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Medical Marijuana for Schizophrenia: Weighing the Risks and Benefits

As clinicians wait for more evidence, here’s where cannabis data fits into schizophrenia treatment protocols.

With more states legalizing medical as well as recreational for marijuana, it’s only a matter of time before your patients or clients ask about CBD, cannabis, or marijuana. But for individuals diagnosed with schizophrenia, marijuana – in any form – can actually worsen the symptoms, according to Julie Foster, FNP, MSN, medical director of Pohala Clinic, a center for integrative care and alternative medicine approaches located in Portland, Oregon.

That’s why she and many other experts recommend that people with schizophrenia or a tendency toward psychosis steer clear of all forms of the substance.

The Chemistry of Marijuana

Marijuana is a mixture of the dried flowers of Cannabis sativa plant that consists of more than 500 chemicals. This includes delta-9-tetrahydrocannabinol (THC), which has hallucinogenic properties and is responsible for the “high” and cannabidiol (CBD), touted to provide health benefits such as antioxidative, anti-inflammatory, and neuroprotection effects, according to NIH’s National Institute on Drug Abuse (NIDA). Both “medical” and “recreational” marijuana can contain a mixture of THC and CBD.

Additionally, there are a plethora of products marketed as CBD or hemp-infused including drops, vape pens, and tinctures that do not contain THC or contain it in lower amounts that will not cause a “high.” Hemp is not marijuana, however. It is a completely separate plant even though they are both cannabis varieties.

NIDA reports that other uses being explored include treatment of epilepsy, anxiety disorders, substance use disorders, schizophrenia, cancer, pain, inflammatory diseases, and acne, among other conditions. However, more research is needed to fully understand the effects and whether or not there are actual benefits for these conditions.

Marijuana Legalization in the States

As of October 2020, marijuana is fully legal in 22 states (see state-by-state breakdowns for recreational and medical use). Testing regulations and the amounts of possession legally allowed do vary by state.

In those states where marijuana is legally accessible, individuals with schizophrenia may be tempted to try it, either for social reasons or in some cases, to help them cope with symptoms – despite the risks that exist, Foster explains.

She points out that in Oregon, for instance, marijuana was legalized in 2016 for both medical and recreational purposes. Since then, she says she has seen “patients who were chronically mentally ill or have the propensity for mental illness (such as a family history of mental illness, stressful life events, and the use of drugs) become psychotic from using marijuana.”

Foster also explains that while some people may believe that marijuana with a lower THC:CBD ratio may be less likely to cause or exacerbate psychosis, the risk still exists, making it important that those with a tendency toward psychosis simply avoid marijuana completely.

“My first thought about schizophrenia and marijuana is that they are [at odds with one another],” Foster says. “Unless followed closely as a medication, I think marijuana could easily contribute to the delusions and hallucinations that come with schizophrenia. I have also not found any long-term supporting evidence that people with schizophrenia benefit from its use,” she adds.

Exploring the Risks of Marijuana

Marc Manseau, MD, MPH, a clinical assistant professor of pPsychiatry at the New York University School of Medicine and expert on the intersection between serious mental illness and substance use disorders, agrees that for people with schizophrenia and related diagnoses with a tendency toward psychosis, marijuana use may actually worsen problems, rather than relieving them. To understand the risks, you need to understand what psychosis really is, he says.

“Psychosis is a disruption in the brain’s perception, interpretation, and/or processing of reality. A healthy brain seamlessly filters useful bits of information from the irrelevant noise and constructs a ‘reality’ that allows us to function in the world. When someone is psychotic, however, the system goes awry and things that shouldn’t have any meaning take on special [out of context] importance,” Dr. Manseau explains, adding that the danger lies in the THC, which has psychotic properties.

Although some people mistakenly believe that medical marijuana does not contain levels of THC, thus making if “safer,” this usually isn’t the case, Dr. Manseau clarifies. In fact, there are no regulations as to what medical marijuana must contain, which can be dangerous for people with a tendency for psychosis.

Marijuana and Psychosis: A Troubling Connection

The risks and benefits of marijuana have been the subject of much research in recent years. In a literature review conducted by Dr. Manseau that appeared in Neurotherapeutics, he points out that a number of studies have found a clear association between frequent (once daily or more) use of cannabis at an early age (approximately 14 years old) and psychosis.

Dr. Manseau also cites specific factors that could increase the risk of developing a psychotic disorder following cannabis use. Factors include a family history of schizophrenia, past abuse or neglect, and growing up in an urban environment. He also stresses that cannabis use in people with a schizophrenia diagnosis may also have more severe symptoms and lower functioning than their counterparts. On the flip side, he says that among people with psychosis, discontinuing cannabis use has also been found to improve mood and anxiety and reduce psychotic symptoms.

A separate review of a dozen studies that recently appeared in the Journal of Clinical Psychiatry found cannabis use was associated with poorer symptomatic outcomes in people who suffered from various anxiety and other mood disorders, including depression.

He also says that further complicating matters is that some research suggests there could be benefits from using CBD to treat psychosis. But at this point, he and his colleagues believe the risks outweigh any possible benefits. “This is certainly not yet definitive and doctors require much more solid evidence to recommend treatments to patients. So, it’s still too preliminary to even recommend CBD to anyone with schizophrenia,” he says.

To get more specific, “For people with schizophrenia, the high THC content [15-30% or even higher] on average in today’s weed is simply dangerous, since THC is known to increase the risk of psychosis,” Dr. Manseau stresses. He also says that some people believe that since they know marijuana with high THC is dangerous, they will just take more care with what they use [in terms of THC content].

Since medical marijuana is not regulated by the FDA—not even in states where it is legal – there is no guarantee that this won’t trigger a problem, Dr. Manseau says, adding, “All medical marijuana is likely to have at least some THC, and THC can increase the risk of developing and exacerbate psychosis.”

Modern Marijuana: Stronger Strains May Increase Risks

Further, for anyone tempted to try self-medicating with marijuana, both Foster and Dr. Manseau warn that what is available on the streets today is not the same as it was a few decades ago.

“Marijuana today is stronger [meaning it has a higher average THC content],” Foster says. Dr. Manseau points out that this is worrisome since other studies show that using high THC marijuana increases the risk of psychosis.

“Today’s marijuana may also be mixed with other things [including other drugs or substances that can increase the psychosis effect],” Foster adds. This makes it much more dangerous, especially for people who are susceptible to psychotic reactions. And because it’s not regulated, there’s simply no way to know.

Living with Schizophrenia: Understanding the Cannabis Pull

While most medical experts have studied the impact of cannabis on schizophrenia in others or have read the latest literature, Julie A. Fast, author of Loving Someone with Bipolar Disorder, Take Charge of Bipolar Disorder, Get it Done When You’re Depressed, Bipolar Happens! and The Health Cards Treatment System for Bipolar Disorder, brings a much deeper understanding of schizophrenia to the table. That’s because she has a similar diagnosis called schizoaffective disorder. “This means that I have bipolar disorder and a separate psychotic disorder. I do not have schizophrenia, but I share many of the symptoms when I get sick [with schizoaffective disorder],” she explains.

She draws on her experiences as a person living with a mental illness to assist mental health professionals. Due to her diagnosis, she’s able to provide an important perspective on what it’s like which also helps to engage patients in treatment and recovery. “My specialty is creating management plans for people who live with mood and psychotic disorders. I also do a lot of work in the anxiety and personality disorder world,” she says.

Since she has first-hand knowledge of what it feels like to be psychotic, her insights are particularly helpful in teaching doctors how to support their patients when they are experiencing an episode.

“When I am psychotic, it is incredibly uncomfortable. Nothing makes sense. I see people as dangers to myself and am not able to process information in a normal way. The senses are confused and life is chaotic,” Fast states.

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“I also experience paranoia, which is my main delusion [or false belief]. In this state, I truly FEEL that people are following me or are out to get me. Delusions are [part of ] the reason schizophrenia is so hard to manage,” she says.

When someone is experiencing schizophrenia or psychosis, he or she is also eager for relief—that’s where the temptation of marijuana comes in. “It’s a rough and very disabling illness that has to be managed daily. It makes sense that people will hear about cannabis and think, ‘Hey, it’s used for anxiety. I have a lot of anxiety with my schizophrenia, I want to feel better, so I will try cannabis,’” Fast says.

But she knows most patients don’t understand the full risks. That’s where clinicians can help fill the gaps.

Using Medical Marijuana: How Patients Can Stay Safe

Here is a rundown of what Foster suggests to the patients she works with:

  • If you are going to use marijuana, it’s important to work with your psychiatrist and other trusted members of your mental health team who understand the dangers of THC on people vulnerable to experiencing psychosis and who can guide you in the best way.
  • Understand that even if something is labeled as low THC or no-THC, this doesn’t mean it’s true since marijuana is not currently approved by the Food and Drug Administration (FDA). The only way to know how it will impact you is to actually try it, which is not worth the risk if it could lead to psychosis.
  • Keep in mind that just because it’s called “medical marijuana” doesn’t mean that it’s safe, whether you are consuming it as a tincture, in plant form, as a topical product, or as an edible. “Medical marijuana” is simply a name. Only testing with your own body will let you know if something is safe. (Also keep in mind that there are several FDA-approved cannabis-based medications with very restricted indications including nausea, appetite stimulation, and epilepsy, but these are not medical marijuana.)

Support is also crucial. “I think the best way for people with schizophrenia to work through their ‘stormy passages’ of worsening delusions or hallucinations is to have a community of support that understands schizophrenia, a close relationship with their mental health providers, and a strong rhythm for their daily life,” says Foster. “We know that people who don’t have a support system, who do not trust their providers even when not psychotic, and who get out of healthy routines and lifestyles will flounder. While schizophrenia is a challenging illness to live with, with the right supports in place, one can still lead a happy, full, and successful life.”

See our full Clinician’s Guide to treating schizophrenia.

NIDA. Is Marijuana Safe and Effective as Medicine? Updated June 2018. Accessed 20 September 2018.

Mammen, G et al. “Association of Cannabis With Long-Term Clinical Symptoms in Anxiety and Mood Disorders: A Systematic Review of Prospective Studies.” J Clin Psychiatry. June 5, 2018. 79(4).

Iffland, Kirsten and Grotenhermen, Franjo. “An Update on Safety and Side Effects of Cannabidiol: A Review of Clinical Data and Relevant Animal Studies.” Cannabis Cannabinoid Res. June 21, 2017.

Volkow ND. The Biology and Potential Therapeutic Effects of Cannabidiol. Presented at Drug Caucus Hearing on Barriers to Cannabidiol Research. June 24, 2015.

Manseau M. For an unlucky few marijuana isn’t so chill. Medium. Oct. 17, 2017.

Manseau, M, Goff DC. “Cannabinoids and Schizophrenia: Risks and Therapeutic Potential.” Neurotherapeutics (2015) 12: 816-824.

Matthews S. Smoking cannabis just 5 TIMES as a teenager raises the risk of psychosis, reveals ‘worrying’ study. DailyMail.com. Accessed online April 20, 2018.

“Patients and Families: Schizophrenia.” American Psychiatric Association. January 2017. Available at: www.psychiatry.org/patients-families/schizophrenia/what-is-schizophrenia

“Schizophrenia.” Mayo Clinic. Available at: www.mayoclinic.org/diseases-conditions/schizophrenia/symptoms-causes/syc-20354443. Accessed May 2, 2018.

Szalavitz M. Marijuana Compound Treats Schizophrenia with Few Side Effects: Clinical Trial.” Time. May 30, 2012.

Vadhan NP et al Acute effects of smoked marijuana in marijuana smokers at clinical high-risk for psychosis: A preliminary study. Psychiatry Res. 2017; 257: 372.

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Medical Marijuana and Mental Health: Cannabis Use in Psychiatric Practice

Psychiatrists and other behavioral health professionals need to better understand the relationship between cannabis and mental disorders so that they can respond to increasing medical and recreational marijuana use among their patients. More than half of states now allow for medical use, and 8 states and the District of Columbia have legalized adult personal or recreational use.

Knowledge about herbal cannabis, the endocannabinoid system, and cannabinoid pharmacology is rapidly expanding. However, compared with the literature on non-medical cannabis use, the scientific literature on therapeutic use of cannabis is underdeveloped, as noted in a recent systematic review of medical cannabis and mental health. 1 Although herbal cannabis has a long history of medicinal use, its federal prohibition under the Controlled Substances Act of 1970 with Drug Enforcement Administration Schedule I status has focused the federally supported cannabis research agenda for half a century on the potential harms rather than on the historically acknowledged therapeutic benefits of this complex plant.

Medicinal potential of cannabis

For the sake of this discussion, herbal cannabis refers to plant material derived from the flowering tops of Cannabis indica, sativa, or ruderalis biotypes. Indica, sativa, and indica-sativa hybrid strains are commonly available on the medicinal cannabis market.

Herbal cannabis is biochemically rich in a variety of compounds, both psychoactive and non-psychoactive. It has been reported that there are 483 compounds unique to marijuana, including more than 60 cannabinoids and some 140 terpenes. The phytocannabinoid that produces much of the psychoactive effect is delta-9-tetrahydrocannabinol (THC). However, there is increasing interest in another constituent, cannabidiol (CBD), which is not considered psychoactive but appears to have therapeutic value for a wide variety of conditions, either alone or in combination with THC.

Although federal policy has disallowed access to cannabis even for medicinal use since the passage of the Controlled Substances Act, THC was approved in a synthetically manufactured formulation in 1985 as an oral medication indicated for nausea and vomiting associated with chemotherapy. Originally a Schedule II medication, molecular THC was later reclassified under Schedule III, which indicates lower abuse potential. From the late 1970s into the early 1990s, a few patients gained access to herbal cannabis through the federal Investigational New Drug program, but no new patients were enrolled after 1992.

It is ironic that currently in the US the non-psychoactive compound CBD is generally accessible for medicinal use only in the form of federally prohibited herbal cannabis products available under state medical marijuana laws. Grant and colleagues 2 have summarized succinctly a point made by many others: “Based on evidence currently available the Schedule 1 classification is not tenable; it is not accurate that cannabis has no medical value, or that information on safety is lacking.” Interestingly, the US government has held a patent on substituted CBD derivatives as antioxidants and neuroprotectants for nearly 2 decades.

Perceived benefits of medical cannabis

Regardless of the legal status of cannabis, many patients with psychiatric disorders use cannabis and report improvement in their symptoms. Patients use cannabis for symptoms of PTSD, anxiety disorders, depression, ADHD, bipolar disorder, chronic pain, insomnia, opiate dependence, and even schizophrenia. In addition, patients use cannabis for neurological conditions such as the spasticity of multiple sclerosis, agitation in dementia, and specific seizure disorders that are unresponsive to standard therapies. Patients also use cannabis to reduce the nausea and anorexia of cancer chemotherapies and to improve their mood and outlook-frequently with their oncologist’s approval.

With the advent of state medical cannabis laws beginning with California in 1996, medical cannabis has become commercially available in many states as herbal material that may be smoked or vaporized, as well as consumed in a wide variety of other preparations (Table). In addition to the various formulations available through state-based programs, pharmaceutical-grade whole herbal cannabis extracts have been under development during the past 2 decades. The first product to gain approval for medical use was Sativex, a whole herbal extract standardized to a THC:CBD ratio of 1:1 and administered as a sublingual spray. Sativex was approved in Canada for use in multiple sclerosis in 2005 and chronic cancer pain in 2006, and has been approved for medical use in at least 2 dozen countries, although it is not FDA approved. More recently, a liquid formulation of pure plant-derived CBD (Epidiolex) has been undergoing trials as an anticonvulsant for seizures refractory to other available treatments.

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Health effects of cannabis: the recent National Academy review and beyond

The National Academy of Sciences, Engineering, and Medicine recently issued a report using weight-of-evidence categories in reviewing and evaluating the overall scientific literature that supports therapeutic and other health effects of cannabis or cannabinoids. 3 The report concluded that there are several clinical problems for which there is conclusive or substantial evidence that cannabis or cannabinoids are effective-chronic pain, chemotherapy-induced nausea and vomiting, and patient-reported multiple sclerosis spasticity symptoms.

The report also concluded that there is moderate evidence that cannabis or cannabinoids are effective for improving short-term sleep outcomes in individuals with sleep disturbances associated with a variety of conditions. While none of those conditions is regarded as a psychiatric disorder, they all can be associated with other psychiatric symptoms (beyond sleep disturbance) and are all encountered by psychiatrists as comorbid conditions in clinical practice: obstructive sleep apnea, fibromyalgia, chronic pain, and multiple sclerosis. Sleep disturbances are also ubiquitous in the nosological schemes of psychiatry, notably in PTSD where nightmares are a factor.

At the community level, psychiatrists often advise against cannabis use, while some may recommend or approve it as an adjunctive therapeutic for patients with specific diagnostic entities and/or target symptoms. Patient reports that cannabis may relieve some of their symptoms are corroborated by a growing body of clinical literature that is as yet underdeveloped from a research perspective. 1 For other patients, the expression of a psychotic disorder may have been preceded by long-term cannabis use and/or cannabis use may be seen as an ongoing factor that exacerbates symptoms of mental illness.

The National Academy report concluded that there is substantial evidence of a statistical association between cannabis use and the development of schizophrenia or other psychoses, and that the risk is highest among the most frequent users. The increased risk is a weak effect, and the causal implications of the association unclear. Although cannabis use may lead to exacerbation of psychosis in some patients, the possibility remains that patient use for symptom relief may account in part for the statistical association.

Schizophrenia, CBD, and THC

Molecular CBD has been shown to treat symptoms of schizophrenia under controlled clinical trial conditions, with results comparable to those of treatment with an approved antipsychotic medication, and with a favorable adverse-effect profile. 4 Other studies support the view that CBD may have therapeutic potential as an antipsychotic and may counter or offset psychotomimetic effects of THC. Differences between THC and CBD notwithstanding, in a small case series, 6 patients with schizophrenia and a history of symptom relief with cannabis use were treated with the addition of low-dose prescription THC to regimens that included clozapine in some cases or multiple antipsychotics in 1 patient. 5 Four of the 6 patients showed improvement with the addition of THC to their regimen, and in 3 of the 4 patients a specific antipsychotic effect was evident. As with the anxiogenic potential of THC, dosage may be important in the relationship between THC and psychosis.

Cannabis and cognition

The National Academy report also acknowledged that there is moderate evidence of a statistical association between cannabis use and better cognitive performance among individuals with psychotic disorders and a history of cannabis use. It has been speculated that this could represent a less cognitively vulnerable subgroup of patients who would not have developed psychosis in the absence of exposure to cannabis, but this is not known. More generally, there is moderate evidence of a statistical association between acute cannabis use and impairment in the cognitive domains of learning, memory, and attention. However, results have been mixed on the question of longer-term and residual cognitive impairment. A recent report indicates neuropsychological decline in persistent long-term users with cannabis use disorders, although an earlier meta-analysis found no residual impairment. 6,7 Evidence of impaired academic achievement and educational outcomes was judged to be limited according to the National Academy report. Again, with cognitive functioning as with the risk of psychosis, dosage may be an important factor, since the findings of impairment relate primarily to heavy long-term use and even more specifically to those patients with cannabis use disorders.

Cannabis, cannabinoids, and dementia

Although the National Academy report did not find evidence of therapeutic effects of cannabis or cannabinoids for symptoms associated with dementia, several interesting findings in this area are worth mentioning. Basic scientific evidence suggests that cannabinoids may suppress neuronal excitotoxicity and neuroinflammation and be potentially beneficial in targeting plaque formation in Alzheimer disease. 8 However, the only clinical applications of cannabinoids in patients with dementia have involved targeting behavioral disturbances including agitation, food refusal, and irritability in small open studies with reported success.

A recent single-photon emission computed tomography study of patients with cannabis use disorders found decreased cerebral blood flow in a number of regions including the hippocampus. The investigators speculated that individuals with cannabis use disorders may be at increased risk for Alzheimer disease based on previous findings relating that risk to decreased hippocampal blood flow. 9 Further studies will be necessary to investigate the potential therapeutic applications of cannabinoids in dementia, and whether excessive long-term cannabis use is a potential risk factor.

Cannabis and PTSD

Evidence that cannabis or cannabinoids are effective for improving symptoms of PTSD is considered limited by the National Academy report, but clinical reports and case series excluded under its research quality criteria are more positive for the benefits of cannabis for PTSD symptoms. A growing number of states have included PTSD as one of the acceptable indications for recommending or approving medicinal use of cannabis. Clinicians who have written large numbers of medical cannabis recommendations have documented that a sizeable minority have been for psychiatric indications, with PTSD being perhaps the most common. 10

Greer and colleagues 11 reported on 80 patients with PTSD who were approved for medicinal use of cannabis through the New Mexico Medical Cannabis program. As a retrospective assessment, the study’s methodology limits the scientific conclusions that can be drawn. However, the authors reported decreases of 75% overall and separately in each of the 3 respective (DSM-IV) symptom clusters: re-experiencing, hyperarousal, and avoidance, as measured by current versus retrospective baseline Clinician Administered PTSD Scale (CAPS) scores, with and without cannabis use, respectively. The study was not included in the National Academy report, but it was reviewed by Walsh and colleagues, 1 who noted that most studies on the therapeutic use of cannabis by persons with mental health conditions are not of methodologically high quality.

The beneficial effects of cannabinoid medicines for PTSD are consistent with what is known about the psychobiology of PTSD and the emerging research on the endocannabinoid system. 12 Components of the endocannabinoid system include cannabinoid (CB1 and CB2) receptors; endogenous ligands anandamide, 2-arachidonoylglycerol (2-AG), and others; and enzymes that regulate endocannabinoid ligand production. Endocannabinoid signaling occurs in retrograde fashion, with postsynaptic release of ligands that bind to presynaptic cannabinoid receptors and inhibit presynaptic neurotransmitter release. This contrasts with the classic monoaminergic neurotransmitter systems that have shaped much of our thinking in psychopharmacology, and represents a potential alternative strategy for psychopharmacologic intervention (Figure).

CB1 receptors are widespread throughout the brain. Based on animal and human studies, the endocannabinoid system appears to be involved in the extinction of aversive memories, and both THC and CBD have been shown individually in separate studies to facilitate extinction of the conditioned fear response. 13,14 Recent neuroimaging studies have found increased CB1 receptor availability in multiple brain regions in PTSD, including the amygdala-hippocampal-cortico-striatal circuit implicated in its pathophysiology. 15

The National Academy report also found limited evidence of an association between cannabis use and increased severity of symptoms among individuals with PTSD, but the cause-and-effect relationships are unclear. Individuals with more severely symptomatic PTSD may be more likely to self-medicate with cannabis. The possibility of symptom exacerbation with cannabis use must be weighed against reported therapeutic benefit in individual cases. Other psychiatric diagnoses for which the National Academy report found limited evidence for effectiveness include Tourette syndrome and social anxiety disorders.

Cannabis and opioids

The National Academy report did not find evidence to support or refute the conclusion that cannabis or cannabinoids are effective in achieving abstinence from addictive substances. However, one study of molecular THC to decrease opioid withdrawal during acute detoxification and increase treatment retention with naltrexone found that patients who elected to continue smoking marijuana were more likely to complete treatment. 16

On the issue of whether cannabis access might impact opioid use and related problems, other recent studies have found decreased mortality 17 due to opioid narcotic overdoses and reductions in hospitalizations18 related to opioid dependence and opioid overdose in states that have passed medical cannabis laws. Another recently published analysis of data on 44,000 illicit opioid users who completed the National Survey on Drug Use and Health from 2007 to 2013 found that marijuana use was associated with a 55% reduced risk of past year opioid abuse. 19

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Knowledge gaps: risks and benefits of cannabis for psychiatric patients

Much of the foregoing discussion has focused on the 2 compounds in herbal cannabis that have received the most research attention and have also been of greatest clinical interest: THC and CBD. There are, however, numerous other compounds that are unique to cannabis. The concentrations of these compounds vary widely among the genetically different strains of cannabis and the conditions under which the plant is grown. At this point, we have insufficient research on cannabis and its constituent cannabinoids and terpenes to fully understand its potential to help or harm psychiatric patients and therefore guide clinical practice.

Many states with medical cannabis dispensaries have “counselors” who help guide patients to find the strain of cannabis most likely to benefit the patient’s symptoms. While such guidance is an imprecise proposition and there is substantial subjectivity in whether a given variety of cannabis will reduce symptoms, there are some generalities that guide dispensary counselors in their decisions about cannabis strain selection.

Most medical cannabis is from the Cannabis sativa plant, the Cannabis indica plant, or a hybrid variety derived from cross-breeding the two. Broadly speaking, the conventional wisdom is that marijuana and its extracts from Cannabis indica tend to be more sedating and produce more muscle relaxation than those from Cannabis sativa varieties, and patients with anxiety, insomnia, and chronic pain are frequently steered toward those strains. However, named strain variations are not the only source of self-selection of specific varieties of cannabis by patients. Many medical dispensaries offer laboratory analyses of the major cannabinoid concentrations in the cannabis they sell. As with the products mentioned above, the primary cannabinoid compounds of interest have been THC and CBD, but there are others of potential interest.

The medical cannabis patient and the practicing psychiatrist

Psychiatric patients may use medical cannabis to ameliorate their symptoms, either while in active psychiatric treatment or as a “more natural” alternative. If they are in active psychiatric treatment, they may be receiving additional pharmacotherapy. The astute clinician would want to know the details of the patient’s cannabis use; be alert for adverse effects and potential drug interactions; openly discuss the strengths and weaknesses of cannabis use in psychiatric treatment; and follow the emerging literature on its potential effect on psychopathology, treatment outcomes, and long-term prognosis.

Patients may feel stigmatized not only by their mental disorder, but also by their cannabis use, and may be reluctant to discuss it with their provider for fear of being denied treatment or labeled a substance abuser in need of rehab. Open discussions between psychiatrist and patient about the patient’s cannabis use can potentially be beneficial, especially if the psychiatrist is receptive to learning about the perceived benefits of using cannabis.

Physician advice on reducing smoking and alcohol consumption has a real impact on patient behavior. Perhaps an open and stigma-free discussion about the frequency of cannabis use and the dosing and composition of cannabis might reduce the subsequent risk for a cannabis use disorder or a psychotic break. Actual therapeutic benefit from cannabis use for any given patient might help to minimize total psychotropic medication burden, decrease reliance on opioid analgesics, and/or decrease or eliminate alcohol use. The challenge for modern psychiatry is to recognize the widespread use of cannabis in our society, to advocate for research that fills in our knowledge gaps, to recognize that there are both risks and benefits for psychiatric patients, and to acknowledge that patients need to discuss their cannabis use with their psychiatrists without shame or fear.

MORE ABOUT Christopher G. Fichtner, MD

Dr. Fichtner is a Clinical Professor of Psychiatry at the University of California, Riverside School of Medicine, and a staff psychiatrist with the Riverside University Health System-Behavioral Health. He received his medical degree from The University of Chicago Pritzker School of Medicine (1987). Dr. Fichtner is a diplomate of the American Board of Psychiatry and Neurology and a Fellow of the American Psychiatric Association, with specialty certification in administrative psychiatry. In addition, he is a Fellow of the American Association for Physician Leadership and a past President of the American Association of Psychiatric Administrators. His work in federal (VA), state, and county public mental health systems included a stint as Illinois State Mental Health Director (2003 to 2005), which shaped his views on drug policy.

In 2010, Well Mind Books published Cannabinomics: The Marijuana Policy Tipping Point, in which he argued that impending large-scale policy change was evident in 3 converging policy trajectories: growing consumer demand for medicinal cannabis access (medical marijuana); increasing recognition of drug war failure, especially as it relates to widespread cannabis use (public health); and the increasingly apparent economic potential of a socially integrated cannabis industry (legalization).

In Cannabinomics, he intimated that marijuana policy reform would likely be associated with public health benefits-especially through naturalistic substitution of cannabis for alcohol. Examples of patient use of cannabis as an alternative to opioid analgesics also featured prominently in the book. Emerging data-cited briefly in his article with Howard Moss, MD, in this issue of Psychiatric Times-support the view that marijuana policy liberalization holds potential as a partial solution to the opioid crisis.

Dr. Fichtner’s media appearances in connection with his book have included interviews with Dylan Ratigan (MSNBC), Paul Eggers (First Business, PBS), Bill Moller (WGN Radio), and Brad Pomerance (Charter California Edition).

In 2016, Dr. Fichtner received the UCR School of Medicine Psychiatry Education Service Award.

Disclosures:

Dr. Fichtner reports no conflicts of interest concerning the subject matter of this article. Dr. Moss reports that he owns 24 common stock shares of GW Pharmaceuticals currently valued at $2900 in his IRA. GW Pharmaceuticals is the maker of the drugs Sativex and Epideolex.

Dr. Fichtner and Dr. Moss are Clinical Professors of Psychiatry at the University of California, Riverside School of Medicine.

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