Mental Health and Cannabis Loose Ends

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Mental Health and Cannabis Loose Ends

• 2006 National Organization for the Reform of
  Marijuana Laws Conference, San Francisco,
  California
• Sunil Aggarwal
• 4th Year MD/PhD student
• University of Washington
• Departments of Geography and Medicine

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• Cannabis use and schizotypy weak evidence
• Cannabis Abuse Disorder mental disorder or
  acceptance of a governmental disorder?

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Please Bear in Mind

• Mental illness has always been a source of
  misunderstanding, fear, and social contestation
• Socially constructed or biologically grounded?
  Or both?
• DSM-IV Diagnostics and Statistical Manual for
  Mental Disorders (available freely)

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Cannabis use and schizotypy

• FACTS
• - Higher rates of cannabis use (and other
  psychoactive substances) in schizotypic
  population cf. w/ gen. pop.helpful?
• - In predisposed individuals, cannabis use can
  exacerbate psychotic Sx that were once in
  remission
• - Can cannabis use can unmask schizotypy in
  predisposed? Some weak evidence

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Problems with this type of research

• Design, method, assumptions
• Doesnt consider context or mental health effects
  of marijuana stigmahow does criminalization of
  cannabis figure into the lived experience of the
  cannabinated state and the life experience of a
  cannabis user in general
• As Mirken and Earleywine state in their letter in
  response to a recent study Someone using a
  substance that is both illegal and socially
  frowned-upon almost by definition has ideas or
  beliefs that others do not share. This is not a
  sign of mental illness, but rather an indication
  of a rational, thinking person realistically
  assessing his or her situation. Considering the
  widespread use of undercover officers in drug
  stings, the same can be said for feeling other
  people cannot be trusted.
• Fergusson, DM et al. Tests of causal linkages
  between cannabis use and psychotic symptoms.
  Addiction, 100, 3354366, 2005.
• Mirken B, Earleywine M. The cannabis and
  psychosis connection questioned a comment on
  Fergusson et al. Addiction. 2005
  May100(5)714-5 author reply 715-6.

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United Kingdom Advisory Council on the Misuse of
Drugs Findings -(2006)

• The evidence for the existence of an association
  between frequency of cannabis use and the
  development of psychosis is, on the available
  evidence, weak. The council does not advise the
  reclassification of cannabis products to Class B
  it recommends they remain within Class C.

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UK ACMD contd

• In the last year, over three million people
  appear to have used cannabis but very few will
  ever develop this distressing and disabling
  condition. And many people who develop
  schizophrenia have never consumed cannabis. Based
  on the available data the use of cannabis makes
  (at worst) only a small contribution to an
  individuals risk for developing schizophrenia.
• For individuals, the current evidence suggests,
  at worst, that using cannabis increases the
  lifetime risk of developing schizophrenia by one
  per cent.

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Cannabis Abuse Mental Disorder a la DSM-IV

• DSM-IV used by clinicians and researchers around
  the world in numerous areas such as family
  medicine, internal medicine, psychiatry,
  emergency medicine, psychology, social work,
  nursing, occupational and rehabilitation therapy,
  counseling, and other health and mental health
  fields
• Diagnosis code 305.20
• Important mental disorder for which we have
  public health, medicine, and law enforcement
  working jointly for DIAGNOSIS, TREATMENT, AND
  PREVENTION need accuracy

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Cannabis Abuse Disorder Diagnostic Criteria
(cannabis substance)

• A maladaptive pattern of cannabis use leading to
  clinically significant impairment or distress, as
  manifested by one (or more) of the following,
  occurring within a 12-month period
• (1) recurrent cannabis use resulting in a failure
  to fulfill major role obligations at work,
  school, or home (e.g., repeated absences or poor
  work performance related to cannabis use
  cannabis-related absences, suspensions, or
  expulsions from school neglect of children or
  household)

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(2) recurrent cannabis use in situations in which
it is physically hazardous (e.g., driving an
automobile or operating a machine when impaired
by cannabis use) (3) recurrent cannabis-related
legal problems (e.g., arrests for
cannabis-related disorderly conduct) (4)
continued cannabis use despite having persistent
or recurrent social or interpersonal problems
caused or exacerbated by the effects of the
cannabis (e.g., arguments with spouse about
consequences of intoxication, physical fights)
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Cannabis-related legal problems, Criterion A3

• Diagnosis (1 of 15 possible ways)
• Patient X has a maladaptive pattern of
  substance use leading to clinically significant
  impairment or distress as manifested by recurrent
  substance-related legal problems occurring within
  a 12-month period.

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Specific Guidance from the DSM-IV

• Legal problems
• arrests for substance-related disorderly
  conduct
• legal problems may occur as a consequence of
  arrests for cannabis possession.
• cocaine abuse possession or use
• hallucinogen abuse possession
• amphetamine abuse possession or use
• ETC.

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DSM-IV Guidelines continued

• The category of Substance Abuse does not apply
  to caffeine or nicotine.
• The term abuse should be applied only to a
  pattern of substance use that meets the criteria
  for this disorder the term should not be used as
  a synonym for use, misuse, or hazardous use
• In order for an Abuse criterion to be met, the
  substance-related problem must have occurred
  repeatedly during the same 12-month period or
  been persistent.

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DSM-IV Guidelines Continued

• Substance-Related Disorders are distinguished
  from nonpathological substance use (e.g.,
  social drinking) and from the use of
  medications for appropriate medical purposes by
  the presence of a pattern of multiple symptoms
  occurring over an extended period of time (e.g.,
  tolerance, withdrawal, compulsive use) or the
  presence of substance-related problems (e.g.,
  medical complications, disruption in social and
  family relationships, vocational or financial
  difficulties, legal problems)

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Implications and Corollaries

• One way that social drinking, an example of
  nonpathological substance use, can be
  distinguished from pathological cannabis-related
  use disorders is by the presence of legal
  problems
• One way the use of medications for appropriate
  medical purposes can be distinguished from
  pathological cannabis related use disorders is by
  the presence of legal problems.
• Not considered
• -that medications might, in fact not be legal
• -that other forms of nonpathological substance
  use are possible with substances aside from
  alcohol, nicotine, and caffeine

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Cannabis Abuse Mental Disorder in (Legal
Problems-A3) in Action

• 2003 NSDUH survey questions re abuse taken right
  from DSM-IV
• IF MAR12MON 1 - 3 During the past 12 months,
  did using marijuana or hashish cause you to do
  things that repeatedly got you in trouble with
  the law?
• 1 Yes
• 2 No
• 3 DK/REF
• 13.685 yes answers in 2003
• Big difference when extrapolating to the 22
  million abusing and dependent figure

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Mental Disorder Legal Problems In Action,
Continued

• Marijuana arrests and increase in marijuana use
  disorders. Earleywine M. JAMA. 2004 Aug
  18292(7)802
• Recurrent marijuana-related legal problems
  qualify users for the abuse diagnosis. Marijuana
  arrests increased dramatically in the decade
  studied (1991-2001)which could account for the
  observed increases in the disorders.

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This Big Questions

• Is there any other medical explanation other than
  an underlying cannabis abuse mental disorder that
  would explain why individuals engage in cannabis
  use that can lead to legal problems or has a high
  potential of doing so?
• Will we let moralism influence our answer to this
  question? Or radical empirics and reason?
• Remember homosexuality was officially a
  sociopathic personality disturbance until 1973

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Conflation of Cannabis With Chemical Concentrates

• Dr. Nora Volkow, Director of the American
  National Institute on Drug Abuse
• This interacts with our endocannabinoid system
  which is all throughout our bodies. Which is so
  connected with how we live and experience our
  physical bodies and mental states.
  Human-cannabis political ecology.

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We must end

• American federal regulatory denialism of
  cannabiss medicinal properties
• Medical moralism