The legalization of marijuana in the U.S. for medicinal use in 36 states and recreational use in 18 states has brought up many thorny issues for practicing psychiatrists as we try to weave our way through these rapidly changing times.
In spite of all the latest research, many questions have gone unanswered and require more thorough study before we can fully understand how to safely incorporate it into our practices.
In my previous role as medical director of psychiatry within a large multi-specialty medical practice in New York, I began to work with patients who were started on medical marijuana after its legalization in 2014.
There were mainly chronic pain patients that had been started on medical marijuana in an attempt to help them wean down off high doses of opiates with varying degrees of success. Some of the drawbacks were the costs, which ranged from $200 to over 300 per month, making it difficult for most patients to afford. It was also difficult to distinguish the isolated effects of marijuana from opiates or the myriad of pain and psychiatric medications. To complicate matters even further, no one really knows how marijuana interacts with many of these other medications. Overall effects on sleep, mood, and anxiety were difficult to assess given this complexity.
Practicing psychopharmacology has always been both an art and a science but adding opiates, alcohol, and marijuana to the mix makes it a much more murky process.
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Since ancient times marijuana has been taken for its medicinal and euphoric effects. We know that it has a powerful anti-inflammatory effect, which can help with pain relief. Its other medical uses include reducing nausea for cancer patients on chemotherapy and possible relief for those suffering with post-traumatic stress disorder (PTSD), Multiple Sclerosis (MS), glaucoma, HIV/AIDS, and some forms of epilepsy. There is even some early research by Gary Wenk, Ph.D., that it could help prevent memory loss in aging by reducing inflammation in the brain.
Some of my psychiatric patients used it to treat their insomnia, anxiety, and depression with varying success because in some it actually exacerbated their condition. Additionally, marijuana has been known to “expand consciousness” leading to an enhanced appreciation of the simple pleasures in life such as listening to music, enjoying good food, and being out in nature. Marijuana use has increased by 75 percent in the over-65 population in just the last three years. Many of these people had used pot in the 60s or 70s and are now seeking help with chronic medical conditions and the anxiety that comes along with aging.
The cons, however, are significant, especially in adolescents and young adults. Much research, including a recent study out of New Zealand, revealed that for those who begin to use marijuana regularly in their early teens, there can be long-term memory impairment with a lowering of IQ, poor job and academic performance, and greater risk of depression later on in adulthood. Individuals from traumatic backgrounds are at higher risk of developing this pattern and are four to seven times more likely to become dependent on alcohol, marijuana, and other drugs.
Additionally, marijuana use can cause increased impulsiveness, impaired driving ability, heightened anxiety, paranoia, and apathy. Probably due to the higher potency of THC in marijuana today compared to the 1960s, there is a greater risk of it triggering psychosis, even in those without a genetic predisposition of schizophrenia.
All of these negative effects can occur in adults as well but they are especially worrisome in our adolescent and young adult patients whose brains are still actively developing up until the late 20s.
Since 2019 rates of marijuana use have increased dramatically in adolescents, as have rates of ER visits where marijuana is involved. Reasons for this increase may be the decreased perceived risk coupled with the rise in vaping and the stress of the Covid pandemic.
Last, there are the documented harmful health effects of smoking marijuana such as an increase in bronchitis and other chronic lung conditions.
Psychiatry’s Role In The Debate
After weighing both sides of the equation, what is my responsibility and recommendations as a psychiatrist to my patients and community? Will having marijuana dispensaries in my town lead to there being more widespread use in adolescents and young adults? Will this lead to an uptick in mental illness and addiction, poor academic performance, and motor vehicle accidents?
We are just beginning to gain experience as physicians working with medical marijuana where clearly more research is needed to flush out the issues. This includes knowing which conditions respond best at what doses and ratio of THC/CBD, understanding the harmful drug interactions, and using it safely to avoid abuse and dependency. Marijuana will have to be moved from a Schedule I to Schedule II drug so that the necessary research can be performed on humans.
It’s unfortunate that we are moving as quickly as we are as a nation without having enough careful discussion, education, and caution. Many parents wrongly feel that marijuana carries a much lower risk than alcohol and adopt a casual, laissez-faire attitude when advising their kids.
I am glad that my patients on medical marijuana will be able to obtain a cheaper, high-grade product instead of resorting to buying it on the street where it can be tainted with phencyclidine (PCP/Angel Dust), and other impurities. I’m also relieved that African Americans and other minorities will not fear being arrested and sent to jail for the possession of small quantities of marijuana.
Given the pros and cons, we need to continue to form interdisciplinary committees at both large medical facilities, academic institutions, and out in the community to further necessary research and to educate both professionals and the lay public. These committees should work in tandem with local and state governments and must include both medical and mental health professionals who have the most experience in this field. Let’s proceed, but do so with the appropriate level of caution so that marijuana is safely introduced into our society.