Month: <span>September 2021</span>

Cannabis: A New Drug Epidemic?

By Dr. Olga Megwinoff

During the late 1990’s when I was a psychiatry resident at NYU Langone Medical Center, the opiate epidemic was just beginning. We were taught that if a patient had pain, you had to give them prescription painkillers. At the time, “research” showed that they were necessary to control pain and did not have addiction potential when used to treat people for pain. This didn’t make sense to me, but who was I to question my teachers or “the research?” I was but a lowly resident.

The mood about marijuana reminds me of the early days of opioid painkiller use. Though I don’t believe marijuana will ever be understood to be as dangerous as prescription painkillers have proven to be, I do believe we are in a similar period of time that predated the opioid crisis. There are many market and industry powers that are working together in the same way to encourage more and more people to use marijuana, promote false medical claims, and reduce fear of any risk associated with use.

The Risks Involved with the Use of Marijuana

Currently, as an addiction psychiatrist working in a New York City outpatient addiction treatment center, I hear from patients how they perceive little risk in their use of Marijuana. It seems that as it has been medicalized, decriminalized, and now legalized, the message that most people get is that marijuana is a very safe drug, in fact “safer than alcohol which is legal” seems to be the catchphrase now.

This concerns me, however, because as an addiction psychiatrist, I am very well aware that Marijuana, though perceived as very low risk, actually does have addiction potential, can be abused, and can have major psychiatric consequences that include:

  • Aggravation of anxiety
  • Mood disorders
  • Psychosis
  • Dependence
  • Brain damage (in adolescents and young adults)

The Market Forces vs the Medical Field’s Perspective

In this blog, I’ll attempt to point out the different market forces pushing to legalize cannabis for medicinal and recreational use, in contrast to what is known in the medical field.

To start, legal cannabis sales in the U.S. passed $17.5 billion in 2020, a 46 percent increase over sales in 2019. Sales are expected to skyrocket to approximately $40 billion by 2025 (1). In terms of legislation, state governments are promoting legalization of cannabis because legal revenue will translate to huge taxes, instead of this money being lost to the black market. Legislators also hope to lower policing expenses and reduce the racial disparity in marijuana arrests – African Americans are four times more likely to be arrested for possession of cannabis than white Americans (2).

I will establish, first, that “Medical Marijuana” is a misguided industry term used in legislation, not a scientific medical term (3). As of 2021, 36 states have legalized marijuana for “medical” purposes and 18 states have recreationally legalized cannabis. Yet, in sharp contrast, on the federal level, research is limited regarding cannabis since it was a schedule I substance until December 2020. According to the DEA, “a schedule I drug has a high potential for abuse and the potential to create severe psychological and/or physical dependence. These drugs are determined to have no accepted medical use” (4). 

            As of May 2021, the FDA, responsible for approving treatments after appropriate and rigorous study, has not yet approved the cannabis plant as safe or as an effective drug for any medical indication. The only FDA approved cannabinoids products are Marinol, Syndros, and Cesamet (synthetic THC, cannabinoid analogs). They have been approved for the treatment of three different seizure disorders, chemotherapy related anti-nausea, and as a cancer related appetite stimulant. Nevertheless, the market has gone way ahead of the science resulting in a lot of concerning unknowns. There is ongoing scientific trials planned but interestingly enough, there’s little funding for them (3).

The media plays a large role as well. It promotes a narrative that transforms public reactions and reinforces drug policy implementation (5). It is of concern that cannabis legalization is promoted by the media without a critical lens; cannabis is promoted as a “magical fix,” and “safe” despite the lack of scientific evidence for it.

There are many unestablished facts about cannabinoids. Studies reveal there are more than 500 compounds in the marijuana plant, the majority of these are unknown. In addition, scientists don’t know basic details about the drug, such as what a standard dose should be. It is suggested that cannabis at low doses could help with anxiety, but at higher doses is anxiety provoking. Quality is also not controlled. Many CBD preparations in the market are contaminated with THC and other compounds, including Benadryl.

Furthermore, newer cannabis strains developed in the 1990’s have increased THC levels. Prior to the 1990’s, top grade pot had 20% THC levels. Newer products have concentrations as high as 40-80%. Moreover, synthetic cannabinoids and cannabis concentrate products can contain up to 80-90% THC (6). With these stronger strains we are seeing new afflictions. For example, Hyperemesis Syndrome (severe nausea and vomiting syndrome) was a rare occurrence in the emergency rooms and is now quite common.

Many patients with psychiatric disorders use cannabis with the idea that it may be helpful for treating primary depressive disorders, general anxiety disorders, post traumatic stress disorder, or psychosis to name a few. However, very low quality studies suggest that cannabis could lead to small improvements in anxiety, but there are no other quality studies thus far.

Potential Medical Complications Caused by Marijuana Use

Furthermore, exposure to cannabis can induce medical complications such as cardiovascular and respiratory problems. It can even impair brain function. Marijuana is a sedative and can reduce someone’s ability to drive and it decreases cognitive and memory function. There is some indication that there may be white and grey brain matter and cortical thickness alterations. In addition, cannabinoids cross the placenta and can affect pregnancy outcomes and neurodevelopment of the fetus (6).

In other words, inhaled herbal cannabis contains mutagens and can result in lung damage, exacerbations of chronic bronchitis and certain types of cancer. (7)

Cannabis is one of the most commonly used drugs in the global market, only second to alcohol and tobacco use (8). Similar to other psychotropic drugs, cannabis has the potential to produce rewarding/reinforcing effects by enhancing dopamine signaling in the addiction pathways in the brain (9). The rewarding effects of cannabis are directly associated to the actions of THC on cannabinoid CB1 receptors in the brain (9).

Understanding Cannabis Use Disorder

Cannabis Use Disorder, characterized in the DSM-5 diagnostic manual, consists of a pattern of cannabis use that causes significant psychiatric distress and social impairment within the context of repeated attempts to stop using. In other words, prolonged and sustained cannabis use is associated to an insidious addiction that is very hard to break. This addiction is often associated to psychiatric symptoms of anxiety, depression, and insomnia. These all can have profound effects on careers and relationships. In the words of Dr. Glazer (2020), “People go nowhere slowly.” In 2019, 4.8 million Americans ages 12 and older were diagnosed with Cannabis Use Disorder.

Other DSM-5 diagnostic disorders such as Cannabis Intoxication consists of the following:

  • Euphoria
  • Increased appetite
  • Tachycardia
  • Altered judgement
  • Possible anxiety
  • Psychosis

Cannabis Discontinuation Syndrome has been well established in the medical literature and consists of symptoms of the following:

  • Anxiety
  • Dysphoria
  • Sleep disturbance
  • Irritability
  • Decreased appetite

Evidence shows that cannabis use and Cannabis Use Disorder have increased in recent years in states that have legalized marijuana. These epidemiology studies have estimated that around one in six (1:6) of those who use cannabis during adolescence and one in two (1:2) of daily cannabis users will meet the criteria for Cannabis Use Disorder. This is of concern because in addition to the addiction aspect, epidemiological data proposes that recreational cannabis use is positively associated with psychotic disorders, depressive and anxiety symptoms, including panic disorder. Cannabis has also been negatively associated with bipolar disorder, it leads to lower remission rates and early onset of symptoms. To be specific, frequent use of high-potency cannabis has been associated with increased paranoia and elevated risk of psychotic disorders among individuals with no psychiatric history (11).

 THC vs CBD

It is speculated that many of cannabis’ negative effects are associated with THC. However, some patients with psychiatric disorders that use cannabis can see some possible improvements that are most likely due to its CBD component. CBD (cannabidiol) is the second major component of marijuana and is more promising for therapeutic use as mono therapy (6).  It is still unregulated, mislabeled, and it is frequently contaminated. Only 30% of CBD products that are available commercially are accurately labeled and many have THC.

Some evidence suggests that CBD may be anti-seizure, neuro-protective, antipsychotic, and anti-inflammatory.  Positive observational studies on social anxiety shows that it can decrease anxiety. In one study with cancer patients, fewer depressive symptoms were shown. Nevertheless, there’s no evidence that CBD can help people sleep and any topical application claims are false because it is not absorbed in the blood this way. CBD has a mostly pharmacologically benign profile, but it exhibits liver toxicity (10) at doses of at least 1,500 mg a day. CBD also has drug-drug interactions, specifically with morphine, epileptic drugs, benzodiazepines, some antidepressants, etc. Nevertheless the possible positive association to CBD, more rigorous and larger studies are needed to know for certain its effects on people.

Dr. Olga Megwinoff’s Perspective on Marijuana Use

My last point is that in my personal experience, it is very difficult to treat clients with chronic cannabis dependency. Marijuana is quite addictive and there is no good treatment or MAT (medication-assisted treatments) for Cannabis Use Disorder. In the last few years, only CBD has been suggested as being helpful with cravings and withdrawal symptoms.

In my opinion, the implications of legalizing marijuana remain to be seen, but it is clear that there are numerous contradictions in practice, policy, and scientific knowledge. Besides, the huge economic incentives driving the consumption of cannabis corrupt any well intended motivations of the market.  I’m concerned about the morbidity of prolonged cannabis use within the context of this widespread accessibility.

I do believe Marijuana should be legalized. The real issue is that there is an overwhelming amount of misinformation, mislabeling, and false claims as this drug is pushed into the market. This misinformation understates the risk and exaggerates the benefits of cannabis. Decreased perceived risk and overstated benefits led to an epidemic of prescription painkiller abuse. I fear the same may be true for legalized and “medical” marijuana.

Sources:

  1. Alfonso Tortolani, P. “Why the Pandemic Was a Breakout Moment for the Cannabis Industry”. com, May 31, 2021
  2. ACLU, (June 2013) “Report: The War on Marijuana in Black and White.” Retrieved from:https://www.aclu.org
  3. Hill, K., Williams, A.R., and Watkins,“Clearing the Smoke: Cannabis and Mental Health”, APA and AAAP Webinar, April 8, 2021
  4. deadiversion.usdoj.gov
  5. Rothstein, R. and Finnigan, R., “Marijuana and The Media: The Influence of Media Narratives on Legislation Outcomes”, sociology.ucdavis.edu, n.d.
  6. St. Marie, R. and Leo, R., “Cannabinoid-Based Medications for Pain”, Current Psychiatry, Vol.20, No.5, May 2021
  7. Ghasemiesfe, M., Barrow, B., Leonard, S., et al. “Association Between Marijuana Use and Risk of Cancer: a Systemic Review and Meta-Analysis”, JAMA Network            Open 2019;2(11)
  8. Carlinger, H., et al, “Cannabis Use, Attitudes, and Legal Status in the US: A Review”. Prev Med, 2017
  9. Zehra, A., et al, “Cannabis Addiction and the Brain: A Review”, Focus Vol 17, No 2, Spring 2019
  10. Ewing, L., Skinner, C., and Koturbash, I., “Hepatotoxicity of a Cannabidiol-Rich Cannabis Extract in the Mouse Model”, Molecules 2019 May;24 (9):1694
  11. 11. Sabioni, P. and Le Foll, B., “Psychosocial and Pharmacological Interventions for the Treatment of Cannabis Use Disorder”, Focus Vol 17, No 2, Spring 2019
Alcohol and Anxiety | Manhattan Alcohol Addiction Treatment

Anxiety and Alcohol Use

By Ronnit Nazarian, Psy. D

A common theme that I have found while speaking with patients who overdrink has been that they also experience an underlying anxiety disorder. Moreover, they have mentioned having difficulty finding something that helps them disconnect from their stress and anxiety that works as well as having a drink. To most people looking in from the outside, a person who experiences anxiety and a person who experiences drinking problems are often viewed as two separate individuals. Contrary to common belief, however, research shows that approximately 50% of individuals who experience alcohol problems also meet the criteria for one or more anxiety disorders.1 Alcohol use and anxiety are strongly linked and often called co-morbid disorders that interact with each other. One of the major contributors to an increased alcohol intake is a person’s level of anxiety.4

At Fifth Avenue Psychiatry, we recognize that many people who have an increased alcohol use will drink in order to cope with their anxiety (e.g., work stress, social stress, etc.). While alcohol may be used to help cope with anxiety, it can also have long-term consequences in increasing a person’s level of anxiety in the long term. In this blog, we discuss the ways anxiety and alcohol are linked, the consequences of using alcohol as a coping mechanism, alcohol-induced anxiety, and treatment approaches for dual diagnosis of anxiety and alcoholism.

Using Alcohol as a Coping Mechanism (Self-Medication Model)

A mild amount of anxiety is typical for anyone to experience as a reaction to a stressful situation. When someone suffers from an anxiety disorder, their reactions to stress can impact their daily functioning, relationships, sleep cycle, and work production. Those who struggle to cope may turn to the use of alcohol and drugs, engaging in compulsions, and avoiding events to decrease the anxious feelings.

Below are some of the ways people use alcohol to cope with anxiety:

  • Drinking at a party to feel confident, less shy, and to socialize
  • Drinking at the end of the week to destress
  • Drinking to numb negative thoughts and emotions
  • Drinking to feel included and connected to others
  • Drinking to relax
  • Drinking to forget bad memories
  • Drinking to feel happy
  • Drinking to no longer feel in control
  • Drinking to no longer make decisions
  • Drinking to take a break from reality
  • Drinking to fall asleep

What drinking starts as “liquid courage” or a “way to let loose” for a person, it easily becomes a way of self-medicating as it becomes a means of coping. Research shows that most individuals who experience drinking problems and self-medicate with alcohol also experience a generalized anxiety disorder, social phobia, and panic disorder.More specifically, it appears that alcohol problems begin after the onset of anxiety disorders. Many individuals who experience social phobia and agoraphobia have reported initially using alcohol as an attempt to control anxiety. Active alcohol use can exacerbate symptoms of anxiety, which plays a significant role in the difficulty of diagnosing anxiety disorders in the face of active alcohol use. The lines blur with distinguishing between symptoms of alcohol withdrawal versus anxiety disorders when symptoms of withdrawal appear like symptoms of anxiety. 3

Over time, as individuals continue to self-medicate with alcohol as a coping strategy, they may require increasingly higher doses of alcohol. Consequently, this can result in an individual developing an independent substance use disorder. Individuals who self-medicate with alcohol are at risk of increased psychiatric co-morbidity, suicidal behavior, levels of stress and dysfunction, and lower health-related quality of life.5

How Alcohol Increases Anxiety Levels (Substance-Induced Anxiety Model)

Using alcohol to cope with anxiety can in turn significantly increase anxiety levels. While alcohol can diminish feelings of anxiety and provide short-term relief, it can lead to increased anxiety. Specifically, alcohol can act as an “Anxiogenic,” which creates feelings of anxiety and panic attacks when withdrawing from alcohol. This feeling can lead someone to continue to drink alcohol to decrease those uncomfortable feelings. This leads to a vicious cycle in which alcohol and anxiety play off each other and makes it no longer clear which disorder (anxiety or alcoholism) is the operating cause.2

Treatment for Co-Occurring Anxiety Disorders and Alcohol Use Disorders

There are many treatment models available to assist individuals with co-occurring disorders. The selection of treatment approach depends on the way in which, and the reasons why a person uses alcohol to cope. For individuals who use alcohol to cope with social anxiety, a combination of Cognitive Behavior Therapy (CBT) and Exposure Therapy can be helpful to challenge thoughts and behaviors surrounding events that cause anxiety. Individuals who use alcohol to cope with stress or intense emotions would benefit from Dialectical Behavior Therapy to learn how to regulate their emotions and tolerate distress. At the root of all treatment models, it would be critical for patients to develop new healthy coping strategies to replace their unhealthy behaviors, such as drinking alcohol. Alongside engaging in therapy, it may be beneficial for the individual to receive pharmacological treatment to decrease the feelings of anxiety that drive a person to drink.

When developing a treatment plan, it is important for the clinician to understand the individual’s presenting problems and determine which of the problems should be the primary focus of treatment. A majority of treatment typically begins with the elimination of alcohol use first.  With alcohol out of the way, one can gain a better understanding of the primary reasons that drive a person to drink.  Sometimes with the reduction of alcohol use, many symptoms such as anxiety and depression are actually reduced. Ultimately though, in many cases, challenging and treating anxiety symptoms that resulted in overdrinking is the ultimate goal.

  1. Anker, J. J., & Kushner, M. G. (2019). Co-Occurring Alcohol Use Disorder and Anxiety: Bridging Psychiatric, Psychological, and Neurobiological Perspectives. Alcohol research: current reviews40(1). https://doi.org/10.35946/arcr.v40.1.03
  2. Brady, K., Tolliver, B., & Verduin, M. (2007). Alcohol use and anxiety: diagnostic and management issues. The American journal of psychiatry, 164 2, 217-21; quiz 372 .
  3. Kushner, M. G., Sher, K. J., & Beitman, B. D. (1990). The relation between alcohol problems and the anxiety disorders. The American Journal of Psychiatry, 147(6), 685–695. https://doi.org/10.1176/ajp.147.6.685
  4. Smith, J. P., & Randall, C. L. (2012). Anxiety and alcohol use disorders: comorbidity and treatment considerations. Alcohol research: current reviews34(4), 414–431.
  5. Turner, S., Mota, N., Bolton, J., & Sareen, J. (2018). Self-medication with alcohol or drugs for mood and anxiety disorders: A narrative review of the epidemiological literature. Depression and anxiety35(9), 851–860. https://doi.org/10.1002/da.22771

 

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