Medics with prescribed marijuana

[WildlandEMT89]

Why would natural be better for you than man made? I mean I can think of situations for preference of either forms of medicine. Smoke is still smoke. Honestly, I'll take the same stance on alcohol as anything else. A little bit, may not do a lot of damage, but a great deal of anything certainly can. Even cigarettes or caffeine.

I'm not saying this should be a disqualifier or application for termination of employment, but if you are a chronic user of OTC medications, controlled substances/medications (including alcohol), or the addicted to legal substances and drugs, you really should take a step back and do a simple self eval for being fit for duty. After determining that under this circumstance that you're good to go, do you think 10 times out of 10 the next guy would be? Would you feel completely ok with admitting to doing these things at a physical health examination or is it something you would not bring up even if asked?

As previously stated, no one SHOULD be taking vicodin before a shift, it is as negligent as having a beer before taking a drive. Under the influence is under the influence and should not be based on levels in blood, urine, saliva, or otherwise. You know what you're doing is wrong-there isn't a grey area.

Professionalism isn't limited to EMS for me. Would taking vicodin or medicinal marijuana be acceptable for all professions? Say 8 hours before flying a passenger airplane? 12 hours before engaging in a fire fight against an enemy in combat?

My answer is, I would prefer someone to not be reliant on any particular substance/medication/drug at all.

I agree with most everything you have said, but having done some research into the topic there are many smoke free avenues of ingestion as well as strains made specifically to not give a hallucinogenic effect.

That being said given the drugs federal status it really has no place in the public service and I can't see it being allowed by any agencies until that changes

 

[Drax]

I agree with most everything you have said, but having done some research into the topic there are many smoke free avenues of ingestion as well as strains made specifically to not give a hallucinogenic effect.

That being said given the drugs federal status it really has no place in the public service and I can't see it being allowed by any agencies until that changes

I didn't realize it was classified as a hallucinogenic drug at all. Wasn't during EMT school anyway. I mean, can we really determine it has no long term effect? Medication can take a toll on your liver after prolonged or excessive use.

I don't think I've seen any official studies on the substance, therefore I can not say whether or not it has beneficial properties and whether or not it's use outweigh's the cons of having it legalized either medicinally or recreationally.

 

[LACoGurneyjockey]

That being said given the drugs federal status it really has no place in the public service and I can't see it being allowed by any agencies until that changes

If it were legal under federal law would you then be ok with the paramedic treating your family having smoked weed earlier that day? Vicodin is legal, does that make it ok before or during a shift? Same goes for alcohol. The issue is how it impacts your judgement, cognition, and ability to make decisions on the fly, not its legal status.

 

[Drax]

If it were legal under federal law would you then be ok with the paramedic treating your family having smoked weed earlier that day? Vicodin is legal, does that make it ok before or during a shift? Same goes for alcohol. The issue is how it impacts your judgement, cognition, and ability to make decisions on the fly, not its legal status.

Hit the nail on the head.

 

[WildlandEMT89]

If it were legal under federal law would you then be ok with the paramedic treating your family having smoked weed earlier that day? Vicodin is legal, does that make it ok before or during a shift? Same goes for alcohol. The issue is how it impacts your judgement, cognition, and ability to make decisions on the fly, not its legal status.

I personally do but believe that drug use has a place among fist responders of any role while active wether the substance has just been taken our is merely residual in the system. If something is debilitating enough to warrant such drastic medicating I feel that it off debilitating enough to warrant medical leave.
And while marijuana is not a hallucinogenic, it's effects are often described as such, I was not intending to refer to that being the classification.

I was merely trying to state that if someday federal law changes stance on the subject that SOPs will have a lot more to take into account aside from a blanket yes or no.

 

[DrParasite]

No but here if you test positive for narcotics and have a script it is ok. People work while taking pain medication all the time.

Same with adderall. You will test positive for amphetamines. But it's ok if you have a script.

not only that, but I don't know of any MD's who will prescribe nicotine or cigarettes.

The question isn't the substance itself, but rather having a physician directive to take it.

If your physician is directing you to take any substance, that is legal with the doctors order, why should your employer be able to punish you? And why should your employers subjective policy trump a medical professional who is treating you for a condition?

 

[Rialaigh]

not only that, but I don't know of any MD's who will prescribe nicotine or cigarettes.

The question isn't the substance itself, but rather having a physician directive to take it.

If your physician is directing you to take any substance, that is legal with the doctors order, why should your employer be able to punish you? And why should your employers subjective policy trump a medical professional who is treating you for a condition?

Not to drive off topic here with a sly remark but....because I can go to any number of doctors within 30 miles of here, complain about chronic back pain and anxiety, and get a script for 120 norcos and some xanax...bet I could pick them up with in 3 hours...


I completely understand employers skeptacism of employee conditions requiring controlled substances.


There are many reasons an employers subjective policy should trump just about anything. The first of which is the employer should have the right to make just about any rules he/she wants and enforce them. If its a private company (I will completely agree that government agencies are held to a different standard, and rightfully so), the it is private money. They can decide who to hire, who to fire, what standards to use, etc. I have no issue at all with private companies having nearly free reign over all decision making. If a private company states you cannot drink or eat anything with caffeine while on duty but you can smoke anywhere you want...its up to them. If you don't like it don't work there. If the people utilizing the service don't like it they will lose their contract....just let the free market work..

 

[MonkeyArrow]

Assuming it becomes legal under federal law, I can see a case like this going to court very quickly where an employee takes marijuana under the direction of a doctor to treat XYZ, tests positive for it, and gets fired. IMHO, it's a pretty strong and valid argument to sugget that an employer prventing you from getting the necssary medical treatment you require is borderline criminal negligent. Just like a policy not requiring seatbelt use is negligent as it will increase the chances of getting someone hurt in an accident, so it restricting access to a medical treatment.

If you're worried about decision making abilities, you ask the employee to get a note from a doctor saying John's decision making process is not impaired by this medication in order to remove liability. Or even if you're still worried, you give him paid leave/short-term disability. It is not the employer's place to restrict your access to living a healthy lifestyle.

 

[LACoGurneyjockey]

If you're worried about decision making abilities, you ask the employee to get a note from a doctor saying John's decision making process is not impaired by this medication in order to remove liability. Or even if you're still worried, you give him paid leave/short-term disability. It is not the employer's place to restrict your access to living a healthy lifestyle.

I'm not worried about the liability, and I fail to see how a doctors note makes a narcotic pain med any less of a mind altering substance. I live in the area where I work, and I'm simply not ok with the medic who treats me being under the influence of vicodin, marijuana, Ativan, whatever the duck a doctor decides to say "doesn't impact Johns decision making process". How is being reliant on opiates living a healthy lifestyle. There is no data that suggests narcotics have any benefit in long term pain management, and enormous potential for abuse and addiction. A healthy life style would be removing you and your chronic back injury from a career that will continue to physically tax you beyond your means, and requires more mental presence than you're willing to put in.

 

[Carlos Danger]

There is no data that suggests narcotics have any benefit in pain management beyond 3-4 weeks, and enormous potential for abuse and addiction.

Uh.....what?

 

[LACoGurneyjockey]

Uh.....what?

In 2 words, were you trying to say you think opioids are a good solution in the long term for chronic pain, particularly in an EMS setting? You're gonna have to be more specific...

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3073133/
http://www.medpagetoday.com/PainManagement/PainManagement/33014

Don't get me wrong, I think 50mcg of fentanyl will do wonders for that hip fracture, but sending grandma home with 3 months of percocet is not an effective solution, and is only going to lead to dependance and ultimately withdrawals or addiction, your choice.

 

[Carlos Danger]

Don't get me wrong, I think 50mcg of fentanyl will do wonders for that hip fracture, but sending grandma home with 3 months of percocet is not an effective solution, and is only going to lead to dependance and ultimately withdrawals or addiction, your choice.

The management of chronic pain is a broad and complex topic that is unfortunately made much more complicated by the ignorance and prejudices held by many, as well as both the direct and collateral effects of that ongoing farce that we still ridiculously refer to as the "war on drugs".

I can't help but wonder about your (and most others) qualifications to judge the appropriateness of the analgesic prescriptions written by a physician for a specific patient. The fact that so many are so quick to judge that opioids aren't necessary for individuals is one of those prejudices that I mentioned above. These days, no one gives out a script for controlled substances lightly. There still aren't exactly a lot of options, though, for people who hurt.

Also, you are vastly overestimating the effects of chronic controlled substances on an individual's ability to work. Not everyone who takes vicodin or asks for dilaudid in the ED is a drug seeker or ends up dying of an OD. There are lots of normal, functional, otherwise healthy people who take controlled substances every day. They work, drive, make decisions, and yes, even treat patients.

 

[LACoGurneyjockey]

The management of chronic pain is a broad and complex topic that is unfortunately made much more complicated by the ignorance and prejudices held by many, as well as both the direct and collateral effects of that ongoing farce that we still ridiculously refer to as the "war on drugs".

These days, no one gives out a script for controlled substances lightly. There still aren't exactly a lot of options, though, for people who hurt.

Also, you are vastly overestimating the effects of chronic controlled substances on an individual's ability to work. Not everyone who takes vicodin or asks for dilaudid in the ED is a drug seeker or ends up dying of an OD. There are lots of normal, functional, otherwise healthy people who take controlled substances every day. They work, drive, make decisions, and yes, even treat patients.

...but they don't do so nearly as well as someone not impaired. And back to someone else's post earlier, I could walk into a pain management clinic 20 minutes from home complaining of chronic back pain, and have a script filled before bed that night.
You are vastly overestimating the competency of some doctors who make their living on pain management.
I may be prejudiced, and that may come from my own struggles with addiction, having an all too close up view of what it did to my ability to work and my general wellbeing.

I never mentioned "the war on drugs", nor did I imply someone with chronic pain being treated with opioids is a drug seeker. The war on drugs is a joke, but that doesn't mean the healthcare professional responsible for my or my family's wellbeing has a pass to do whatever drugs they want.
If you need narcotic pain meds to function as a medic, I don't think this is the place for you anymore. Just like if you needed alcohol, marijuana, or any other altering substance. You can't really believe that your decision making is unaffected by 10mg of hydrocodone, and once you get to that point of tolerance being without your drugs is just as debilitating. Yes, if you've been taking vicodin every 4 hours for the past 4 years, you won't have much of an altered mentation when you're on it (at least, not that you can notice anymore). But then try going without for a day, and see if you can function. Or you get a 5 hour hike out at hour 3.5 since your last pill. Are you going to be able to function as well as your partner, or are you going to be a liability to your patient and yourself? If you fell asleep at the wheel an hour after your last dose, can you say with 100% certainty that would have happened in the exact same way had you not been taking a medication known to cause drowsiness?

If you hurt, I don't think the solution is for you to suck it up and stop pretending, that's just absurd. But I also don't think you should continue to do a job that requires so much of you mentally and physically, with such a severe injury that requires long term narcotic pain management to have any quality of life. And the reality is, if you continue to take opioids for an extended period of time, you have such a high probability of developing an addiction on top of what was (and maybe still is) legitimate chronic pain.

 

[Rialaigh]

The management of chronic pain is a broad and complex topic that is unfortunately made much more complicated by the ignorance and prejudices held by many, as well as both the direct and collateral effects of that ongoing farce that we still ridiculously refer to as the "war on drugs".

I can't help but wonder about your (and most others) qualifications to judge the appropriateness of the analgesic prescriptions written by a physician for a specific patient. The fact that so many are so quick to judge that opioids aren't necessary for individuals is one of those prejudices that I mentioned above. These days, no one gives out a script for controlled substances lightly. There still aren't exactly a lot of options, though, for people who hurt.

Also, you are vastly overestimating the effects of chronic controlled substances on an individual's ability to work. Not everyone who takes vicodin or asks for dilaudid in the ED is a drug seeker or ends up dying of an OD. There are lots of normal, functional, otherwise healthy people who take controlled substances every day. They work, drive, make decisions, and yes, even treat patients.

I'm not sure where your from but I am a 24 year old male here in the south. I could get off shift in 30 minutes and have a script written, filled, and picked up for 90 norcos by 10am. I have no medical history indicative of needing pain meds (really no medical history at all). If I stated I was anxious I could have myself 30 xanax with it.




You may see them, the population I treat I don't. I would put money that 95%+ of the patients that I have picked up this year, that are on narcotics more then 6 months out of the year, are also on government disability. I don't see the people that work or make responsible decisions yet are on narcotics daily. I see lots of people who drive on them...and regularly pick them up out of the ditch. Part of the problem here (like everywhere) is a very high percentage of the people that live in the county I work use narcotics. And there are 0 pain doctors or pain clinics in the county, It is simply from family practice doctors handing the stuff out to everyone because the residents are too poor or don't have the right insurance to travel out of the county to the pain clinic (or more simply put just dont have a ride.).


In America we condition ourselves to have problems simply so we can fix them. We give everything a label in the name of finding a cure. I'm not saying pains not real, I am saying we do pain management incredibly poorly....

 

[Carlos Danger]

The last two posts prove my point about prejudice.

In EMS, you see the negative results of people abusing narcotics very visibly. What's much less visible to you is the majority of people who use them responsibly. I've known flight nurses and even a surgeon who used narcotics long-term, and quite a few people who use clonazepam and other benzos for anxiety. All were working professionals who you would never know was "on something".

As a clinician, it would serve you well to find a way to view these things more objectively.

 

[Rialaigh]

The last two posts prove my point about prejudice.

In EMS, you see the negative results of people abusing narcotics very visibly. What's much less visible to you is the majority of people who use them responsibly. I've known flight nurses and even a surgeon who used narcotics long-term, and quite a few people who use clonazepam and other benzos for anxiety. All were working professionals who you would never know was "on something".

As a clinician, it would serve you well to find a way to view these things more objectively.

I am fairly sure that the majority of people do not use them responsibly in my area. I can also assure you that regardless of the number of people that use them responsibly, the United States by far has the worst problem of narcotic abuse in the world. I see the negative results of people abusing them because they are visible, because they are a major problem with the healthcare system and how we handle these patients.

Objectively the US has the largest problem of prescription drug abuse in the world. Objectively the US does an incredibly poor job of pain management despite having more tools than any other country in the world. Objectively the US spends more on recovering drug addicts than any other country with much worse results for the systems we use.



This goes way off the marijuana topic and likely deserves a topic of its own. On the topic of legalized pot, I see a very complicated solution coming down the pipeline involving multiple supreme court rulings and lots of money spent on lawsuits. Any way it falls there will be lots of issues with enforcement. Along these lines this begs of the question of EMS personnel or other public service people using performance enhancing drugs to improve performance during work

 

[Carlos Danger]

My comments were not intended to address the broad topic of chronic pain management and how good or bad we are at it, or rates of prescription drug abuse or federal drug policy.

I was simply responding to the assertions that 1) people on controlled substances are unable to perform, and 2) opioids don't work for longer than a few weeks. Both ideas are nonsense.

 

[Ewok Jerky]

ON TOPIC
I agree that this is borderline legal advice. I don't think the situation has been worked out legally yet, I am sure there will be a Supreme Court case (in the US, I have no idea how things work in CA) within the next 10 years. But you bet your butt if you test +, especially after an incident, you will get canned. It is a liability in the companies eyes, no matter what state you are in.

At my old employer, I was never asked about anyb medical conditions or medications that would preclude me from doing my job. I had to pass a physical every year that was it. For the CA DMV though, I think there is a question on their about medicaitions...thank the universe I have been out of CA for a few years now though, so someone might be able to correct my memory.

There was an incident where one of our medics was accused, repeatedly of erratic behavior in and out of the station. She was tested, it was + for I don't know exatly what, but she was put on some sort of leave. This person was clinically a good medic, but a real a-hole to eeryone around her, a real short fuse. Anyways, she was able to come back because it turned out she had some sort of perscription(s) and her behavior was explained as "medication interactions", and she was basically put on probation for a period of time and told to get her act together, and not let it get out control again. If you are taking cannibis (for anxiety/sleep???) with a Rx, I don't really think it is your employers business...until it effects your ability to perform your job safely. Plenty of peeps walk around on beta blockers and diuretics and are at risk for a syncopal episode now and then, but we don't make them quit their career because of it.

OFF TOPIC
Yes it is farely easy in this country to abuse the system. That does not meen that plenty of people (probably the majority of them) are using long term opiates approiatly to manage their chronic pain. I just finished a rotation in primary care, and half of our visits were monthly med refills for people with chronic pain taking 5, 10, 15, 20mg of oxycodone. They have pain contracts, come in once a month in person for a refill, and take tests to show they aren't diverting. In two months I could count the suspects on 1 hand who we suspected of diverting/seeking, and they all were made aware of the suspicions and given ultimatums for following the contract or being fired as patients.

In EMS, we see a lot more the abuse, and not a lot of the success of chronic pain management regimes.

Chronic pain is real, and opiods are the best treatment we have for long term pain management when conservative measures have failed.

 

[Ewok Jerky]

I was simply responding to the assertions that 1) people on controlled substances are unable to perform, and 2) opioids don't work for longer than a few weeks. Both ideas are nonsense.

1) I agree [see my post above]

2) While most patients on long term opiates do develope tolerance, and require ever increasing doses, current long-term opiate regimes see a dose-reduction benefit when switching to a different opiate once a max dose has been reached. The new drug will eventually require a dose increase, as before, but again can be switched to another opiate, or back to the original.

 

[Ewok Jerky]

In 2 words, were you trying to say you think opioids are a good solution in the long term for chronic pain, particularly in an EMS setting? You're gonna have to be more specific...

Yes, opiods are THE BEST solution for long term chronic pain. Do you have a better alternative? Now, if I require daily doses of ANY pain killer to get through my day, I will be thinking of a career change, but that is MY decision to make. Unless it starts effecting my ability to perform my job. We can't fire big fat medics for being obese can we? Unless it starts to interfere with their ability to perform their duties.

Don't get me wrong, I think 50mcg of fentanyl will do wonders for that hip fracture, but sending grandma home with 3 months of percocet is not an effective solution, and is only going to lead to dependance and ultimately withdrawals or addiction, your choice.

You are right , we should reduce that fracture. Now grandma has arthritis and can't walk or perform ADLs because of chronic hip pain. Now can we give her some effective pain management?