In this day of medical marijuana in some states, and recreational marijuana as well, what is a treatment program to do when it comes to testing for the drug. We checked with the Joint Commission and with the Substance Abuse and Mental Health Services Administration (SAMHSA). Both say the same: test at admission, and from then on, it’s up to you.
The requirements for opioid treatment programs (OTPs) cited in the Joint Commission Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC) do not specify that marijuana must be tested for, except at admission. Megan Marx-Varela, associate director of the Joint Commission’s behavioral health care program, replied to our question about this by citing Standard CTS 02.020.09, element of performance 4 (for OTPs), which states: “On admission the program tests the patient for opiates, methadone, amphetamines, cocaine, marijuana, and benzodiazepines. The need for testing for additional substances is determined by individual patient circumstances and local drug-use patterns.”
As for SAMHSA, in 2014, a Dear Colleague letter to OTPs noted that marijuana is still listed as a Schedule I controlled substance (and it still is in 2016). In accordance with federal law, SAMHSA still views marijuana as an illicit drug in all OTPs, regardless of the state they operate in. This means SAMHSA, as a federal agency, does not accept medical marijuana or recreational marijuana.
As for drug testing, however, marijuana testing is required only at admission.
Both SAMHSA and the Joint Commission specify that admission to an OTP requires running the following toxicology tests: opioids, methadone, buprenorphine, amphetamines, cocaine, marijuana, and benzodiazepines. SAMHSA states that if there is a history of prescription opioid analgesic abuse, “an expanded toxicology panel that includes these opioids should be administered.”
However, any additional testing, beyond admission, “is based on individual patient need and local drug use patterns and trends,” states SAMHSA.
Alcohol vs. Marijuana
We asked specifically what the difference is between recreational marijuana and recreational alcohol use in OTP patients. SAMHSA’s response: “Using methadone and alcohol together is particularly dangerous because of the interactions between the two substances. According to the National Institutes of Health (NIH), when used at the same time, alcohol can increase the risk of experiencing serious and life-threatening side effects from methadone.”
Using alcohol and methadone together “can create health concerns that are more severe based on the combined use of these two substances,” added SAMHSA. “Individuals who mix methadone and alcohol may be more likely to experience respiratory depression, irregular heartbeat, drowsiness, and coma.
We also asked about the effects of combining marijuana with methadone. “Illicit drug use, specifically cannabis, is common among opioid-dependent individuals and has the potential to impact treatment in a negative manner,” SAMHSA responded. “Studies demonstrate that rates of cannabis use were high during methadone induction, dropping significantly following dose stabilization.”
Problems With Marijuana
SAMHSA offered the following evidence of the harms of marijuana, including citations.
Approximately 9% of people who experiment with marijuana will become addicted to it; among those who start using the drug in their teens, the number goes up to about 1 in 6, and among daily users to 25-50%. (Lopez-Quintero C, Perez de los Cobos J, Hasin DS, et al. Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: Results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug Alcohol Depend. 2011; May 1;115(1-2):120-130. doi: 10.1016/j.drugalcdep.2010.11.004. Epub 2010 Dec 8.)
Early (animal) studies show that early THC exposure can weaken the dopamine system in the reward areas of the brain—an effect that, in humans, would explain why early and chronic marijuana use may increase the likelihood of developing other substance use disorders later in life. Agrawal A, Neale MC, Prescott CA, Kendler KS. A twin study of early cannabis use and substance use and abuse/dependence of other illicit drugs. Psychol Med. 2004; Oct;34(7):1227-37.) “This potential risk factor could further complicate the treatment course among those already struggling with substance abuse disorders,” stated SAMHSA.
Marijuana significantly impairs coordination and reaction time and is the illicit drug most frequently found to be involved in automobile accidents, including fatal ones. The recognition of this effect along with known methadone induced sedation is a major concern among OTP clients that drive. (Brady JE, Li G. Trends in alcohol and other drugs detected in fatally injured drivers in the United States, 1999-2010. Am J Epidemiol. 2014; Mar 15;179(6):692-9. doi: 10.1093/aje/kwt327. Epub 2014; Jan 29.)
The takeaway from all of this information: you do not have to test OTP patients for marijuana once they are admitted, but you may want to provide education about the deleterious effects of combining marijuana with methadone. Even more important, however, you may want to bring up alcohol–which just about nobody tests for because it doesn’t show up in urine tests. SAMHSA and the Joint Commission wisely leave testing decisions up to clinicians.
References, and for Further Reading
SAMHSA 2014 Marijuana Dear colleague letter. http://www.samhsa.gov/sites/default/files/programs_campaigns/medication_assisted/dear_colleague_letters/
Federal Guidelines for Opioid Treatment Programs. http://store.samhsa.gov/product/PEP15-FEDGUIDEOTP.
Scavone JL, Sterling RC, Weinstein SP, Van Bockstaele EJ. Impact of cannabis use during stabilization on methadone maintenance treatment. Am J Addict. 2013;Jul-Aug;22(4):344-351. doi: 10.1111/j.1521-0391.2013.12044.x.
Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs: Chapter 9. Drug Testing as a Tool. https://www.ncbi.nlm.nih.gov/books/NBK64151/.