There may also be situations in which appropriate use of medical marijuana may interfere with recovery from other substances of abuse, such as benzodiazepines or alcohol, or contravene employment of the optimal therapies for comorbid medical or psychiatric conditions, for example, other sedating psychoactive medications. Medical marijuana use could in theory lead a patient or other patients in a program to relapse to the substance of choice, although preliminary evidence suggests this may not necessarily be the case.25
Self-medication with medical marijuana for symptoms other than those for which the drug is approved may become an obstacle to efficacious treatment of other psychiatric problems. For instance, a veteran being treated for depression with cognitive behavioral therapy (CBT) may find the apathy chronic marijuana often induces to be an obstacle to the homework and activation exercises used in CBT.2
Patient-Physician Partnership
The nature of VA as a beneficiary health care system precludes the organization from denying VA services to veterans participating in state medical marijuana programs. However, the system does allow providers to make decisions to modify treatment plans on clinical grounds so long as those modifications are made in partnership with patients in accordance with VA’s emphasis on shared decision-making in medical care.
It should be noted that despite this emphasis, the autonomy of both patient and physician is legally and administratively circumscribed. If a clinician’s independent reading of the medical literature and professional judgment regarding the patient’s specific clinical circumstances determine medical marijuana is clinically indicated, the clinician is not free to communicate this recommendation to the patient without risking criminal prosecution or institutional sanctions. These considerations may weigh heavily on practitioners who think that medical marijuana would benefit patients, especially in states where it is legally available.
Conversely, patients residing in states with medical marijuana laws who believe the substance would relieve their symptoms can seek out a community provider to assist them in obtaining registration. However, patients’ self-determination is limited in that they do not have the choice to have their PCP, who presumably is most familiar with their medical history, recommend or prescribe medical marijuana. Veterans also are not permitted to use VA pharmacy benefits to have VA pharmacists fill the prescription.
This is a clear statement of the limit of veteran entitlement: VA will not pay for medical marijuana. No exception is made if the veteran is using medical marijuana to treat service-connected injuries or illnesses. Directive 2010-035 (now rescinded) and the original VA OGC opinion assert that medical marijuana does not meet criteria as a core health benefit that VHA as an entitlement program must provide as an aspect of basic care.5,20 The justification for this exclusion is that non-Food and Drug Administration (FDA) approved drugs are not encompassed in the medical benefits package outside either an Investigational New Drug Application or compassionate use FDA provision. Veterans may experience this as a social justice issue and a violation of the VA fiduciary duty to its beneficiaries. A sharp demarcation is made between the private use and public possession of marijuana. Veterans who carry marijuana on VA property, even if they are certified to carry medical marijuana, will be prosecuted under CSA.
Conclusion
Studies estimate that 50% of veterans experience chronic pain, and nearly half of these patients receive prescription opioids.26 Conversely, up to 35% of VA patients are diagnosed with both substance use and mental health disorders.27
The one aspect of the controversy that stakeholders on the pro and con sides of the medical marijuana question agree on is the need for more empirical data.28 There is an urgent need for more study of the use of medical marijuana as a treatment for posttraumatic stress disorder, which is a qualifying health condition in a growing number of states.29
Along with federal law, it is federal agencies, including the DEA, FDA, and the National Institute on Drug Abuse, that may be the biggest obstacle to conducting this vital research.30 These regulatory obstacles must be removed before researchers can conduct the scientific studies needed to provide a factual foundation to inform what has too often been a political debate. Solid science grounding legal reform and shaping public policy toward medical marijuana may be the only means of resolving the ethical dilemmas that confront veterans daily and the VA clinicians committed to caring for them.31,32
In the interim, VA practitioners should be provided effective training in educating and counseling patients about the implications of VA policy regarding state-approved medical marijuana programs for their individual health care. Such a patient-centered approach represents the most ethically acceptable means of mediating the conflict between state and federal law regarding medical marijuana in its current stage of evolution.