“Hey doc, can you give me the good stuff - (medical marijuana), as
nothing else works for me”. This oft repeated statement is commonly
being heard by mental health professionals, and seeing the trends, those
doctors who haven’t heard it, are likely to hear it soon. If you
are like me, then such statements often evoke a strong reaction. The reaction
is based on finding the patient’s statement to be inaccurate- after
all- has the patient really tried all options and really, nothing works?!!
Or is the reaction a product of one’s own viewpoint about marijuana,
as we have mostly known it as a gateway drug to other substances? Further,
over the years psychiatrists have learned about the ill effects of cannabis,
whether it is cannabis dependence, amotivational syndrome, or it being
a co-occurring disorder which makes treatment of psychiatric conditions
more difficult. Another possibility is that it is a question that physicians
have limited knowledge about, and doctors hate to be seen as people who
don’t have answers. Patients do look up to us as experts and anytime
they touch upon an issue such as this, it could hit a raw nerve. Finally,
could it be really true that one substance could be helpful for a variety
of conditions?
Currently medical marijuana could be prescribed for more than 50 indications
which cut across different specialties. The last time any substance gained
such interest was when opiates came about, as they could help with pain
from pretty much every source in the body. We all know how that led to
the opioid epidemic! So, there is no doubt that most physicians do get
skeptical about medical marijuana. However, no matter what drives the
strong feelings about marijuana, ignoring the question never helps. At
the bare minimum, it should be seen as an opportunity to have a discussion
about what the patient hopes to achieve by using medical marijuana. At
least they would acknowledge that it is needed to address their mental
health or medical issues, which could lead to a healthy discussion about
pros and cons of the already available interventions.
I do wonder as to what is so appealing about medical marijuana, and so
I ask my patients the same question. One common explanation given by patients
is that they see prescribed medications as “chemicals” and
don’t want their body to be exposed to chemicals.
On the other hand, medical marijuana is seen as a “natural substance”
and so devoid of side effects. It is fascinating that they don’t
ask for arsenic- as that is a natural substance as well, but will leave
that discussion for another time). Also, somehow the word “medical’
in front of marijuana legitimizes it, and ironically, makes it sound that
it is very well researched. Another reason why it is appealing is that
unlike any new medicine that gets introduced into the market, the reality
is that marijuana has been used recreationally for decades now; thus,
sending the message that it is indeed “safe,” and by making
it “medical marijuana,” we are eliminating any risks which
the uncontrolled marijuana from the street might carry. So, what’s
the bottom line? Is it all sham, or could there be some medicinal value
to it? In this article, I highlight some key things about marijuana, which
we all should familiarize ourselves with.
It is important to understand that marijuana’s use for recreational
purposes has increased in recent times, it is more potent and now also
legalized in many places (more than half of states now allow for medical
use, and 8 states, and the District of Columbia, have legalized adult
personal or recreational use.) Although we are learning more about cannabinoid
pharmacology, compared with the literature on non-medical cannabis use,
the scientific literature on therapeutic use of cannabis is underdeveloped.
Our knowledge is still in stages of infancy. There are approximately 500
biochemical compounds in marijuana. The two most commonly talked about
are delta-9-tetrahydrocannabinol (THC), which is psychoactive, and cannabidiol
(CBD), which is non-psychoactive, but it does appear to have therapeutic
value for a wide variety of conditions either alone or in combination
with THC. Herbal cannabis is under schedule I, which limits any meaningful
research. THC is schedule III, but most of the interest, understandably
so, has been on CBD. Ironically, the only way to get CBD is through herbal
cannabis, and this explains the paucity of research. There is no doubt
that the FDA needs to ease restrictions so that conclusive research could
be done on cannabis and its various constituents.
In recent years, more and more patients seem to be advocating for use of
marijuana in conjunction with other treatments or even all by itself.
There is enthusiasm and a new-found love for marijuana as a treatment
option for mental issues. So, a reasonable question to ask is “
Do we have any research on cannabis and mental health issues?” Fortunately,
the answer is – yes!
It is important for providers to familiarize themselves with what is known
so that the community could be educated on it as well. It is beyond the
scope of this article to go into details, but The National Academy of
Sciences has very diligently summarized all the research pertaining to
the effects of cannabis and health, including mental health issues.
There is substantial evidence of statistical association between use of
cannabis and increased risk of psychotic disorders. However, in individuals
with psychosis and history of cannabis use, there is moderate evidence
of statistical association of better cognitive performance. There is also
moderate evidence of statistical association of increase in mood symptoms
in patients with Bipolar Disorder. Further, there is moderate evidence
of statistical association of increased risk of suicidal ideation and
attempts (especially with heavier users,) as well as increased suicidal
completion. There is moderate evidence of a statistical association between
acute cannabis use and impairment in the cognitive domains of learning,
memory, and attention. There are hardly any noteworthy clinical trials
in patients with dementia, but there is some basic science research which
points towards suppression of neuronal excitotoxicity and neuroinflammation
and potentially beneficial effects of cannabis in targeting plaque formation
in Alzheimer disease. Nothing, perhaps, is more interesting than the role
of cannabis in PTSD. Most of the studies done do not meet the scientific
standards to be included in the meta-analyses, but it is noteworthy that
the most commonly prescribed reason for medical marijuana in psychiatry
is PTSD, and there are several case reports/small studies that show beneficial
effects of cannabis and suppression of symptoms of PTSD across all domains.
Such reports do enthuse supporters of medical marijuana tremendously and
instills hope in many patients who suffer with anxiety and other mental
health issues. Finally, there is not much evidence to support or refute
the use of cannabis to address opiate addiction. It is very important
to understand that the evidence of statistical significance is that of
association and not causation. For the purists, this distinction is of
utmost importance.
To conclude, cliché as it may sound, there is indeed a necessity
of more research. It is highly doubtful that medical marijuana will turn
out to be a miracle drug to treat it all; but based on whatever little
is known thus far it is also unfair to dismiss the possible beneficial
effects of cannabis. As more literature emerges, it is imperative for
the medical community to keep itself updated on it, else we would be failing
our patients. It is equally important to impress upon the fact to our
patients that a lot is still unknown. We should not be reluctant to discuss
it with patients as that would make it stigmatizing for patients to discuss
their current concurrent use of substances including marijuana. One should
be non-judgmental in such discussions and mindful of one’s own preconceived
notions about marijuana, which also have no scientific basis. Equally
essential is for providers to be aware of the regulations pertaining to
prescription of medical marijuana in the state that they practice. “Drug
counselors” who work in medical marijuana clinics do prescribe based
on their own and collective experience of their peers, e.g. a certain
strain of cannabis is more sedating than the other one, hence, is commonly
used to treat insomnia. The numbers are not small, so there is definitely
some merit to their prescribing practice. But it hasn’t gone through
any scientific rigor for it to be called an “evidence based conclusion.”
Whatever the final outcome of research might be, one thing is for sure
- the discussion on medical marijuana has just started and the romance
between medical marijuana and mental illness is here to stay!