Is marijuana predictive of a certain rx success?

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Some people feel really good when they're stoned. Many people dislike the feeling of being high, some can take it or leave it, others thing it adds to the flair of some events and will smoke occasionally, while another group truly enjoys the feeling. The feeling is one that if they could substance their sober internal state with one of being high, they'd be much happier, and much better functioning.

Is their any evidence that certain rx drugs (for the treatment of depression and/or anxiety) show benefit over others in people who describe this relationship with marijuana?

I do recall seeing data that those that experience paranoia and other psychotic symptoms with marijuana are much more likely to develop a permanent psychotic disorder and there is data suggesting that marijuana use greatly increases the odds of one becoming schizophrenic.

But that's as far as I can recall that's it as far as I know. If someone else knows more....

Originally Posted by upright

Some people feel really good when they're stoned. Many people dislike the feeling of being high, some can take it or leave it, others thing it adds to the flair of some events and will smoke occasionally, while another group truly enjoys the feeling. The feeling is one that if they could substance their sober internal state with one of being high, they'd be much happier, and much better functioning.

Is their any evidence that certain rx drugs (for the treatment of depression and/or anxiety) show benefit over others in people who describe this relationship with marijuana?

I can't get the primary study on this computer right now, but this is kind of relevant:
http://psychcentral.com/news/2010/07...nts/15496.html
Different Effects of Marijuana in Bipolar and Schizophrenic Patients

Can using marijuana actually make you smarter? A recent study suggests that some patients with bipolar disorder who use marijuana actually performed better on certain neurocognitive tests. However, marijuana appeared to have the opposite effect on schizophrenic patients.
Dr. Ole Andreassen of Oslo University Hospital in Norway and his colleagues studied the effects of marijuana on bipolar and schizophrenic patients. They believe that the different effects of marijuana on cognition indicate “different underlying disease mechanisms in the two disorders.”
Marijuana is known to have a number of negative effects, including decreased cognition. Recent research has suggested that marijuana use can worsen symptoms of schizophrenia, and early use is associated with psychosis. The effects of marijuana on bipolar patients are less well known.
Andreassen and his team enrolled in their study 133 patients with bipolar disorder and 140 with schizophrenia. The patients were questioned about prior drug use. Over the previous 6 months, 18 bipolar patients and 23 schizophrenia patients had used marijuana.
All of the study participants then underwent several types of testing to assess neurocognitive function, including the logical memory test, the color-word interference set-shifting subset test, the digit span forward test, the verbal fluency test, and learning tests.
The bipolar patients who used cannabis performed better in verbal fluency than bipolar patients who did not use cannabis. They appeared to perform slightly better on the learning test, although these results were not statistically significant.
Marijuana use, however, worsened function in the schizophrenic participants, particularly with regard to focused attention, logical memory-learning, and logical memory-recall.
“Both neuropsychological test performance and individual effects of substance use can be regarded as endophenotypes, mediating factors between the neurobiological substrate and the expressed phenotype,” Andreassen writes.
Endophenotypes, characteristic traits used by researchers thought to be genetically linked to psychiatric disorders, are continually present even when more typical symptoms of mental illness are absent. Some have postulated a biological relationship between bipolar illness and schizophrenia. Andreassen’s results provide evidence to suggest that the two illnesses may be separate disease processes.
It is important to note that marijuana use results in a number of other negative effects that worsen overall function, and the data from this study do not promote the use of marijuana in bipolar patients. Advises Andreassen, “The evidence linking drug use/abuse with poor outcome in severe mental disorder must still be decisive for clinical advice.”
Andreassen’s results are available in the November 2009 issue of Psychological Medicine.
Source: Psychological Medicine

You guys are going the wrong way with this. I'm not referring to use of marijuana and its association with schizophrenia, a factoid every med student should be familiar with.

I'm referring to a study (or by simple observations from your professional experience) that may show certain beneficial responses to specific rx pharmaceuticals (to tx depression or anxiety) based on one's perception of being stoned. Some people, often those with depression or anxiety, feel more normal when they're stoned.

Seems like something worth looking into if no one hasn't imo.

MJ seems to help if one is feeling uncomfortably lucid. In most cases it simply kills motivation, worsens depression, and increases/ adds paranoia. I do not have any studies to back this up.

Part of taking a good substance use history is, as you suggest, to elucidate what subjective effects the substance has. Certainly our experience is that it varies from patient to patient. A lot has been made in some circles of the patient who mentions that methamphetamine or cocaine is calming for them, and hypothesizing that there might be an underlying ADHD that could be treated (preferably with bupropion or atomoxetine instead of stimulants). I haven't found much even anecdotally, let alone in the literature, with cannabis. There is so much variability in potency and "dosing", too, that it's difficult to deduce a treatment plan from the patient report. I _do_ find a number of people who use cannabis as an anxiolytic, and will state quite emphatically that nothing else will do, but that generally stimulates me to try to address the anxiety more aggressively (through both therapy and non-controlled medications) than in the patient who uses socially, or in search of enlightenment or oblivion.

Many patients with schizophrenia and bipolar disorder appear to benefit from smoking cannabis, although epidemiological studies tend to show a worse prognosis in those who are heavy users. Based on the observation that some patients appear to experience remittance of manic and psychotic symptoms with depression, analogues of cannabidiol (which is believe to be responsible for the putative antipsychotic effects) are in clinical trials. We also know that the CB1 blocker rimonabant causes depression, exacerbates it and is linked to suicidality so there may be some virtue in cannabinoids in depression. The problem is there are many different chemicals in cannabis, some of which may have positive effects on mental disorder, others which worsen the course of these illnesses. There may be genetic factors that predict differential response. There may be differences between different types of cannabis and composition of cannabinoids which may also lead to different effects.

I cannot imagine that it is a good treatment for anxiety disorders in the same way I wouldn't want to use alcohol or benzos longterm because of worsening. We know that in the short term, cannabinoids decrease release of CRF, but then this builds up and you get a massive release and lots of glucocorticoids = hippocampal damage and lots of stress, depression, anxiety, and cognitive impairment.

Originally Posted by upright

You guys are going the wrong way with this. I'm not referring to use of marijuana and its association with schizophrenia, a factoid every med student should be familiar with.

When I was a visiting medical student in the US in 2008, this was not generally accepted by American psychiatrists (cf. European colleagues) and thus many psychiatrists were not familiar with the cohort studies, so most medical students did not learn this. The association is still controversial so I suspect many med students still don't learn about this.

not to hijack the thread, but do you guys have any suggestions for treating anxiety in opiate addicts? Especially when they're still anxious while on methadone or suboxone (though that at least gives my benzo-denial speech more weight). Comorbid anxiety seems to be about 100% in this population, far more prevalent and intense than depression, in my limited experience.

Any magic bullets? Nothing seems to work that well. I was pinning my hopes on lyrica for awhile, and now there are studies showing abuse of that too.

Originally Posted by Chrismander

not to hijack the thread, but do you guys have any suggestions for treating anxiety in opiate addicts? Especially when they're still anxious while on methadone or suboxone (though that at least gives my benzo-denial speech more weight). Comorbid anxiety seems to be about 100% in this population, far more prevalent and intense than depression, in my limited experience.

Any magic bullets? Nothing seems to work that well. I was pinning my hopes on lyrica for awhile, and now there are studies showing abuse of that too.

Vistaril, Seroquel (yes, yes, I know...they might snort it...but that's a small minority), gabapentin, trazodone. Dose high, get aggressive with CBT and formalized relapse prevention programs.

Originally Posted by OldPsychDoc

Part of taking a good substance use history is, as you suggest, to elucidate what subjective effects the substance has. Certainly our experience is that it varies from patient to patient. A lot has been made in some circles of the patient who mentions that methamphetamine or cocaine is calming for them, and hypothesizing that there might be an underlying ADHD that could be treated (preferably with bupropion or atomoxetine instead of stimulants). I haven't found much even anecdotally, let alone in the literature, with cannabis. There is so much variability in potency and "dosing", too, that it's difficult to deduce a treatment plan from the patient report. I _do_ find a number of people who use cannabis as an anxiolytic, and will state quite emphatically that nothing else will do, but that generally stimulates me to try to address the anxiety more aggressively (through both therapy and non-controlled medications) than in the patient who uses socially, or in search of enlightenment or oblivion.

Awesome answer. Thanks for that.

Any magic bullets? Nothing seems to work that well. I was pinning my hopes on lyrica for awhile, and now there are studies showing abuse of that too

A significantly large number of my Suboxone patients scored (+) as having ADHD when given a TOVA test. When I tried them on a stimulant their anxiety decreased. This was after trying them on several SSRIs, and a nonstimulant.

I would treat their anxiety as I would any person, try to make sure you really have pathological anxiety, treat it with an SSRI, if a few trials fail, do TOVA testing, and if it's positive, try a non-stimulant first.

While the manufacturer recommends that Suboxone not be given with a benzo, it doesn't state the same about a stimulant. Also, as you likely already know, several people with ADHD have substance abuse problems and if you control it their likelihood of improving while abstaining from meds of abuse (except for stimulants) will likely improve.

Originally Posted by whopper

A significantly large number of my Suboxone patients scored (+) as having ADHD when given a TOVA test. When I tried them on a stimulant their anxiety decreased. This was after trying them on several SSRIs, and a nonstimulant.

I would treat their anxiety as I would any person, try to make sure you really have pathological anxiety, treat it with an SSRI, if a few trials fail, do TOVA testing, and if it's positive, try a non-stimulant first.

While the manufacturer recommends that Suboxone not be given with a benzo, it doesn't state the same about a stimulant. Also, as you likely already know, several people with ADHD have substance abuse problems and if you control it their likelihood of improving while abstaining from meds of abuse (except for stimulants) will likely improve.

Does one simply refer the patient to a psychologist that does TOVA testing?

Pretty much. The private practice where I worked had a guy that did them for $50. The university where I work at now charges (ouch!) $300. I don't really see a big difference other than that a psychologist with some academic research doing it vs. a private practice guy doing it-the test is quite mechanical and the test scores are straight-forward.

Given that most of the Suboxone patients I got aren't exactly rolling around in cash, I might tell them to go to the $50 guy.