Medical marijuana and psychiatry

Is marijuana really medicine?  I’m not arguing against the potential for marijuana to treat illness, nor do I mean to imply that marijuana is simply a recreational drug that has no place in medicine.  Instead, I simply wish to point out how the “medical” label, I feel, has been misused and co-opted in a way that reveals what “medicine” really is (and is not).

Let me state, for the record, that I have no position on medical marijuana.  I practice in California, a state in which it is legal to use marijuana for medicinal purposes.  Even though I do not prescribe it, I do not judge those who do, nor those who use it.  I agree that it can be helpful in a wide range of illnesses– sometimes even in the place of established medicines.  It is unfortunate that controlled studies on THC and other cannabinoid compounds– studies that could lead to new therapies– have not been performed.

Medical care usually follows a well-established outline: a patient with a complaint undergoes an examination by a provider; a diagnosis is determined; potential courses of treatment are evaluated; and the optimal treatment is prescribed.  Afterward, the patient follows up with the provider to determine the efficacy of treatment, any potential side effects, and interactions with other medications or therapies.  The frequency of follow-up is determined by the severity of the illness, and therapy is discontinued after it is no longer necessary, or becomes detrimental to the patient.

Unfortunately, none of this describes how medical marijuana is practiced.  Any patient can undergo an examination; the vast majority of such patients have already been using marijuana and explain that they find it helpful, and the provider issues a card stating that they “advise” the use of medical marijuana.  Not a prescription, but a card– which permits him or her to buy virtually any amount, of any type of cannabis desired.  Follow-up visits are typically yearly, not to evalaute response to treatment, but to issue a new card.

As a psychiatrist, I frequently see patients who tell me they have been prescribed marijuana for “anxiety” or “depression.”  Often, my evaluation confirms that they do indeed suffer from, say, a clinically relevant anxiety disorder or major depression.  However, when I know they are using another chemical to treat their symptoms (whether cannabis, alcohol, or a medication prescribed by another physician) it becomes my responsibility to determine whether it will interfere with treatment.  In most cases, it also makes sense to collaborate with the other provider to develop a treatment plan, much as a cardiologist might collaborate with a family physician to manage a patient’s coronary artery disease.  [Sometimes the treatment plan might be to continue marijuana because I believe psychiatric meds simply won't have any effect.]

But efforts to communicate with marijuana prescribers often fail (and when I have been successful in communicating with such a prescriber, they’re usually surprised that I made the effort!).  Similarly, if I suggest to a patient that he or she consult with the marijuana prescriber to find a strain, or a delivery method, or a dosing interval, that would provide the best symptom relief, or the least interaction with conventional medications– they often react with shock.  “But I only see him once a year,” is the answer I receive.

Often I say to myself something like, “well, marijuana helps him, so I’ll let him continue using it; I’ll just ‘work around it’ unless it becomes a problem.”  The patient usually tells me that he wants to continue using marijuana “as needed,” but he also wishes to continue in treatment with me, taking the medications I prescribe and following through with any treatment I suggest.

It leads to an uncomfortable compartmentalization of care, in which I feel that I’m practicing “real” medicine, while simultaneously condoning his use of another substance, even though neither of us knows the true chemical content of this substance, doses might vary from day to day, and some might be shared with friends.  To top it all off, patients frequently report a greater response to marijuana than what I prescribe, and yet I ignore it?  This is not the way I was trained to practice medicine, and yet I do it almost every day.

The approval of “medical marijuana” has been, I believe, a successful campaign by proponents of marijuana legalization to take advantage of the fragmented and confused health care system to create a de facto social sanction of marijuana use, rather than (a) introducing it as a true “medicine” through the proper and accepted channels (clinical trials, FDA approval, etc) or (b) decriminalizing it into a legal drug, much like alcohol.  I can see the arguments in favor of either approach, but the “medical” label unfortunately undermines what we actually try to do in medicine.

On the other hand, if it works, maybe we ought to take a closer look at what we actually are trying to do in medicine.  If medicine worked all the time, there would be no need for medical marijuana, would there?

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10 Responses to Medical marijuana and psychiatry

  1. Vince Acosta says:

    Steve, This is exactly the type of Q & A that needs to be covered about legalization of this substance. I believe that the states where the use is legal, the communication between patient, therapist, and provider needs to be continual and data needs to be evaluated to provide a better understanding of this drug. And regulations of such drugs. Seems like the prescription method is a little too open and condones abuse. Is the legalization of marjiuana for medicinal purposes a valid reason or just an excuse?

  2. cYaSK8 says:

    marijuana use is everywhere. has traffic stopped. has the media tried to blame it on sensationalism? (AZ shootings). YES.has the world fallen over? is society plagued with misfits because of pot? NO. it's everyone's perception of the boogeyman. we can poison the masses with alcohol but we say pot is no good even though pot's been around for 10000+ years! pot is illegal to help cops, judges and lawyers stay in business. other than that, it's safer than 90% of the FDA approved drugs but the FDA is too proud and kissing big pharma's ass to let it compete with the garbage pseudo science approved products that is brainwashing everyone.

  3. g.dionne says:

    I am curious if anyone connects Brain Zaps to smoking Marijuana. I am now clean and the Brain Zaps have stopped. The chemical cocktail used by the growers to “enhance” the drug is a toxic soup. Also, “better” drugs raises the price, ensures repeat customers, dependency, etc. Legal,Illegal huh? Weed is Weed is Weed. This is a Big Bucks Business…

  4. [...] When I think about “performance enhancement” in this manner, I can’t help but think about the controversy over medical marijuana.  This is another topic I’ve written about, mainly to question the “medical” label on something that is neither routinely accepted nor endorsed by the medical profession.  Proponents of medical cannabis, I wrote, have co-opted the “medical” label in order for patients to obtain an abusable psychoactive substance legally, under the guise of receiving “treatment.” [...]

  5. juan says:

    i am seeing a psychiatrist and i was wondering if i could get a medical card prescription from them, even though i’m on medications?

  6. Ed Zeldin MD says:

    While I agree that THC can be and often is highly detrimental to psychiatric health, cannabidiol (CBD) has been shown to have strong antipsychotic effect without the burdensome side effects of currently available medication. I believe this is actually the cutting edge of psychopharm and it behooves publications such as The Carlat Report to throw more light on this for the benefit of mental health professionals most of whom are behind the curve.

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