Medical Marijuana Management Program
With the passage of legislation in 2018, it is now possible for physicians in Louisiana to “recommend” marijuana-derived medications for the treatment of a number of conditions as approved by the State. Dr. Eric Ehlenberger has been certified by the LA. State Board of Medical Examiners to provide these recommendations to patients to qualify them for obaining marijuana-derived medications from one of the state-approved pharmacies. Dr. Ehlenberger is also board certified in emergency medicine with over 30 years of experience, advanced certified in pain management with over 10 years of experience and board certified in addiction medicine with over 10 years of experience.
For patients to be eligible to receive marijuana-derived medications they must be diagnosed with at least one of the conditions below and have failed to adequately respond to conventional treatment for this condition.
- Intractable Pain
- Severe muscle spasm
- Spasticity such as Spastic Quadriplegia
- Chemotherapy in the treatment of cancer
- Certain seizure disorders
- HIV/AIDS complications such as cachexia or wasting syndrome
- Debilitating medical conditions such as Parkinsons and Muscular Dystrophy
- Multiple Sclerosis
Note that “pain” is defined as:
“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”
A caveat to the above is the definition of “intractable pain” which legislation defines as “A pain state in which the cause of pain cannot be removed or otherwise treated with the consent of the patient and which in the generally accepted course of medical practice, no relief or cure of the cause of the pain is possible, or none has been found after reasonable efforts. It is pain so chronic and severe as to warrant an opioid prescription.”
It should be emphasized Dr. Ehlenberger does not consider this clinic to be a “medical marijuana clinic.” Nor does he consider this clinic to be an “opioid clinic” because he prescribes opioids or a “pain clinic” because he treats chronic pain. Dr. Ehlenberger offers an “Integrative” medical practice,” one in which he integrates conventional and alternative medical management with the goal to provide the best care for his patients for the management of their condition(s), including pain, anxiety and other general medical conditions as well as addiction.
A patient’s medical conditions will be assessed and managed with whatever treatment options determined to be optimal for the patient, including the use of marijuana-derived medications when appropriate. Similar to the prescribing of opioids for pain, medical marijuana is not the first “go-to” treatment for the above conditions: a patient must first trial and fail conventional, conservative therapy for their condition. For those seeking treatment for pain, marijuana-based medications may be prescribed for pain without first establishing a failed course of opioid therapy. In fact, one of the driving factors for legalizing medical use of marijuana is the hope that it may offset the need to initiate opioid management for chronic pain or reduce the reliance on opioids for pain management.
It should also be emphasized that marijuana remains a Schedule I controlled substance, one in which the federal government has defined as having a “high potential for abuse” and “no currently accepted medical use.” Clearly this arena is full of controversy and conflicting national and state legislation.
The use of marijuana for medical purposes remains highly controversial and suffers from a lack of good quality evidence regarding the specifics of clinical effectiveness and the details of treatment. If interested in applying for the medical marijuana program at Accurate Clinic, please read the education section on this website that is provided as an introduction to the medical uses of marijuana. There will surely be more information to come.
Patients presenting to Dr. Ehlenberger with the desire of being prescribed marijuana-based products should understand that whether or not they will be recommended for use of these products will depend on the outcome of his assessment as to whether they meet the legal criteria as outlined above and whether the benefits of doing so outweigh the risks. For example, at this point in the understanding of risks, THC products are not advised for people under the age of 25 and Dr. Ehlenberger will not recommend them for this age group,
We engage a Bio-Psycho-Social model of medical management, meaning that our approach to managing patients includes not only a biological approach with the use of medications, but also addresses the psychological side of a patient’s condition in which a person is taught methods of using their mind to enhance their coping skills relative to living with a chronic condition. We also engage the social side of our patient’s conditions by working with our patient and their family or significant others, when indicated, to facilitate improved engagement in activities and reduce functional impairment.
For patients seeking marijuana-based medications for pain:
Goals for Managing Chronic Pain
We recognize that severe chronic pain can be devastating to quality of life by impairing a person’s ability to enjoy many of the simple joys of life most people take for granted. Our primary goal of managing pain is to restore quality of life by reducing suffering and improving the ability to engage in work-related, domestic and social activities.
As the measure of successful pain management, our goals are to control pain adequately so that our patients are able meet the activity needs of their employment, maintaining their home and yard and getting a good night’s sleep. To meet these goals we integrate many approaches to prevent and reduce pain, to improve skills for coping with pain and to address the complications of chronic pain including anxiety and depression.
Medication Management of Chronic Pain:
Pain is the most common reason people seek marijuana-based medications. Preliminary research supports their use and effectiveness, especially for nerve pain. There remains a lack of definitive evidence, however, to guide clinicians in specific treatment formulations. It is known that the clinical effects of marijuana-based medications are influenced by not just the amounts but also the ratios of the constituents, especially THC and CBD, but also other plant constituents. As such, it requires some trial and error to identify optimal dosing to achieve the best outcomes.
For those patients not on opioids for chronic pain, marijuana-based medications may be an effective option for avoiding opioids. For those already on opioids, marijuana-based medications often allow for patients to limit their reliance on opioids, allowing them to reduce opioid doses or discontinue them altogether. There is also evidence that marijuana-based medications may reduce the development of tolerance to opioids.
For the many people who have failed to obtain adequate control of their pain with other measures, opioid medications are the backbone of adequate pain management. The term “opioid” refers to both the “natural” medications derived from the opium poppy (the “opiates” – morphine and codeine) and synthetic opiate-derived medications including hydrocodone, oxycodone, methadone and many others. With some exceptions, all opioids share the same benefits, the potential for abuse and addiction and the same side effects but they may differ significantly in potency. That being said, not all people respond equally to any particular opioid. With genetic testing provided at Accurate Clinic, it may be possible to identify specific opioids best suited for an individual for improved effectiveness and less likelihood of side effects.
In an effort to reduce reliance solely on opioids for pain control we often prescribe different classes of medications that reduce pain through mechanisms different from opioids, thus obtaining a synergistic effect for controlling pain. “Neuromodulator” medications are those that act directly or indirectly on nerves to reduce nerve pain such as sciatica, neuropathy or other nerve pain, generally perceived as burning, electric, tingling or sharp pain. Examples of neuromodulators include gabapentin (Neurontin), pregabalin (Lyrica), topiramate (Topamax), milnacaprin (Savella), duloxetine (Cymbalta), venlafaxine (Effexor) and others. These medications are usually tolerated well, especially when initially prescribed at low doses followed by slowly increasing the dose as tolerated. Because these medications reduce pain by different mechanisms than opioids, they can be very successful in reducing pain when used synergistically with opioids.
Topical medications, or those applied directly to the skin overlying the source of pain, include both commercial brand medications as well as unique blends formulated by our physician and provided by special “compounding” pharmacies. Topical medications offer the advantage of improved safety due to less systemic exposure and in many cases improved pain benefit due to enhanced access to the painful tissue. Topical medications can be very effective at safely reducing neck, back and joint pains with minimal likelihood of side effects and are frequently prescribed as a part of the pain control regimen when appropriate.
Complementary & Alternative Medicine
Complementary & Alternative Medicine (CAM) treatment options are extraordinarily helpful in preventing and reducing many painful conditions and no pain management regimen is complete without considering their use. In our pain management programs we place great emphasis on the use of nutriceuticals and natural supplements with evidence-based effectiveness in reducing the pain associated with such conditions as chronic headaches, fibromyalgia, arthritis, and chronic neck and back pain.
Evaluation by our physical therapist is included as part of our pain management programs. Patients are assessed by our licensed physical therapist with the goal of identifying how a person’s chronic pain conditions have affected their strength, range of motion and balance in order to develop an individualized home exercise program to improve whatever problems are identified. Included also is assistance in the proper and most beneficial use of canes, braces and other orthotic devices. Our therapist is also available to assist patients in determining effective sleeping positions, pillow placement and mattresses to optimize sleep.
Our certified personal trainer provides instruction in safe and effective aerobic and resistance exercise as part of a complete exercise program directed at reducing pain and preventing further injury. Our personal trainer is also an expert in teaching “muscle release” techniques that are very helpful in reducing muscle and joint pain. We also offer genetic testing to help identify an individualized exercise program genetically based to provide the most efficient exercise program for each patient.
We currently do not offer the services of a personal trainer, but are looking to provide them again soon.
The role of diet and nutrition is extremely important in the management of chronic pain. All patients enrolled in our pain programs are seen and evaluated by a registered dietitian including a body composition analysis of those patients who are overweight. Vitamin levels and other biomarkers are assessed routinely in an effort to optimize our patients nutritional status. Pain management patients are educated regarding the role of diet in pain and inflammation and are provided with the tools needed to navigate our modern food culture most effectively.
Of particular importance is the role of oxidative stress in obesity, metabolic syndrome and chronic pain. The majority of chronic pain patients are overweight and need help in successfully losing weight. Our pain management patients are strongly encouraged to enroll in our weight loss program and substantial discounts are provided to the patient and their family for enrollment.
Genetic testing is offered to all pain patients as a means of providing safer, more effective pain management. As identified in a study published by Dr. Ehlenberger in 2012, our pain patients have a substantial increased likelihood of having genetic variants in how they metabolize medications. Understanding these variants provides the advantage of safer prescribing by improving the ability to predict the effectiveness of certain medications, their potential for side effects and their potential for drug-drug interactions. As part of our coordinated care program, the impact of these genetic variants can be shared with the patient’s pharmacist and other prescribing clinicians to reduce the likelihood of potentially dangerous drug interactions, a signficant safety concern especially for those people taking multiple medications prescribed by multiple physicians.
Genetic testing also provides insights into a person’s sensitivity to pain and their response to opioids and other medications. Accurate Clinic is active in ongoing research investigating the role of genetics in predicting pain sensitivity, pain tolerance, and opioid tolerance. Dr. Ehlenberger’s strong interest and participation in active medical research reflects the importance Accurate Clinic places on a practice based on evidence-based medicine.
Meditation and Mindful Exercises
The mind is an incredibly powerful tool when harnessed to help control pain and reduce suffering. The truth is, when properly trained, patients can harness a great deal of benefit in living with chronic pain by using their mind to apply simply-taught behaviors, including meditation and other “mindful exercises,” simple mind-based activities that allow a person to focus their minds in ways that allow for improved coping with pain and reduced negative impact on quality of life.
Through the use of medical hypnosis, our patients can learn self-hypnosis techniques that give them the power to use their minds effectively to improve their sense of well-being, their degree of pain and suffering and their energy levels. The techniques can be learned quickly, by anyone, in only a few individual sessions and do not require susceptibility to being placed in a trance. Medical hypnosis is safe and contrary to common misconceptions, the participant does not ever lose control of their mind or their behavior and everyone can benefit from medical hypnosis.
CBT and Counseling
Treating pain is more than just providing medications and physical modalities of management. We believe that it is equally if not more important to address the psyche as a means of reducing pain and improving pain tolerance.
A particularly effective tool for managing pain is to incorporate Cognitive Behavior Therapy (CBT), a collection of techniques and education directed at improving a patient’s skills and ability to adapt to living with chronic pain and improving sleep. CBT also aids in improving communication skill for interacting with both the medical community and family. CBT training is provided in individual and group sessions for those interested or in need of help coping with a life of chronic pain. In addition, a free computer-based CBT education program is provided.
Anxiety and depression are significant and frequent complications of chronic pain and must be addressed for successful pain management. Our licensed counselor is experienced in the problems faced by chronic pain patients and is skilled at providing counseling to assist them. Individual counseling is provided for those patients who need help with anxiety or depression.
To download documents for initial Pain Assessment Visit at Accurate Clinic, click here.