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Medical middle ground between marijuana and pain pills

Apotent cocktail of drugs helps tamp down the stabbing pains in Robert Kridel's deteriorating spinal column.

At the same time, a toke of medical marijuana helps keep him "balanced," taking the edge off a life confined mostly to a $24,000 wheelchair.

The 61-year-old Medford resident's doctor has given him a hard choice: Give up the pain medication Oxycontin or give up the marijuana.

Kridel, who is on disability, has chosen marijuana, which he said he's smoked since he was 8 years old.

"It's scary that you have to pick between pot and pain meds," he said. "There's no compassion for me."

The animated and talkative Kridel said he's already feeling more pain as his doctor begins to wean him off the Oxycontin.

Kridel is in the middle of two hot issues under serious discussion among doctors and public health officials in Oregon and other states: The widespread use and abuse of strong painkillers, and the effects of mixing those painkillers with marijuana.

Kridel said his problems started 16 years ago when he got tetanus.

He was fixing a tractor engine when an accident nearly severed his right index finger and drove his hand into a pile of barnyard dirt.

Surgeons sewed his finger back on and gave him a tetanus booster shot. Within days he began to feel stiffness in his neck and he came down with a fever, symptoms of tetanus, also known as lockjaw.

Over the years, some doctors have questioned whether the tetanus actually resulted in the spinal problems, but Kridel said he's convinced the tetanus caused nerve damage that has severely deteriorated his spine.

He is being treated for osteoporosis, degenerative joint disease and other ailments.

His Ashland doctor prescribed 17 medications, including morphine and Oxycontin. Some of the medications counteract the negative side effects of opiates, which can include constipation, endocrine dysfunction, sleep disturbance, drowsiness, emotional problems and adverse interactions with other medications.

On Feb. 4, Kridel was required to sign a pain management agreement with his doctor that included the following sentence: "I understand that marijuana use (with or without a medical card) is breaking this contract."

Kridel signed the agreement, but asked for an exception to the marijuana prohibition.

His doctor, whose clinic is part of the Providence Medical Group, then wrote: "You will need to choose between marijuana and narcotics for treating pain. I understand that you have chosen marijuana."

The doctor filled a prescription for 60-milligram pills and one for 30-milligram pills of Oxycontin. Kridel is supposed to take the 60-milligram pills in the morning and the 30-milligram pills in the evening. Once he runs out of the 60-milligram pills, he will decrease both doses to 30 milligrams. Kridel then needs to follow up with his doctor to find out how he's handling the decreased prescription.

He said the effects of the reduced dose are letting him feel pains that he hasn't felt in years.

"This is inhumane," Kridel said. "I'm having trouble breathing because my back is in such pain."

Kridel, who receives his medical marijuana without charge from a grower in Williams, takes monthly urine tests to determine the levels of opiates in his system. He is also tested for marijuana.

James Watson, spokesman for Providence Medford Medical Center, said federal law prohibits him or a physician from commenting on a specific case. He did say Providence doesn't have a blanket policy about medical marijuana and opiates.

"It's for the provider to decide," he said. "Providence as an organization does not get in the middle of that discussion."

He said Providence doesn't require boiler-plate pain management agreements. Individual physicians decide whether a pain management agreement allows medical marijuana and opiates, Watson said.

Doctors are constantly trying to determine the best treatment plan for their patients, he said.

Lee Berger, a Portland attorney and marijuana advocate, said it's an ongoing problem for patients who have to decide between medical marijuana and opiates for pain relief.

"As a practical matter, that is the contract you have between you and your doctor, so my advice is you need to find a different physician," he said.

The problem for many physicians is that they get disciplined for overprescribing and disciplined for underprescribing medications for pain, he said.

Berger said marijuana exaggerates the effects of many drugs, including alcohol and opiates. As a result, he said doctors can provide patients with lower dosages of opiates.

Also, many patients report they are unable to function with narcotics.

Berger said there have been studies that show marijuana is also an effective drug to help patients get off prescription pain relievers.

According to the Opioid Providers Group in Southern Oregon, some doctors adopt a "don't ask, don't tell" philosophy and don't require testing for the active ingredient in marijuana — tetrahydrocannabinol, or THC.

Other doctors allow the use of medical marijuana and opiates. But the Opioid Providers Group has found that most providers in Southern Oregon do not prescribe opiates to patients who also use medical marijuana.

Oregon in 2010-11 had the highest rate of prescription-drug abuse in the country at 6.4 percent, compared with 4.6 percent nationwide, according to the Substance Abuse and Mental Health Services Administration.

Dr. Jim Shames, medical director for Jackson County Health and Human Services, said doctors are acutely aware of the potential risk for abuse when a patient is prescribed opiates.

The goal is to attain a "steady-state" condition in which patients receive enough opiates for pain management but not enough to put them in an altered state, he said.

"Opioids have a whole series of risks in and of themselves, including drowsiness, nausea and itchiness," Shames said.

One of the big risks is slowing down the rate of respiration, which could potentially be deadly.

Throwing marijuana into the mix adds an extra dimension to the pain management regime that many doctors don't feel comfortable with, Shames said.

"There is no doubt about the fact that marijuana is a mind-altering drug," Shames said. "You're in a somewhat altered state on one medication, and on the other medication you have lots of dangers attached to it."

Shames said the types of pain management programs he is describing apply to non-cancer patients who experience extreme pain from a variety of conditions.

Despite the possible dangers of providing marijuana with opiates, Shames said he personally doesn't have an absolute conviction against mixing medical marijuana with opiates.

"It's not something I would fall on my sword about," he said.

Because of the widespread abuse of opiates, the trend now is for doctors to try to wean patients off high-dose painkillers or to lower the doses, he said.

"It's a complicated area," Shames said. "We have too many people taking strong dosages of opiates."

Shames said he is sympathetic to patients who suffer from constant pain. Doctors often try different treatments to lessen the need for painkillers, including physical therapy and exercise regimens.

Shames said painkillers are used at the onset of acute pain, but the goal is to eventually taper them off.

He said he also suffers from pain issues from time to time that require occasional treatment with Vicodin, though he tries to avoid taking it.

"I have the worst shoulders you could ever imagine," he said.

Sen. Alan Bates, a Medford doctor and supporter of medical marijuana, said his cancer patients have used medical marijuana to help with nausea and appetite.

But, he said, he hasn't allowed it for patients taking opiates for acute pain issues.

"There is a lot of anxiety amongst physicians about the whole issue," he said.

Also, he said there hasn't been enough scientific studies to determine whether medical marijuana makes sense along with prescription drugs.

Bates said the Oregon Medical Board hasn't taken a position on the use of medical marijuana along with opiates for acute pain relief.

According to the Mayo Clinic, there is scientific evidence to support that marijuana is effective for relieving pain and lessening the symptoms of multiple sclerosis.

Kridel said he would love to be able to discontinue the use of painkillers, but he's also concerned about living life with extreme pain.

"Honestly, I am in trouble," he said.

Kridel said he used to be a farmer and loves sailing, but acknowledges he may never make it out onto Applegate Lake again.

"I can't tell you how much I miss who I was," Kridel said. "I'd give anything to get well."

Reach reporter Damian Mann at 541-776-4476 or dmann@mailtribune.com.

Robert Kridel, 61, has a specially made wheelchair that allows him to recline to help his circulation. Suffering from acute pain, Kridel must make a choice, his doctor says: Oxycontin or medical marijuana, but not both. Mail Tribune / Bob Pennell - Bob Pennell