Thursday, November 24, 2011

Marijuana and Mental Health Controversy

The controversy surrounding marijuana as medicine has changed dramatically in the last 20 years.  20 years ago it was clearly 'illegal' and as such using it was evidence of 'addiction' as the risk/benefit ratio was so negatively weighted with potential incarceration and long  term negative consequences of criminal record.
These days the 'value' of marijauana continues to be supported especially with newer pharmaceutical cannabinoids seeking approval every month.  Further the federal Canadian political legislation has essentially 'decriminalized' marijuana by making it a 'medicine'.  Even in California someone wanting to smoke marijuana just needs to create a disease category, present with symptons and go to the drive through marijuana clinics making millions with the new laxity of the laws there.
There is still no support for 'smoke' of any kind.
But there's really good evidence for it's benefit in spasms and chronic pain especially 'neuropathic' pain (nerve pain) and also with nausea.  The benefits of the pharmaceutical components of standard marijuana are clearly outweighed by 'smoking', marijauna's dangers being essentially the same as tobacco smokers with chronic respiratory disease, cancer, asthma and heart disease associated with smoking. Smoking isn't good for you.
So marijuana cookies and tea are probably okay especially for Multiple Sclerosis and Nerve root pain in Diabetics. It was once the drug of choice for nausea in cancer treatment but better drugs have been developed.  The trouble is marijuana 'users' want to 'smoke' it suggesting that the majority of such are using it not for intrinsic slow release 'medical value' but it's ability to cause a 'high'.  Smoked marijuana is decidedly the route of choice for addicts.
Cesamet, Nabilone and Sativex are pharmaceutical cannabinoids.  Cesamet is on the provincial formulary for chronic pain.
The difficulty though is that 'smoking' is an 'addictive' 'process'.  This was seen with people given nicotine patches who smoked on top of that.  It's the 'ritual'.  Heroin addicts will 'shoot up' rather than 'smoke' heroin once they become addicted to the paraphernalia. There is a link between addiction and rapid access to brain of the compound.
But here's the controversy in mental health.  The Diagnostic and Statistical Manual of the American Psychiatric Association describe clearly Cannibis (Marijuana) Induced Anxiety Disorder and Cannibis (Marijuana) Induced Psychosis.  Bipolar II , the bipolar disorder associated with angry mood swings as opposed to Bipolar I where the mood swings are euphoria and depression, is the most common mood disorder in combination with addiction, clinically.  It's no stretch to say that Cannibis Induced Mood Disorder is readily apparent too.
So how do you decided if the Anxiety Disorder is a product of marijuana use or helped by marijuana use. The subjective experience of alcoholics is that alcohol makes them calmer and less violent yet the overwhelming community experience and 'objective' experience is that this is simply not the case. There is indeed a benefit from one drink and even an alcoholic will be calmed initially by one drink as a marijuana smoker will describe a joint benefiting their anxiety for a half an hour. The anxiety that follows is worse though and with addiction there is increasing need for more substance with decreasing benefit.
Initially a marijuana joint might cause hours of 'calm' but in the addict a half hour is a good success.  The alcoholic will get maybe 10 minutes of benefit from a shot when they're in withdrawal. Indeed the 'anxiety' and 'irritability 'seen in addiction is 'withdrawal.'
If you are using a substance that has caused the addiction to treat the anxiey which is the way the 'withdrawal' is experienced, then it's like pour gasoline on a fire.  There's that briefest moment when the fire is 'doused' but after that the fire is clearly a whole lot worse.
As early as the 30's alcohol withdrawal was called 'restless, irritable, and discontent", "the RID's".  Marijuana has been called 'marijuana maintenance' for those who mixed alcohol and marijuana or switched from alcohol to marijuana. Regardless the marijuana 'withdrawal' is experienced as the 'RID's" as well and lasts weeks if not months.
Drug seeking addicts will always tell me that they felt anxious off marijuana, alcohol or heroin in fact.  The truth is that those who develop addiction had an underlying 'anxiety disorder' and were 'self medicating'.  Normal people don't 'self medicate' and control the use of substances reasonably because they don't have the same underlying anxiety disorder.
Once an addiction is established it takes at least a year, some say 5 years, to be over the addiction. Seasons, 4 of them, seem to be associated with differing 'trigger's' for relapse.  So 'recovery' is not considered to be 'weeks' or 'months' but rather 'years'.
So what to do when a marijuana smoker is 'bullying' and even 'threatening' you and definitely angry if their agenda is thwarted in any way, when they see the doctor and ask for his support in getting them the 'license' to smoke marijuana.  It's said on the 'street' that 'good' doctors 'sign' and 'bad' doctors don't.
The government and it's regulatory bodies are all giving mixed messages but mostly their song is 'opinion poll' and 'cover your ass'.  As usual, clinicians, like soldiers are on their own, damned if they do and damned if they don't but certain to be judged by "monday morning' quarter backs with sometimes years to mull over a decision the clinician must make in the 'real world 'of 'here and now."
I'm in the middle. I've definitely supported 'medical marijuana' for some patients and am wholly behind 'decriminalization' of drugs, drug court and yet I draw the line at full 'legalization' because it will increase the risk to those who are vulnerable and society at large will definitely have more traffic accidents and work accidents and psychiatric problems.
I'd like to be 'black or white' in this grey area.  It's the same with benzodiazepine (valium type drug) prescriptions where patients who are addicted to marijauna, or alcohol or heroin say that the 'benzos' take the edge off.
My oath is 'do no harm' .  In the short run there are 'benefits but in the long run I'm probably at risk of compounding the patients problems.
Each case I think is unique but the politics treat the world as a mass and certainly the marijuana promoters are 'recruiter's and have a 'conflict of interest'. I've none but it's a challenge and I thought it worth mentioning.

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