This newsletter is for your information only and is not a substitute for talking with your psychiatrist, medical doctor, and/or therapist.

Is Marijuana “Medical”?

Medical Marijuana is appropriate for some, needed by less, received and monitored according to the Institute of Medicine guidelines (below) by very few, and is misused or abused by too many.

As of this writing there are 14 states plus Washington DC which have some form of “Medical Marijuana” (Med MJ) laws. Two more states have Med MJ propositions on their ballots this November 2010 – Arizona and South Dakota. California became the first Med MJ state in 1996 and is well known for its Med MJ “cards”, dispensaries known as “clubs”, and “compassionate use” for “sick” people which allows almost anyone to get a card for almost any health or mental health concern as “recommended” by physicians who may liberally grant such for a fee with too often only a cursory “exam”. The 2 most recent states to approve Med MJ, New Jersey and New Mexico, have the most restrictive Med MJ state laws although even those are far looser than the 1998 Institute of Medicine report recommendations (see below) that gave limited medical legitimacy to Med MJ. It should be stated that all these Med MJ laws/ programs/registries were created by voter referendum ballot propositions often funded by organizations and people seeking to legalize MJ for all. Med MJ programs were not started by legislatures, are not approved by mainstream medical organizations or the FDA, and are designed to get around federal law. California and Colorado are currently tightening their laws. In Los Angeles there are “more marijuana dispensaries than Starbucks shops” (> 1000). Many have opened throughout the state improperly. There are even delivery services – convenient whether you’re medically incapacitated or not. Oakland has licensed and taxed 4 dispensaries. LA has begun raiding and closing down the excess and unlicensed dispensaries. In the last 5 years California’s website lists about 50,000 new “cards” approved while Colorado, a much less populous state, approved more than 60,000. I hear repeatedly how merely paying $100 to $150 to a physician known to approve Med MJ for any headache, nausea, pain, sleep complaint, etc., real, psychosomatic, or faked, even in the absence of any serious condition claimed or verified, is easy in either state. Once so approved you can buy roughly 2 oz (varies by state) every 2 weeks of top quality marijuana at for profit or “non profit” (varies by state) dispensaries in addition to being allowed to grow your own at home (varies by state). This quite large amount allows many to save, or resale for profit, or give away significant amounts to unregistered unauthorized users, many of whom make no pretense about their recreational or abusive or dependent usage.

The Institute of Medicine (IOM) http://www.iom.edu/ is an objective, medically scientific, broadly respected medical organization which studies and puts out reports addressing a wide range of nationally and internationally important health related topics intended to provide policy guidance to the public, governments, and other medical scientific bodies. An IOM blue ribbon panel reviewed all available research and related information on the pros and cons of medical usage of available forms of marijuana (cannabis). In 1999 the IOM published its almost 300 page report. The 2003 Executive Summary is available for free at: http://iom.edu/Reports/2003/Marijuana-and-Medicine-Assessing-the-Science-Base.aspx I will excerpt selected highlights of their findings here. Sections in red are quoted directly from the IOM report summary. Efficacy = effectiveness, does it help? “Scientific data indicate the potential therapeutic value of cannabinoid drugs, primarily THC, for pain relief, control of nausea and vomiting, and appetite stimulation; smoked marijuana, however, is a crude THC delivery system that also delivers harmful substances.” Dependence and Withdrawal? “… a concern associated with chronic marijuana use is dependence on the psychoactive effects of THC. Although few marijuana users develop dependence, some do. Risk factors for marijuana dependence are similar to those for other forms of substance abuse. … A distinctive marijuana withdrawal syndrome has been identified, but it is mild and short lived. The syndrome includes restlessness, irritability, mild agitation, insomnia, sleep disturbance, nausea, and cramping.” Marijuana as a “Gateway drug” “In the sense that marijuana use typically precedes rather than follows initiation of other illicit drug use, it is indeed a “gateway” drug. But because underage smoking and alcohol use typically precede marijuana use, marijuana is not the most common, and is rarely the first, “gateway” to illicit drug use.” IOM’s overall Recommendation “Short-term use of smoked marijuana (less than six months) for patients with debilitating symptoms (such as intractable pain or vomiting) must meet the following conditions: 1) failure of all approved medications to provide relief has been documented, 2) the symptoms can reasonably be expected to be relieved by rapid-onset cannabinoid drugs, 3) such treatment is administered under medical supervision in a manner that allows for assessment of treatment effectiveness, and 4) involves an oversight strategy comparable to an institutional review board process that could provide guidance within 24 hours of a submission by a physician to provide marijuana to a patient for a specified use.”

Past and current scientific data and research from good quality studies such as reviewed by the IOM show potential medical marijuana benefit, as well as pros outweighing cons, ONLY for appetite enhancement of the physical wasting and malnutrition of some patients with late stage AIDS, the severe nausea and vomiting of chemotherapy in some cancer patients, and some severe pain caused by some diagnosable severe conditions not responding to standard therapies. Use for the myriad other conditions claimed and listed in various Med MJ propositions are based on opinions, anecdotes, testimonials, case reports, and pseudoscience rather than double blind placebo controlled studies. Marijuana is not advised for chronic use, should not be smoked longer than 6 months due to respiratory concerns including potential heightened risk of cancer, other more appropriate treatments should be tried first and failed, and MJ should not be just “recommended” by a physician but should be prescribed, dosed, and monitored for positive and negative effects including abuse, dependence, and diversion (sell, give away, to others, etc.) just like any other medically useful controlled substance.

Did you know physicians can already legally prescribe synthetic oral (pill) THC (the primary active ingredient in marijuana) called Marinol (dronabinol) for our patients who need it? By the way, if smoking was the only effective means to deliver marijuana why are so many non smoke forms of MJ products available in Med MJ dispensaries and clubs? Check this link: http://www.marijuanagrowing.com/blog/archives/109

Marijuana is known by many names including pot, grass, weed, ganja, Mary Jane, cannabis, hemp, and its cousin hashish. Cannabis (genus) has various species (e.g., sativa, indica) and subspecies with folksy and local names that reportedly indicate somewhat differing potencies and effects. As the public becomes more accepting of MJ as “medicine”, public approval of its recreational use increases. Advocates and potential sellers see that as good while many who treat those who are underage, abuse it, or become dependent see the opposite.

Did you know that 2% of all adults over 40 years old smoke MJ every day? The numbers are far higher when you count those who smoke MJ several times a week, or weekly, or monthly, and so on. Like with cigarettes almost all adults began smoking MJ as teens. Consider that this could be a sign of dependence as well as of enjoyment.

Decriminalization means replacing criminal charges for simple possession of small personal use amounts of MJ with only civil penalties such as fines, community service, and drug awareness programs. This has happened in some US areas. Legalization would remove even such civil penalties and likely result in treating MJ like alcohol and tobacco is treated now with age limits and a commercial taxed industry. This has not yet happened in the US. Med MJ laws make MJ legal for those “registered” persons with a “card” or physician “recommendation” or “certificate” (a “prescription” for MJ violates federal DEA laws) and is seen by some as compassionate help while many see Med MJ as an intermediate step toward legalization..

Logically, and clinically, if marijuana is a legitimate medicine for even a few people with a few health conditions why don’t we just treat it like other medicines? Some blame the FDA (even though the FDA approved Marinol years ago) or pharmaceutical companies and mainstream medicine as conspirators, or the antidrug “War on Drugs” lobby. Alternatively, others see the supplement and herbal or generic and brand pharmaceutical industries or organized crime all lobbying for a place in a new legal MJ (and more) marketplace. Can you think of any other “medicine” made available by the public voting in elections for it? And without any clinician or doctor of any type having any role besides writing a “recommendation” for its essentially unbridled use? Do you think at least some of the sponsors could have another agenda? Medical historians and anthropologists have interesting input about this and the last several thousand years human years human use of psychoactive plants and chemicals.

The Arizona Medical Use of Marijuana proposition election is 11/2/10 and is typical in allowing 2.5 oz every 2 weeks and/or 12 plants home grown (if more than 25 miles from any of the maximum 120 dispensaries in the state) for registered users for cancer, glaucoma, HIV/AIDS, Hepatitis C, ALS, Alzheimer’s dementia agitation, pain, or other chronic debilitating diseases bought from “nonprofit” "dispensaries" if the “patient” has a “written certification” by a physician. One can’t drive high or use (just not smoke?) in public nor can a certified user be fired for a positive MJ drug test or have their use held against them in custody and visitation cases. Striking to me is that the “patient” may be any age, even a young child if their registered “caregiver” and 2 doctors approve. Just think about the many problems with that (e.g. pro MJ parent signing up his or her kids so the parent(s) can use or giving into demanding teens, or selling it, etc) versus the very small number of legitimate youth cases? If opiate and benzodiazepine abusers can find doctors to write those prescriptions excessively, one can find doctors to certify illegitimate Med MJ as we see in all other states. Supporters of this proposition state it is more restrictive than California’s version.

So what problems from marijuana does a Child, Adolescent, and Adult Psychiatrist see in daily work with patients? Let’s be clear on a few things up front. Some, even many, may use MJ to some degree without problem or without a currently apparent problem, much like tobacco and alcohol. I see people who seek help or have been sent, sometimes at least partly unwillingly, for help. My perspective is affected by my experience. But you should understand other perspectives, not just your own. Tobacco is easily the #1 killer drug in the US and by far the #1 preventable cause of death every year. Nothing else is even close. But it kills many years later, in many ways, although use typically begins in adolescence. If there were no tobacco, no alcohol, no guns, if all motorcyclists wore helmets, and we prevented all impaired driving, hospitals and ERs would be almost empty, there would no longer be a physician shortage, and we doctors would all have a lot more time off. Did you know there are 50% more suicides than murders every year and that most suicides and many homicides are on some drug (including MJ) at the time? Alcohol is the 2^nd leading killer drug and unlike tobacco can kill immediately even at first use via alcohol poisoning although most alcohol deaths are years down the line like tobacco. Tobacco and alcohol are legal with age limits of 18 and 21. Opiates, which are all narcotic pain meds like Vicodin, Percocet, codeine, Demerol, Fentanyl, Oxycontin, morphine, methadone, Suboxone, etc (and the illegal heroin) are legal but controlled by prescription and are nonetheless increasingly frequently and seriously abused and are now a more common cause of death than are motor vehicle accidents in at least 16 states! Fortunately, marijuana is not directly deadly alone in an overdose though it is often combined with others in overdoses, motor vehicle accidents, suicides, and homicides. Med MJ by proposition doesn’t require any doctor monitoring, and has none of the other protections of prescription regulations. Other than whoever wrote the recommendation, doctors and other providers don’t know who is taking Med MJ unless the “patient” chooses to tell. Below are the most common problems I see with MJ: 1) Perceptual distortions – this is, of course one of the main points of smoking MJ. Time slows, colors, music, touch, sensations, smells, lights, etc are all altered; reaction time is delayed. This is the major MJ cause of impaired driving, DUIs, accidents, injuries. 2) Short term memory is damaged while “high” and during the up to 30 days MJ stays in your brain cells after use. The more you use and more often you use, the more “Swiss cheese memory” (holes in your memory) you cause and the longer it lasts. Brain processing speed is slowed. These effects, of course, impact school, work, and more. ADHD meds don’t help “potheads” whether they have ADHD or not. 3) Amotivational Syndrome = apathy, don’t care, do little, the ultimate slacker; work and school decline, the person “ain’t goin’ nowhere” and doesn’t care and doesn’t see that as a problem. Just hanging out at home with the music on, TV on, laying on the couch, munching, chillin’, playing the same video game for hours, etc. Sound familiar? 4) Alexithymia – unaware of his or her feelings, out of touch with feelings, doesn’t know his or her feelings, denial of sad, down depressed, angry, etc. Again, this is often the point with substance abuse – to ALTER feelings, not feel unpleasant or unwanted feelings, not deal with or even be conscious of the sadness or anxiety related to losses, stress, or progressing through or failing at the developmental tasks of one’s age and life stage. This is common and deleterious. The active substance abuser (and yes MJ is a major substance of abuse) almost always denies this until the process of recovery is far along. Some patients tout MJ as an aid for their depression, anxiety, sleep, or anger via “self medication”. Others later admit their denial, report MJ worsened or caused their depression or anxiety, or eventually see their life was held back by their use. 5) Relationships with peers, parents, or romantic partners frequently suffer as the user drifts more to other users and away from those who don’t use or don’t approve. “Paranoia” and social anxiety with oversensitivity is often worsened by MJ amplifying the tendency to withdraw, stay home, and not mix with others. 6) While uncommon there is clear evidence that some persons’ psychotic symptoms (hallucinations, delusions, irrational thinking, severe paranoia) are exacerbated or caused by marijuana. MJ abuse is a common problem worsening the difficulties folks with serious mental illness face.

Saying MJ is less harmful than alcohol or tobacco depends on what effects you consider and is not much of an endorsement to me.

Knowledge of the huge and growing abuse of prescription and over the counter medications like opiate pain pills, benzodiaepines (Xanax, Klonopin, Ativan, Valium, etc.), Ambien, DXM (dextromethorphan), K2, Spice, as well as the problems with tobacco and alcohol should raise awareness that Med MJ as put forth in these propositions represents, as many backers seek, wider use and misuse, and does not eliminate inappropriate or illegal use, sales, production, dealers, or MJ related gang and criminal enterprises. Let’s show some integrity and get honest – if decriminalization or legalization is the goal then address those issues head on. Skip the voter initiative Med MJ proposition subterfuge which undercuts true scientific medical use of marijuana so that the few who need it get the professional quality care they deserve.