve or remit. Polypharmacy with marijuana may place a patient at risk for substance use disorders or additive adverse effects or can hinder the recovery process.

6. Consider alternatives. If a patient feels strongly about continuing medical marijuana use, and you feel that their marijuana use is not clinically harmful and that psychiatric symptoms require treatment, consider medications without a known potential for abuse (eg, antidepressants, buspirone, or hydroxyzine for anxiety; alpha-agonists or atomoxetine for attention-deficit/hyperactivity disorder, etc.). Start such medications at low dosages, titrate slowly, and monitor for benefits and adverse effects.

7. Continue the conversation. Maintain an open and nonjudgmental stance when discussing medical marijuana. Roll with resistance, and frame discussions toward a shared goal of improving the patient’s mental health as safely as possible while using the best medical evidence available.

8. Offer additional support. Refer patients any additional services as appropriate, which may include psychotherapy, a pain specialist, or a substance abuse specialist.

Twenty-eight states and Washington, DC, have legalized marijuana for treating certain medical conditions, but the United States Drug Enforcement Administration (DEA) still classifies marijuana as a Schedule I drug “with no currently accepted medical use and a high potential for abuse.”¹ In certain states, clinicians can recommend, but not prescribe, medical marijuana. There is limited guidance in caring for patients who use medical marijuana and request or use DEA-controlled prescription medications, such as benzodiazepines, stimulants, and/or opiates. Physicians can take the following steps to ensure safe care for patients who use medical marijuana and request or take a DEA-controlled prescription medication:

1. Understand your patients’ point of view. Talk with patients who use medical marijuana about the history, frequency, and method of use, and reasons for using medical marijuana. Assess for psychiatric illnesses and any past or active treatment with DEA-controlled prescription medications.

2. Perform screens. Screen for risk factors, past psychiatric history, and prior or current substance use disorders. Treat any existing substance use disorders as appropriate.

3. Provide education. Discuss the risks of marijuana use and its potential adverse effects on the patient’s illness. Explain that marijuana is not currently an FDA-approved treatment and that there often are safer, efficacious alternatives.

4. Set clear boundaries. Be upfront about what is safe clinical practice or the usual standard of medical care and practice within the scope of state and federal laws. Document treatment agreements, utilize prescription drug monitoring programs, and use blood and/or urine toxicology screens as needed. Be aware that a routine drug screen can detect marijuana exposure but may vary in detecting the quantity or length of marijuana use.²

5. Try harm reduction. Any marijuana use, including use that falls short of a Cannabis use disorder, may adversely impact cognition, mood, and/or anxiety.³ Reducing use or abstaining from marijuana use for at least 4 weeks^4,5 or reducing or discontinuing the DEA-controlled medication if a patient continues marijuana use are reasonable interventions to see if psychiatric symptoms improve or remit. Polypharmacy with marijuana may place a patient at risk for substance use disorders or additive adverse effects or can hinder the recovery process.

6. Consider alternatives. If a patient feels strongly about continuing medical marijuana use, and you feel that their marijuana use is not clinically harmful and that psychiatric symptoms require treatment, consider medications without a known potential for abuse (eg, antidepressants, buspirone, or hydroxyzine for anxiety; alpha-agonists or atomoxetine for attention-deficit/hyperactivity disorder, etc.). Start such medications at low dosages, titrate slowly, and monitor for benefits and adverse effects.

7. Continue the conversation. Maintain an open and nonjudgmental stance when discussing medical marijuana. Roll with resistance, and frame discussions toward a shared goal of improving the patient’s mental health as safely as possible while using the best medical evidence available.

8. Offer additional support. Refer patients any additional services as appropriate, which may include psychotherapy, a pain specialist, or a substance abuse specialist.

Twenty-eight states and Washington, DC, have legalized marijuana for treating certain medical conditions, but the United States Drug Enforcement Administration (DEA) still classifies marijuana as a Schedule I drug “with no currently accepted medical use and a high potential for abuse.”¹ In certain states, clinicians can recommend, but not prescribe, medical marijuana. There is limited guidance in caring for patients who use medical marijuana and request or use DEA-controlled prescription medications, such as benzodiazepines, stimulants, and/or opiates. Physicians can take the following steps to ensure safe care for patients who use medical marijuana and request or take a DEA-controlled prescription medication:

1. Understand your patients’ point of view. Talk with patients who use medical marijuana about the history, frequency, and method of use, and reasons for using medical marijuana. Assess for psychiatric illnesses and any past or active treatment with DEA-controlled prescription medications.

2. Perform screens. Screen for risk factors, past psychiatric history, and prior or current substance use disorders. Treat any existing substance use disorders as appropriate.

3. Provide education. Discuss the risks of marijuana use and its potential adverse effects on the patient’s illness. Explain that marijuana is not currently an FDA-approved treatment and that there often are safer, efficacious alternatives.

4. Set clear boundaries. Be upfront about what is safe clinical practice or the usual standard of medical care and practice within the scope of state and federal laws. Document treatment agreements, utilize prescription drug monitoring programs, and use blood and/or urine toxicology screens as needed. Be aware that a routine drug screen can detect marijuana exposure but may vary in detecting the quantity or length of marijuana use.²

5. Try harm reduction. Any marijuana use, including use that falls short of a Cannabis use disorder, may adversely impact cognition, mood, and/or anxiety.³ Reducing use or abstaining from marijuana use for at least 4 weeks^4,5 or reducing or discontinuing the DEA-controlled medication if a patient continues marijuana use are reasonable interventions to see if psychiatric symptoms improve or remit. Polypharmacy with marijuana may place a patient at risk for substance use disorders or additive adverse effects or can hinder the recovery process.

6. Consider alternatives. If a patient feels strongly about continuing medical marijuana use, and you feel that their marijuana use is not clinically harmful and that psychiatric symptoms require treatment, consider medications without a known potential for abuse (eg, antidepressants, buspirone, or hydroxyzine for anxiety; alpha-agonists or atomoxetine for attention-deficit/hyperactivity disorder, etc.). Start such medications at low dosages, titrate slowly, and monitor for benefits and adverse effects.

7. Continue the conversation. Maintain an open and nonjudgmental stance when discussing medical marijuana. Roll with resistance, and frame discussions toward a shared goal of improving the patient’s mental health as safely as possible while using the best medical evidence available.

8. Offer additional support. Refer patients any additional services as appropriate, which may include psychotherapy, a pain specialist, or a substance abuse specialist.