Medical Marijuana: Please Don't Let Me Be Misunderstood

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:
 

• Legalization will benefit those with illnesses. Some wrote in with their own anecdotes of how marijuana helped the following: OCD, seizures, Crohn’s disease, migraines, chronic pain such that the user could stop taking narcotics, bone disease, and “saved my marriage, my heart, and my soul.” One commenter asserted that in Oregon, marijuana cures cancer.

• FDA approval is a catch-22 because cannabis is a Schedule I drug, and this stymies research. In a country where 17 states have legalized medical marijuana, I agree that the FDA should revisit this issue.

• FDA-approved medications have resulted in many deaths, and FDA-approved medications have been withdrawn for safety reasons.  Readers specifically noted Ambien, Xanax, Oxycontin, Vioxx, Avandia, Fen-Phen, and silicone breast implants. They contend that marijuana is safer than these substances.

• Other legal substances are unsafe, specifically alcohol, tobacco, and the above-mentioned prescription drugs. This is similar to the point made above, and I agree, but I am not sure it’s relevant to the discussion of medical marijuana.

• Marijuana is safe and effective, and any facts that are presented to the contrary are wrong.  There is really no answer to this because this point of view, by definition, is closed to discussion.

• Marijuana doesn’t kill.  If you stay out of a car, don’t lace it with it toxins, and don’t mix it with other drugs, this is probably true.

• There are inconsistencies in medical practice, and people can get Viagra by calling an 800 number.  

• Marijuana is an herbal product that has been used as medicine for thousands of years and should not treated as a pharmaceutical.  Again, this is different issue from those addressed in medical marijuana legislation.

• Doctors are pawns of the pharmaceutical industry and can’t profit if medical marijuana is legalized.  One writer suggested that psychiatrists would be put out of business because marijuana would replace Prozac, and several commenters stated as a fact that my co-author and I are pharmaceutical “shills” who are more interested in dinners and harbor cruises. Neither Dr. Hanson nor I have any financial relationships with pharmaceutical companies, and it’s been years since I’ve gotten so much as a pen, much less a chicken salad sandwich, from a drug rep. I’m not terribly worried that medical marijuana will put me out of business, but I am concerned that it will make my job harder.

• There were some insults that added nothing to the conversation. "Psychiatrists are the worst kind of quacks because they believe their own nonsense.  Their 'successes' are people who are drugged into the equivalent of a chemical lobotomy.”

 
Personally, I do believe that marijuana should be re-scheduled and that it should be available for use for specific indications where other treatments have been inadequate. But it should be prescribed cautiously, purchased from a pharmacy, with a prescription noting dosage and frequency, and marketed without the propaganda that it lacks adverse effects or the possibility of addiction. 

I do not believe that non-psychiatrists should prescribe medical marijuana for psychiatric symptoms, (especially if the patient is also seeing a psychiatrist) and I certainly don’t believe that legislators should propose psychiatric indications for cannabis in opposition to current treatment standards. I believe that if marijuana is used as “medicine,” it should be used because conventional medications, including Marinol, the oral form of  synthetic THC, either haven’t worked or have caused unacceptable side effects.  
 

The current mechanism of prescribing medical marijuana is not about cancer, AIDS, MS, or chronic pain patients.  Unlike other “medications,” marijuana (medical or otherwise) causes smokers to get high, and legalization requires that we address how this will play out for the work place and our overall productivity as a society. 

If the conversation is about increasing access to marijuana for all Americans, one might contend that our current War on Drugs has been a dismal failure, and discussions  regarding decriminalization or legalization might best be left to the lawmakers, the constituents, the crime fighters, and the addiction specialists. That’s a conversation that can be had without my input.
 
If you’d like to read the original article with the comments in the Baltimore Sun, click here.
 
If you’d like to read an article by a Steve Balt, a California psychiatrist who discusses the issues involved in treating patients who are getting medical marijuana from another prescriber, click  here.
 
And, finally, if you’d like to read an article from Time magazine called "The United States of Amerijuana," click here.
 
Please note, the ideas expressed here are mine alone and do reflect the views of the co-author of the original article, Dr. Hanson.  

 —Dinah Miller, M.D.

If you would like to comment on this article here, please register with CLINICAL PSYCHIATRY NEWS. If you are already registered, please log in to comment.
 
You can also comment on our original Shrink Rap blog by clicking here.  
 
DR. MILLER is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

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:
 

• Legalization will benefit those with illnesses. Some wrote in with their own anecdotes of how marijuana helped the following: OCD, seizures, Crohn’s disease, migraines, chronic pain such that the user could stop taking narcotics, bone disease, and “saved my marriage, my heart, and my soul.” One commenter asserted that in Oregon, marijuana cures cancer.

• FDA approval is a catch-22 because cannabis is a Schedule I drug, and this stymies research. In a country where 17 states have legalized medical marijuana, I agree that the FDA should revisit this issue.

• FDA-approved medications have resulted in many deaths, and FDA-approved medications have been withdrawn for safety reasons.  Readers specifically noted Ambien, Xanax, Oxycontin, Vioxx, Avandia, Fen-Phen, and silicone breast implants. They contend that marijuana is safer than these substances.

• Other legal substances are unsafe, specifically alcohol, tobacco, and the above-mentioned prescription drugs. This is similar to the point made above, and I agree, but I am not sure it’s relevant to the discussion of medical marijuana.

• Marijuana is safe and effective, and any facts that are presented to the contrary are wrong.  There is really no answer to this because this point of view, by definition, is closed to discussion.

• Marijuana doesn’t kill.  If you stay out of a car, don’t lace it with it toxins, and don’t mix it with other drugs, this is probably true.

• There are inconsistencies in medical practice, and people can get Viagra by calling an 800 number.  

• Marijuana is an herbal product that has been used as medicine for thousands of years and should not treated as a pharmaceutical.  Again, this is different issue from those addressed in medical marijuana legislation.

• Doctors are pawns of the pharmaceutical industry and can’t profit if medical marijuana is legalized.  One writer suggested that psychiatrists would be put out of business because marijuana would replace Prozac, and several commenters stated as a fact that my co-author and I are pharmaceutical “shills” who are more interested in dinners and harbor cruises. Neither Dr. Hanson nor I have any financial relationships with pharmaceutical companies, and it’s been years since I’ve gotten so much as a pen, much less a chicken salad sandwich, from a drug rep. I’m not terribly worried that medical marijuana will put me out of business, but I am concerned that it will make my job harder.

• There were some insults that added nothing to the conversation. "Psychiatrists are the worst kind of quacks because they believe their own nonsense.  Their 'successes' are people who are drugged into the equivalent of a chemical lobotomy.”

 
Personally, I do believe that marijuana should be re-scheduled and that it should be available for use for specific indications where other treatments have been inadequate. But it should be prescribed cautiously, purchased from a pharmacy, with a prescription noting dosage and frequency, and marketed without the propaganda that it lacks adverse effects or the possibility of addiction. 

I do not believe that non-psychiatrists should prescribe medical marijuana for psychiatric symptoms, (especially if the patient is also seeing a psychiatrist) and I certainly don’t believe that legislators should propose psychiatric indications for cannabis in opposition to current treatment standards. I believe that if marijuana is used as “medicine,” it should be used because conventional medications, including Marinol, the oral form of  synthetic THC, either haven’t worked or have caused unacceptable side effects.  
 

The current mechanism of prescribing medical marijuana is not about cancer, AIDS, MS, or chronic pain patients.  Unlike other “medications,” marijuana (medical or otherwise) causes smokers to get high, and legalization requires that we address how this will play out for the work place and our overall productivity as a society. 

If the conversation is about increasing access to marijuana for all Americans, one might contend that our current War on Drugs has been a dismal failure, and discussions  regarding decriminalization or legalization might best be left to the lawmakers, the constituents, the crime fighters, and the addiction specialists. That’s a conversation that can be had without my input.
 
If you’d like to read the original article with the comments in the Baltimore Sun, click here.
 
If you’d like to read an article by a Steve Balt, a California psychiatrist who discusses the issues involved in treating patients who are getting medical marijuana from another prescriber, click  here.
 
And, finally, if you’d like to read an article from Time magazine called "The United States of Amerijuana," click here.
 
Please note, the ideas expressed here are mine alone and do reflect the views of the co-author of the original article, Dr. Hanson.  

 —Dinah Miller, M.D.

If you would like to comment on this article here, please register with CLINICAL PSYCHIATRY NEWS. If you are already registered, please log in to comment.
 
You can also comment on our original Shrink Rap blog by clicking here.  
 
DR. MILLER is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

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:
 

• Legalization will benefit those with illnesses. Some wrote in with their own anecdotes of how marijuana helped the following: OCD, seizures, Crohn’s disease, migraines, chronic pain such that the user could stop taking narcotics, bone disease, and “saved my marriage, my heart, and my soul.” One commenter asserted that in Oregon, marijuana cures cancer.

• FDA approval is a catch-22 because cannabis is a Schedule I drug, and this stymies research. In a country where 17 states have legalized medical marijuana, I agree that the FDA should revisit this issue.

• FDA-approved medications have resulted in many deaths, and FDA-approved medications have been withdrawn for safety reasons.  Readers specifically noted Ambien, Xanax, Oxycontin, Vioxx, Avandia, Fen-Phen, and silicone breast implants. They contend that marijuana is safer than these substances.

• Other legal substances are unsafe, specifically alcohol, tobacco, and the above-mentioned prescription drugs. This is similar to the point made above, and I agree, but I am not sure it’s relevant to the discussion of medical marijuana.

• Marijuana is safe and effective, and any facts that are presented to the contrary are wrong.  There is really no answer to this because this point of view, by definition, is closed to discussion.

• Marijuana doesn’t kill.  If you stay out of a car, don’t lace it with it toxins, and don’t mix it with other drugs, this is probably true.

• There are inconsistencies in medical practice, and people can get Viagra by calling an 800 number.  

• Marijuana is an herbal product that has been used as medicine for thousands of years and should not treated as a pharmaceutical.  Again, this is different issue from those addressed in medical marijuana legislation.

• Doctors are pawns of the pharmaceutical industry and can’t profit if medical marijuana is legalized.  One writer suggested that psychiatrists would be put out of business because marijuana would replace Prozac, and several commenters stated as a fact that my co-author and I are pharmaceutical “shills” who are more interested in dinners and harbor cruises. Neither Dr. Hanson nor I have any financial relationships with pharmaceutical companies, and it’s been years since I’ve gotten so much as a pen, much less a chicken salad sandwich, from a drug rep. I’m not terribly worried that medical marijuana will put me out of business, but I am concerned that it will make my job harder.

• There were some insults that added nothing to the conversation. "Psychiatrists are the worst kind of quacks because they believe their own nonsense.  Their 'successes' are people who are drugged into the equivalent of a chemical lobotomy.”

 
Personally, I do believe that marijuana should be re-scheduled and that it should be available for use for specific indications where other treatments have been inadequate. But it should be prescribed cautiously, purchased from a pharmacy, with a prescription noting dosage and frequency, and marketed without the propaganda that it lacks adverse effects or the possibility of addiction. 

I do not believe that non-psychiatrists should prescribe medical marijuana for psychiatric symptoms, (especially if the patient is also seeing a psychiatrist) and I certainly don’t believe that legislators should propose psychiatric indications for cannabis in opposition to current treatment standards. I believe that if marijuana is used as “medicine,” it should be used because conventional medications, including Marinol, the oral form of  synthetic THC, either haven’t worked or have caused unacceptable side effects.  
 

The current mechanism of prescribing medical marijuana is not about cancer, AIDS, MS, or chronic pain patients.  Unlike other “medications,” marijuana (medical or otherwise) causes smokers to get high, and legalization requires that we address how this will play out for the work place and our overall productivity as a society. 

If the conversation is about increasing access to marijuana for all Americans, one might contend that our current War on Drugs has been a dismal failure, and discussions  regarding decriminalization or legalization might best be left to the lawmakers, the constituents, the crime fighters, and the addiction specialists. That’s a conversation that can be had without my input.
 
If you’d like to read the original article with the comments in the Baltimore Sun, click here.
 
If you’d like to read an article by a Steve Balt, a California psychiatrist who discusses the issues involved in treating patients who are getting medical marijuana from another prescriber, click  here.
 
And, finally, if you’d like to read an article from Time magazine called "The United States of Amerijuana," click here.
 
Please note, the ideas expressed here are mine alone and do reflect the views of the co-author of the original article, Dr. Hanson.  

 —Dinah Miller, M.D.

If you would like to comment on this article here, please register with CLINICAL PSYCHIATRY NEWS. If you are already registered, please log in to comment.
 
You can also comment on our original Shrink Rap blog by clicking here.  
 
DR. MILLER is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.