Feature

View of medical cannabis in psychiatry may be changing


 

Lessons from patients’ reports

Rachna J. Patel, DO, a psychiatrist who describes herself on her website as “The Medical Marijuana Expert,” treats patients with anxiety and PTSD, and agrees that marijuana is a tool that, when used correctly, can benefit patients. “A visit with me, a medical marijuana doctor, is much like a visit with any other doctor,” said Dr. Patel, who practices in Walnut Creek, Calif.

Dr. Patel applies some basic considerations when assessing patients for potential medical marijuana treatment, notably the efficacy and side effects of past treatments and patient concerns about past treatments, including the potential for dependency or addiction. She also assesses the impact of anxiety or PTSD on the patient’s quality of life.

Education is key, she said, to addressing patients’ concerns and managing possible risks. “The risks are generally minimized and even eliminated by educating patients on selection of the appropriate combination of cannabinoids, as well as teaching them to use medical marijuana at the lowest effective dose and with the lowest effective frequency,” she said.

“Having practiced in the field of medical marijuana for 4-plus years, I haven’t found marijuana to be a gateway drug,” she said. “The patients I see aren’t looking to ‘get high’ off of medical marijuana. In fact, they’re seeking to get off of the pharmaceutical drugs they’ve been prescribed.”

Dr. Patel walks patients through what she calls “The Patel Protocol for Medical Marijuana,” which includes “teaching patients how to select the appropriate combination of cannabinoids in marijuana products, figuring out how much to use and how often to use it, how to avoid side effects, and what to do in case patients do experience side effects,” she said.

In her experience, “when it comes to dosing, just like with many pharmaceutical medications, it really varies from patient to patient, even more so because cannabinoids are hydrophobic, so their pharmacology is not typical of most pharmaceutical medications.” Dr. Patel follows up with her patients often by phone after the initial office visit, then continues with office visits at least once a year.

“The best way any doctor can help to monitor their patients’ use of medical marijuana is to be as informed about it as any other pharmaceutical drug they’re prescribing,” she said. “Become familiar with the pharmacology [of medical marijuana],” she advised. “Know what scenarios could lead to side effects and how those side effects can be avoided. Know in what scenarios it [marijuana] can exacerbate underlying medical conditions.”

Dr. Fichtner agrees with Dr. Patel’s approach but adds that he generally does not recommend cannabis as a first-line treatment for his patients with serious mental illness. Rather, his approach generally is to prescribe evidence-based treatments.

“But when I do find a history of marijuana use and the patient reports it has been helpful, I work with the patient to assess possible benefits in the areas of symptom management and possible reductions in polypharmacy,” he said. “The latter is of particular concern in PTSD, where patients may be on complex multidrug regimens involving off-label medication prescriptions with only partial symptom relief. It is important to take the patient’s claim seriously, rather than merely jumping to the conclusion that they have a substance use disorder that is undermining their psychiatric care.”

Dr. Patel said a surprising and positive side effect she has observed during her years of recommending medical marijuana is that patients’ use of any anxiety and PTSD medication decreases over time.

“Even though I never expected it, with the use of medical marijuana, many of my patients have been able to significantly reduce or even eliminate the use of their prescription medications for their anxiety and/or PTSD,” she said. “Over time, I find that patients use the medical marijuana on an as-needed basis.”

Dr. Fichtner is the author of book, “Cannabinomics: The Marijuana Policy Tipping Point” (Northbrook, Ill.: Well Mind Books, 2010). Dr. Daviss, Dr. Morhaim, and Dr. Patel had no relevant financial conflicts to disclose.

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