Feature

View of medical cannabis in psychiatry may be changing


 


Some psychiatrists and other physicians who treat pain have been open for some time to recommending medical cannabis for their patients. The psychiatric community in general, however – largely because of concerns about addiction and psychosis – has been reluctant to do so, despite the drug’s proven benefits for illnesses such as anxiety, posttraumatic stress disorder, and mood disorders.

But this reluctance might be changing, some psychiatrists say.

“Clinicians are increasingly open to this kind of dialogue,” said Christopher G. Fichtner, MD, a Fellow of the American Psychiatric Association (FAPA), and clinical professor of psychiatry at the University of California, Riverside. “As a doctor, I try to be aware of how my patients are using cannabis, what benefits they may attribute to it, and whether they have problems related to its use. At times, it may be possible to advise them about the value, for example, of products rich in cannabidiol (CBD) – known to be anxiolytic, possibly antipsychotic, and potentially mood stabilizing – as opposed to products higher in tetrahydrocannabinol (THC) that are more psychoactive and may aggravate psychotic symptoms for some patients.

“Our ability to advise patients along these lines is helpful to the extent that patients are able to consistently obtain reliable cannabis products,” Dr. Fichtner said, noting that European and Brazilian research supports the view that CBD might have some antipsychotic properties (Schizophr Res. March 2015;162[1-3]:153-61) and (Schizophr Res. 2015 May;164:[1-3]:155-63).

Currently, 25 states and the District of Columbia have legalized cannabis for medical use; and voters in three additional states – Arkansas, Florida, and North Dakota – approved medical cannabis measures on Nov. 8. “Although medical marijuana laws have not made it possible to prescribe cannabis in the strict sense, they allow doctors to recommend it for patients who experience benefit from using it,” Dr. Fichtner said. “Cannabinoid products available in dispensaries are not subject to the same level of regulation and quality control as Food and Drug Administration–approved medicines, but they are often labeled qualitatively and/or quantitatively with the result that they probably are more reliable than marijuana obtained on the streets.”

Traditional vs. counter views

The American Psychiatric Association came out strongly against cannabis use for medicinal purposes in 2013. The APA’s position statement cites the absence of “current scientific evidence” showing that marijuana is in any way beneficial for treating “any psychiatric disorder. In contrast, current evidence supports, at minimum, a strong association of cannabis use with the onset of psychiatric disorders,” the statement says. Likewise, the American Medical Association reaffirmed its opposition to the use of medical cannabis in 2013, citing the drug as a “public health concern.” Another medical group that is in strong opposition to the use of medical cannabis is the American Society of Addiction Medicine (ASAM). In addition to rejecting smoking as a means of delivery, ASAM’s policy statement says “cannabis, cannabis-based products, and cannabis delivery devices should be subject to the same standards that are applicable to other prescription medications and medical devices.”

In a policy revised in 2015, the National Institute on Drug Abuse (NIDA) said that although the FDA has neither recognized nor approved the marijuana plant as medicine, the FDA has approved three medications that contain cannabinoid chemicals. Marinol and Syndros, which include dronabinol, a synthetic delta-9-THC, are approved for treating anorexia tied to weight loss in patients with AIDS. Cesamet, which contains nabilone and has a chemical structure that is similar to THC, also has received FDA approval for nausea and vomiting caused by cancer chemotherapy.

Earlier this year, a new organization founded by David L. Nathan, MD, a Distinguished Fellow of the APA (DFAPA), joined the cannabis debate. The group, known as Doctors for Cannabis Regulation (DFCR), does not advocate for the use of medical cannabis. However, DFCR does support, among other things, “cannabis legalization for adults, preventive education of minors, and regulation of the industry.”

Dr. Steven R. Daviss

Dr. Steven R. Daviss

“A social justice aspect overlays the whole discussion,” said Steve Daviss, MD, DFAPA, a DFCR founding member and president of FUSE Strategies for Behavioral Health Integration in Baltimore.

DFCR argues that prohibiting cannabis overburdens the criminal justice system, drains law enforcement, and treats African Americans unfairly, saying that population is “nearly four times more likely than whites to be arrested for cannabis possession, despite similar usage rates between the two groups.” The group, which launched with more than 40 founding members – including 10 psychiatrists – also cites evidence showing that medical cannabis use is correlated with a 25% reduction in deaths from opioid use. In 2014, Marcus A. Bachhuber, MD, of the Philadelphia VA Center, and his colleagues reached those conclusions after comparing three states with medical cannabis laws that were effective before 1999 with 10 states that had enacted medical cannabis laws between 1999 and 2010 (JAMA Intern Med. 2014;174[10]:166-73).

“This is a rapidly changing area; new therapeutics are being developed; and there is great potential for good here” as well as the potential for risks, just as with any other medicine,” said Dan Morhaim, MD, an emergency medicine physician who represents Baltimore County’s 11th legislative district in the Maryland House of Delegates. “It’s not the devil weed; nor is it a panacea,” said Dr. Morhaim, who was active in the process of passing Maryland’s medical cannabis law. “Our job ought to be to see it as another tool in the toolbox to be used responsibly, just as we would with any other medicine.”

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