Two weeks ago on this CPN website, Dr. Annette Hanson and I wrote about our objections to proposed legislation in the Maryland General Assembly to legalize medical marijuana. The same article appeared as an op-ed piece in the Baltimore Sun, in both its print publication (3/9/12) and online (3/7/12).
The response to the articles was notable, and with the exception of a few supportive e-mails, the majority of commenters – and e-mailers, and a single phone caller – were strongly opposed to our viewpoints. I want to use this column to talk about my thoughts on the comments in the Sun.
Let me start by saying that if I believed that legislation was about making marijuana accessible to those with cancer, AIDS, or debilitating pain, I would not be writing an article in opposition to the legislation. If I thought the legislation would have no adverse impact on the treatment of psychiatric patients, I would also not be commenting. And finally, if the legislation proposed either the legalization or decriminalization of marijuana, I would view that as a legal issue.
I am a general adult psychiatrist, and substance use and abuse are common among psychiatric patients. Many patients report a history (past or present) of recreational marijuana use that has not had any negative impact on their lives. It does seem, however, that a percentage of the population does not do well with marijuana. For them, marijuana leads to addiction, a lack of motivation, an increase in psychiatric symptoms, and tremendous unmet potential. In clinical practice, I will point out the ways in which these patients' lives are not going well – ways that are typical of what I see with people who smoke too much weed – and suggest they try an experiment on themselves: Give up marijuana for a few months and see if life gets better. Very few people take me up on this suggestion – at least not at first – and I’ve heard a lot of rhetoric about NORML and how the government lies to people about the evils of marijuana.
My patients insist that pot helps them sleep, or feel less anxious, and they argue that it has nothing to do with their persistent symptoms or their inability to progress in their lives – problems that led them to seek treatment with me.
Among those who are not psychiatric patients, cannabis may induce a sense of complacency that leaves the smokers satisfied with their lives and with what “medical marijuana” has done for them, when they should be striving for so much more. So I believe that marijuana interrupts the lives of some of the people who use it and blinds them to the reality of their problems, and legalizing medical marijuana would provide an easy means to both obtain and divert cannabis. It may also cause these problems in well-meaning people who seek treatment but would not otherwise consider regular use of an illicit substance, just as the legal use of benzodiazepines, narcotics, and barbituates has done more harm than good for some patients.
The current mechanism of recommending medical marijuana and providing a one-year use card bypasses the usual risk-benefit discussions and worries about adverse outcomes that we’ve learned about with other medications the hard way.
The truth remains that in some states, medical marijuana is used primarily to treat psychiatric symptoms such as anxiety, depression, and insomnia, and prescribers of medical marijuana make substantial incomes seeing patients for cursory evaluations that do not resemble the usual standards of medical care.
Thompson and Koenen write in “Physicians as Gatekeepers in the Use of Medical Marijuana,” in The Journal of the American Academy of Psychiatry and the Law (2011;39:460-4):
“During the course of a typical day of psychiatric evaluations for Social Security Disability, it is not uncommon for every examinee to have a medical marijuana card or so called green card; and the data support this observation. Studies have revealed that a large percentage of individuals seeking marijuana do so for the treatment of anxiety, depression, and other psychiatric conditions. In many cases, individuals seeking medical marijuana have a history of alcohol and drug abuse since adolescence and continue to use illicit substances.
Physician tolerance of the use of medical marijuana among patients with substance abuse problems is a serious concern. Teenagers frequently obtain medical marijuana for purposes of treating psychiatric problems commonly associated with adolescence. The fact that teenagers can smoke marijuana (because it is medicine) complicates substance abuse treatment in this vulnerable population.…The co-author has evaluated patients who presented to the clinic too intoxicated on medical marijuana to engage in meaningful treatment.”
I’ve broken down the 45 comments from the Sun article into the following categories: