Medical Marijuana in Minnesota: Chronic Pain Tabled ‘Til 2016

February 18, 2015 / Thomas Cohn, MD

Minnesotans will have to wait until 2016 to learn if the state will add chronic pain to a list of conditions approved to apply for medical marijuana.

The state has been dragging their feet in regards to adding chronic pain to the list of approved conditions for medical marijuana, and now they’ve decided to table the idea until next year. State officials said they feared approving the condition could overextend medical marijuana manufacturers who are already in high gear prepping for the program’s launch this summer. The state said potentially adding tens of thousands more medical marijuana patients could be troublesome for Minnesota’s two marijuana manufacturers.

Manny Munson-Regala, assistant commissioner of the medical marijuana program’s launch, said he “didn’t see a way to do this in a thoughtful, structured way,” in terms of having the medicine available for 2015. I do think more testing is needed, as chronic pain can be caused by a myriad of internal issues, but citing supply and demand issues seems like a weak excuse. Under the current timetable, the earliest a chronic pain sufferer could get medical marijuana would be August 2016, if the condition get’s added to the list.

Senator Branden Peterson, R-Andover, was disappointed by the decision. Peterson had a bill that would have made chronic pain an eligible condition starting July 1, 2015. He wasn’t the biggest fan of the state’s supply and demand excuse either.

“I don’t see why we need to wait that long,” said Peterson. “If we acted this session, we could do something that would serve the interests of those patients a lot sooner.”

Although about 88,000 Minnesotans are currently being treated for chronic pain, the state estimates that only about 5,000 would apply for medical marijuana if it were approved.

New Timeline

Here are the important dates now that the state has updated their timeline regarding chronic pain and medical marijuana.

Spring 2015 – A new panel will examine the pros and cons of adding chronic pain to the approved conditions list.

December 2015 – The panel will submit their final recommendation to Health Commissioner Ed Ehlinger.

January 15, 2016 – Ehlinger would have to add chronic pain to the list of qualifying conditions by this date to give lawmakers the opportunity to block the condition if they see fit. If it is not added by January 15, patients would likely have to wait until 2017 at the earliest.

Medical Marijuana: A Growing Acceptance

February 11, 2015 / Thomas Cohn, MD

The world’s view on marijuana appears to be rapidly changing. Marijuana was thought of as solely a recreational drug only a few years ago. It was basically slid into a role as something to use only to escape the world and get high. It has been classified by the DEA as drug in Schedule 1, with no medical value. It was put into the same category as heroin and LSD. More recently, medical professionals have been starting to recognize the research on cannaboids and the beneficial compounds marijuana holds. The public perception of marijuana is starting turn in its favor.

Last week there were three main events that advanced the growing acceptance of the medicinal value of marijuana. The first was that the American Academy of Pediatrics (AAP) came out in favor of re-classifying marijuana to a Schedule 2 drug, just like other narcotics like morphine or Percocet. This would change the federal status from being illegal on all fronts to being considered a drug, and thus legal to study and to be prescribed for certain medical conditions. Currently, with its Schedule 1 status, doing adequate medical research is extremely difficult, stifling the development of medical knowledge and its usage. Preliminary research does show medical value of various cannaboids for seizures, nausea, cancer and pain. However, which cannaboids of the about 100 known compounds work best with the least amount of risks is poorly understood. Furthermore, we do not know if it is a combination of compounds or if a specific delivery mechanism is necessary.

The new US Surgeon General, Dr. Vivek Murthy, M.D. has also joined the chorus. This week he indicated that he supported reclassifying marijuana to Schedule 2 drug. He also reported that cannaboids did have medical value in certain conditions. Again, the reclassification would allow widespread research and development of cannaboids for their medicinal value.

Marijuana in Minnesota

In Minnesota, medical marijuana appears to be slowly moving forward. The growers of marijuana have been selected and several locations for dispensaries have been chosen. It still will be limited in use, and it will not be available for the use in pain management, at least in the early stages. The state will investigate marijuana’s potential benefits for chronic pain suffers during the first year medicinal marijuana is available. Furthermore, several Indian tribes are considering whether they will make medical marijuana legal and available on their reservations. The rules that apply on Indian reservations will be up to the individual tribes since they act as sovereign nations with their own laws.

The value of cannaboids to treat many conditions appears to be more positive, and the research is catching up. Changes in the legal drug status hopefully will become reality soon, and the knowledge of how to use these compounds as medicine will become more solid. For now, it is still illegal to use marijuana, and most physicians, due to legal constraints and lack of definite knowledge of risks, do not actively recommend its use.

Chronic Pain Treatment: A Growth Industry

January 28, 2015January 18, 2016 / Thomas Cohn, MD

A recent article suggested that treating pain is a “growth industry”. In reality, pain treatment has been terribly under-treated, and we are now just starting to figure out that we need to start providing more care. The statistics are clear. Over 40% of the population suffers problems associated with chronic pain. If we recognize how large the problem of pain is, then obviously, we can start increasing the number of treatments for the problems. The article is based on information from Minnesota claim data.

It should not be shocking that we have been seeing an increase in expenditures and number of treatments being performed for those suffering from pain. The true shock is the ignorance we have about the lack of treatment provided for one of the biggest health problems. It is not surprising that from 2010 to 2012, the number of procedures performed for pain increased by 13%. The shock should be that most people are unaware of how severe the problem of pain is and the total lack of government support to guide research toward solutions.

New Solutions

Chronic pain can be a devastating problem, and studies show that it affects nearly half of the global population. The headlines often talk about problems with prescribing opioids and the subsequent drug abuse. We should not be surprised then when we see physicians trying different approaches including more interventions and injections to treat pain problems. With our awareness of problems with drug abuse, and the huge number of people having pain problems, it should be no surprise that expenditures for pain patients may be increasing. Maybe this should actually be applauded, that the underserved are getting some more attention, and we should be asking if we are spending enough yet.

Since chronic pain is such a major problem, more money is definitely needed to be spent on research and treatment. There is virtually no federal research dollars being directed toward pain. Unlike cancer or diabetes, there is no office in the National Institute of Health that is directed toward research for pain despite the size of the problems. If there is a concern about the increase in dollars being spent on pain management, then we need to seriously look at quelling those concerns. Data only tells us we are spending more money on a pain. The real issue is why are we spending a lot more money on this problem and not finding better solutions.

Safety First: Surgical Centers vs. Pain Specialists

January 19, 2015January 16, 2015 / Thomas Cohn, MD

Recently there was an article on whether having a procedure done in a surgery center is safe. In the world of pain management, some practitioners only do procedures in these facilities (or hospitals) while others do most of their procedures in the office. Surgery centers can handle more complex procedures, and can typically handle a deeper level of sedation. In pain management, surgery centers can be beneficial for complex procedures such as implants, but often they rarely are necessary. Sedation for a pain management procedure usually does not need to be very deep, and should be able to be done without a surgery center.

The safety of a surgery center and a procedure in reality is no better than the quality, skill, and experience of the practitioner. After spending more than 20 years performing complex spinal procedures, as well as teaching courses to other physicians, it is the ability of the physician that really matters. Surgery centers are often profit centers for the physicians working in them. Furthermore, a physician who sedates most patients for procedures is often using the sedation to cover for a technique that may cause pain. A skilled interventionist should be able to do most procedures with a local anesthetic and ensure they are practically painless. The use of sedation for many practitioners is a crutch to reduce the need to talk to the patient and to perform the procedure with the least painful technique.

Pain Medicine Safety

In pain medicine, the most common injections – spinal and joint related procedures – should be able to be done quickly and comfortably. The main issue that most practitioners should be treating is the anxiety of the patient. Light medication to treat the anxiety can often be given orally. For longer procedures, IV medication is sometimes easier to use. Universally, procedures that are painful are most often due to the technique and experience of the provider. Experience often allows the practitioner the knowledge of how to perform a procedure when a patient presents a more complex situation.

In the end, safety of a center is dependent on the practitioners. If the provider does not fully know what they are doing or the best techniques, the patient is more likely to have issues with the procedure. Further, if the patient is significantly sedated, the patient will not react when the practitioner does something wrong, making it more likely that significant damage may occur. The best physicians will always care most about the patient and the problem, not the payment they might receive from doing an intervention. The best physicians have years of experience, are board certified, and have an intense, loyal patient following. Skill and experience help keep a patient safe and make a procedure safe and effective. Errors in pain management procedures are generally rare. Surgical centers and sedation are not important in patient safety; the quality of the practitioner is the most important variable.

The Problem With Prior Authorizations in Medicine

January 12, 2015 / Thomas Cohn, MD

The health insurance industry has developed a tool to control their costs and drive the providers and patients nuts. Originally the concept was used to help reduce the use of tests that were duplicates or unnecessary to provide good medical care. Now it has invaded into every corner of medicine, greatly increasing the cost to the medical provider in order to get approval for any test, procedure or medicine. To the patient and the provider, it just seems to be a nice way for the insurance companies to block care.

For patients with pain, many medications and procedures require prior authorization. It’s a timely process, filling out forms, calling a variety of people at insurance companies, writing down a number and making sure everyone has dotted the”I’s” and crossed the “T’s”. It certainly does not save any money and it costs a great deal of time. From a medical point of view, good practitioners tend to know what is appropriate and are not out to run up medical costs for their own profit. However, the rules always seem to favor the insurance company so they can keep more of your money.

Authorization Rules

Many of the rules that now exist surround the use of medications. The rules are usually written by a pharmacist and are based on drugs having similar modes of action. One generally assumed rule is that a patient must take a cheaper drug and the drug must fail in its use before a different drug can be used. The first problem with this is that professionals who do not treat patients and are not allowed to prescribe medications write the rules. They have no experience with patients, side effects and the need to run additional tests to check for problems. Many of the drugs recommended for pain, and are to be used first, are not even approved by the FDA for the specific condition. Some of the drugs have significant dangers, and may even be deadly. The state of Oregon required the use of Methadone, and suddenly the death rate from the drug skyrocketed. Pain experts warned against the move, but those who controlled the money did not listen.

The cost of medicine in the United States is a problem. Prior authorizations are really not the answer to control medical costs. Improved science and better knowledge would be a start. Furthermore, more control of the big pharmaceutical industry is necessary. They are making record profits, and on average they increased drug costs by at least 25% while inflation was 2%. The most important item would be a uniform medical record system, and all information on every person be kept in the same place. This simple tool would eliminate duplicate studies, questions about medications, and greatly ease and improve quality of care. It also would make it extremely easy to study particular diagnoses and solutions.