BLOG POST: Medical Marijuana and Psychiatry - Will the Romance Last?

BLOG POST: Medical Marijuana and Psychiatry - Will the Romance Last?

06-20-2018

“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!

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