Clinicians at VA are expected to know the dosage, frequency, and form of marijuana prescribed and the medical condition for which it is approved. The directive identifies but does not officially recognize as clinical indications for the use of medical marijuana a number of medical conditions for which marijuana is commonly prescribed—glaucoma, chemotherapy-induced nausea, multiple sclerosis, epilepsy, and chronic pain—but it is the specific state laws that determine what medical and psychiatric conditions are approved for the use of medical marijuana.16,21 The PCS clearly states that it is the VA clinician, presumptively the primary care provider (PCP), who is responsible for and directs the patient’s care, just as with any consultant or provider outside VA auspices. Some clinicians find this arrangement problematic, in that they may be potentially liable for bad outcomes and may not refuse a clinically reasonable request for opioids for chronic pain, yet are unable to control the secondary prescribing of marijuana. Clinicians with political, scientific, or moral objections to any use of marijuana for medical purpose may have little recourse under the policy, as there is no indication that such objections would fall under a conscience clause.
The use of medical marijuana is an area of intense research and cultural controversy, and the empirical data to support ethical refusal by a clinician to care for a patient using medical marijuana is often difficult to separate from social attitudes and political positions.22 The VA practitioner has a duty to “adjust treatment plans to promote effective management of these conditions” for which the veteran is using medical marijuana, such as offering adjunctive medications for pain or counseling for substance use.2
The VA clinician in the service of integrated care is required to document all clinical information regarding medical marijuana, including entering the substance as a non-VA prescription in the Computerized Patient Record System. This requirement is essential to protect the veteran from having necessary and appropriate care restricted if the results of toxicology screens are positive for marijuana. One gap in the guidance is that VA clinicians have no ready means of distinguishing prescribed marijuana from illegal marijuana in a standard toxicology screen, and if the patient has a state medical marijuana registration, the clinician must assume the source is prescribed and not illicit. Since the federal practitioner cannot prescribe marijuana, there is even more uncertainty and concern regarding a positive result. Laws passed in 2013 in Colorado and Washington states, which make the recreational use of medical marijuana legal, render toxicology interpretation and medical decision-making even more complex.23
The practitioner is directed to counsel and educate the patient from a nonjudgmental and beneficence-based orientation, which fosters the patient’s autonomy and informed consent. The VA clinician’s discussion of the evidence-base for the health benefits and risks of marijuana should include criteria for a marijuana substance use disorder, emerging data on marijuana withdrawal syndrome and empirical treatment, and most important effective alternative treatments for the target symptoms or conditions for which marijuana is being used.2
Along with this general guidance for the appropriate treatment of patients who use medical marijuana, specific advice is proffered on the 2 most strongly impacted areas of clinical care: pain management and substance use disorders. Practitioners on the ground struggle to reconcile the conflict between state and federal law and policy on medical marijuana in these 2 key domains. Ethics consultation is advised as potentially helpful in resolving ethical dilemmas that arise in patient care.
Pain Management
The PCS articulates the ethical principles surrounding chronic pain treatment with a focus on opioid prescribing for veterans approved to use medical marijuana. A multimodal and stepped-care approach to pain management is endorsed that “should be based on principles of shared medical decision-making and patient autonomy.”2 In this context, veteran safety and minimizing risk to the public are high priorities. Decisions about the use of opioid analgesics need to balance the veteran’s right to pain management and veteran well-being. The informed consent discussion regarding the use of opioids and marijuana should encompass benefits and risks of each substance and its interaction, especially those related to psychomotor impairment, such as driving and memory deficits, which could affect daily functioning. Practitioners are strongly advised to cogently record the clinical evaluation and treatment rationale for prescribing opioids to patients who use medical marijuana.2
Substance Use Disorders
It is the position of the American Society of Addiction Medicine that medical marijuana is not clinically appropriate for patients with substance use disorders.24 The VA policy clearly states that no veteran participating in a state-approved program will be denied substance use treatment or stigmatized for their use of medical marijuana, which is paradoxically a substance of abuse that is illegal in many states outside of these programs. Veterans being treated for other substance use disorders may also develop a marijuana use disorder, even if the drug is medically prescribed, or may concurrently use both legal and recreational marijuana. Just as the principle of justice requires patients who use medical marijuana are not denied participation in substance use treatment, so must veterans who develop abuse of marijuana have equal access to treatment when the addiction risks outweigh the health benefits of marijuana. Central to fairness is the identification of alternative treatments for the conditions for which marijuana is prescribed.2 Unfortunately, diagnosing a marijuana use disorder in a patient using the drug for medical purposes is neither easy nor clear.