Getting patients off Marijuana

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I've had some luck with topiramate for craving plus ssri for anxiety. I suppose gabapentin might be of some utility as well in a very very anxious cannabis dependent person.
 
I have a patient I'm seeing this afternoon who is primarily just MJ. Our addiction guy sent me some articles that explored Gabapentin as well as NAC. Evidence didn't seem all that string but I only perused superficially. He wasn't at all interested in stopping so I didn't do anything last time. I'll post more later.
 
I do not believe in( long term) usefulness of medications in drug addiction...especially not in cases of soft drugs. They just replace one drug with another drug. Underlying issues should be addressed through behavioral therapy.
 
GroverPsychMD said:
This is the hardest thing I have found getting patients off of.
Any techniques or meds that are helpful?
Click to expand...

Does the patient(s) actually want to quit? If not, no wonder you have had problems. Just try to take away my morning coffee, I double dog dare ya...
 
I've read in the benzo communities that people who use gabapentin or pregabalin to help get off benzos sometimes have a hard time getting off those, as well (though not as hard as getting off the benzos). I would wonder if an intervention like gabapentin is possibly just as "addictive" as marijuana (I use addictive in quotation marks not to be facetious but because I really don't know if either of those is in any official capacity considered addictive). I can say from personal experience that I went to a very high stress college, from which I had to do a medical withdrawal, and many years later I found out that some of the students I knew were using marijuana to get through the stress. They're all very high-functioning, successful adults now. Of course that's only anecdotal, but I can also say anecdotally that it seemed to do them more good and less harm than the interventions that were used on me (Klonopin and Ativan).
 
birchswing said:
I've read in the benzo communities that people who use gabapentin or pregabalin to help get off benzos sometimes have a hard time getting off those, as well (though not as hard as getting off the benzos). I would wonder if an intervention like gabapentin is possibly just as "addictive" as marijuana (I use addictive in quotation marks not to be facetious but because I really don't know if either of those is in any official capacity considered addictive). I can say from personal experience that I went to a very high stress college, from which I had to do a medical withdrawal, and many years later I found out that some of the students I knew were using marijuana to get through the stress. They're all very high-functioning, successful adults now. Of course that's only anecdotal, but I can also say anecdotally that it seemed to do them more good and less harm than the interventions that were used on me (Klonopin and Ativan).
Click to expand...
My experience has been more that certain people slide into addiction, whether it's benzos, opiates, cannabis, etc. It may be that certain individuals are less prone to addiction and can utilize the beneficial aspects of a substance without slipping into chronic, compulsive use. I have certainly seen patients smoking 2 grams of marijuana a day who find it extremely disruptive to their lives and mental health, and they can't quit anytime they want. Just like I know people who have 2 beers on Friday to 'relax' and this causes them no problems.
 
Psychotherapy: any of the evidence-based modality for substance abuse will do. Particularly factor in the unique challenges that come with social acceptance of a drug with addiction/abuse potential (e.g.: folks will often get more social support when quitting alcohol or nicotine than cannabis).

Pharmacotherapy: I've used gabapentin before, particularly in patients who have underlying anxiety anyway (very common in folks who smoke MJ to point of addiction). I've also been using NAC for a little while now, particularly in young adults.
 
I started NAC today on my patient. Mostly to appease mom as he's quite indifferent to any treatment. We'll see how it goes. I think it's reasonable for now. The patient has absolutely no motivation to quit. I was pretty clear with them both in our meeting last month that I believed the marijuana was exacerbating any anxiety and paranoia symptoms too much to really address them if they're really there outside the marijuana. He had stopped taking his other silly med combo that I was tapering him off after I inherited him from an inpatient facility. We had planned to reconvene in about 4-5 months to reasses if he had any desire to stop. He popped up on my schedule after a therapist got concerned that he'd stopped his medications (obviously didn't read my note) and was wondering if I could explore medications for his anxiety (again obviously didn't read my note before she sent them in for another appointment after just a couple weeks).
 
notdeadyet said:
Psychotherapy: any of the evidence-based modality for substance abuse will do. Particularly factor in the unique challenges that come with social acceptance of a drug with addiction/abuse potential (e.g.: folks will often get more social support when quitting alcohol or nicotine than cannabis).

Pharmacotherapy: I've used gabapentin before, particularly in patients who have underlying anxiety anyway (very common in folks who smoke MJ to point of addiction). I've also been using NAC for a little while now, particularly in young adults.
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Thank you all for your comments. What I have noticed is that all of their friends smoke mj too so they feel ostracized for the decreased substance use just like you said...
 
GroverPsychMD said:
This is the hardest thing I have found getting patients off of.
Any techniques or meds that are helpful?
Click to expand...

Even harder when they've got a medical marijuana card. Of course, then they don't want to, and there you go. People get very politicized around their marijuana.
 
This post is evidence as to something that I've found to be a significant trend and it is very upsetting. This is not against anyone on this thread because I too have my own problems that can be pointed to me.

The medical education curriculum is heavy biased towards FDA approved meds and commercialization.

What am I talking about?

N-Acetylcysteine has good data showing it helps one go off marijuana. There are faults with the study, but it is a very good study w/ over 100 people and it was double-blinded.
http://www.ncbi.nlm.nih.gov/pubmed/22706327

This IMHO should start a new trend among physicians to consider N-Acetylcysteine for the treatment of cannabis abuse but 1-there's no pharm company that will profit off of this so they're not sending drug reps to us 2-how many practicing clinicians actually read journals? I'm not talking about people on this forum or in academia, I'm talking doctor in the community? I've rarely ever had a conversation with one where they could point to a recent journal study.

It is the only pharmaceutical agent I know of that could have a benefit here. Another issue is this same agent could help in mental illness across the board but again, no pharm company will push it because it's available OTC.

Of course there's other things too such as motivational interviewing, making sure the person doesn't have a comorbid mental illness that the cannabis could be relieving (e.g. pain disorder, an anxiety disorder, etc).

While we're on the topic, I recommend everyone here start looking into SAM-E for depression and joint related pain, milk thistle for liver diseases, SAD lamps for SAD, Vitamin D for autoimmune/cancer/depression/psychosis, and fish oil for mental illness. All of these have tremendous amounts of data supporting their use but few psychiatrists are utilizing them, some more than others but in the case of Vit D and fish oil the price and risk factor are almost non-existent, pushing that even weak to moderate data should factor in their use.
 
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whopper said:
This post is evidence as to something that I've found to be a significant trend and it is very upsetting. This is not against anyone on this thread because I too have my own problems that can be pointed to me.

The medical education curriculum is heavy biased towards FDA approved meds and commercialization.

What am I talking about?

N-Acetylcysteine has good data showing it helps one go off marijuana. There are faults with the study, but it is a very good study w/ over 100 people and it was double-blinded.
http://www.ncbi.nlm.nih.gov/pubmed/22706327

This IMHO should start a new trend among physicians to consider N-Acetylcysteine for the treatment of cannabis abuse but 1-there's no pharm company that will profit off of this so they're not sending drug reps to us 2-how many practicing clinicians actually read journals? I'm not talking about people on this forum or in academia, I'm talking doctor in the community? I've rarely ever had a conversation with one where they could point to a recent journal study.

It is the only pharmaceutical agent I know of that could have a benefit here. Another issue is this same agent could help in mental illness across the board but again, no pharm company will push it because it's available OTC.

Of course there's other things too such as motivational interviewing, making sure the person doesn't have a comorbid mental illness that the cannabis could be relieving (e.g. pain disorder, an anxiety disorder, etc).

While we're on the topic, I recommend everyone here start looking into SAM-E for depression and joint related pain, milk thistle for liver diseases, SAD lamps for SAD, Vitamin D for autoimmune/cancer/depression/psychosis, and fish oil for mental illness. All of these have tremendous amounts of data supporting their use but few psychiatrists are utilizing them, some more than others but in the case of Vit D and fish oil the price and risk factor are almost non-existent, pushing that even weak to moderate data should factor in their use.
Click to expand...
The last patient I got who was on fish oil ended up needing an antipsychotic and had two inpatient hospitalizations...Fish oil was not enough..

But I do see the point of your posting.
 
I have a few patients on NAC for various reasons, and I have found it helpful for MJ, if they want to quit.

I have one patient on Topamax for MJ cravings who found it helpful.
 
GroverPsychMD said:
The last patient I got who was on fish oil ended up needing an antipsychotic and had two inpatient hospitalizations...Fish oil was not enough..

But I do see the point of your posting.
Click to expand...

I don't get it?! THC is natural... it comes from a plant!
You're making it all up!

No way could anyone be hospitalized from something natural...
 
whopper said:
but in the case of Vit D and fish oil the price and risk factor are almost non-existent, pushing that even weak to moderate data should factor in their use.
Click to expand...
Vitamin D and fish oil are not harmless. Vitamin D increases serum calcium, and there was at least one study linking fish oil to prostate cancer (I don't think this relation is clear yet, but certainly needs investigation).

I agree these are typically well tolerated, and so if potentially helpful should be used more than they are. But I also think it foolish to pretend they are without risk.
 
GroverPsychMD said:
Thank you all for your comments. What I have noticed is that all of their friends smoke mj too so they feel ostracized for the decreased substance use just like you said...
Click to expand...

People, places, and things is a necessary modication in the road to recovery.
 
GroverPsychMD said:
This is the hardest thing I have found getting patients off of.
Any techniques or meds that are helpful?
Click to expand...

If they have something like ADHD and take a stimulant for it, you could mandate monthly drug tests. I remember reading that people with ADHD are more likely to smoke marijuanna. If the patient has it, they would not want to give up their stimulants once they try them. For people with ADHD, stimulants are life-changing medicine. As a requirement of the stimulant prescription, make them take a drug test and be clean every month. Two birds with one stone, because you can (for the most part) verify they are using the stimulants properly.

Believe it or not, that method is very effective and should be utilized much more often. The problem is many people do not want to rx a schedule II substance to people with a history of drug abuse. I think it should still be considered.
 
JesusSaves said:
If they have something like ADHD and take a stimulant for it, you could mandate monthly drug tests. I remember reading that people with ADHD are more likely to smoke marijuanna. If the patient has it, they would not want to give up their stimulants once they try them. For people with ADHD, stimulants are life-changing medicine. As a requirement of the stimulant prescription, make them take a drug test and be clean every month. Two birds with one stone, because you can (for the most part) verify they are using the stimulants properly.

Believe it or not, that method is very effective and should be utilized much more often. The problem is many people do not want to rx a schedule II substance to people with a history of drug abuse. I think it should still be considered.
Click to expand...

Another physician has prescribed this patient stimulants but it made him too jittery. It's a lot more anxiety with him than anything else.
 
GroverPsychMD said:
Another physician has prescribed this patient stimulants but it made him too jittery. It's a lot more anxiety with him than anything else.
Click to expand...

D-amp produces less anxiety than mixed salts (adderall). Dexedrine. In fact, d-amp has a calming effect on a lot of people. I wouldn't give up yet because if you find a stimulant he likes, he won't want to keep smoking marijuana. Was he smoking marijuana with the stimulant? That could definitely cause bad anxiety.

I don't think giving him a benzo would benefit him. While you could mandate drug tests with that, the benzo addiction would be harmful in the long run. Probably worse than the marijuanna.

Anxiety can have a lot of causes. Dietary issues, gastrointestinal issues, sinus issues, toxins etc.. maybe look into that stuff... At least he is not using liquor.

There are a lot of nootropics and prescription drugs that help with anxiety but is the issue his anxiety or that he simply doesn't want to stop smoking marijuana? If he is set, in his mind, on continuing to smoke it (regardless of what he is telling you), there is nothing you can do if you can't find a way to mandate drug tests.
 
JesusSaves said:
D-amp produces less anxiety than mixed salts (adderall). Dexedrine. In fact, d-amp has a calming effect on a lot of people. I wouldn't give up yet because if you find a stimulant he likes, he won't want to keep smoking marijuana. Was he smoking marijuana with the stimulant? That could definitely cause bad anxiety.

I don't think giving him a benzo would benefit him. While you could mandate drug tests with that, the benzo addiction would be harmful in the long run. Probably worse than the marijuanna.

Anxiety can have a lot of causes. Dietary issues, gastrointestinal issues, sinus issues, toxins etc.. maybe look into that stuff... At least he is not using liquor.

There are a lot of nootropics and prescription drugs that help with anxiety but is the issue his anxiety or that he simply doesn't want to stop smoking marijuana? If he is set, in his mind, on continuing to smoke it (regardless of what he is telling you), there is nothing you can do if you can't find a way to mandate drug tests.
Click to expand...

He has been seeking benzos from many other docs. I'm starting to cut off his supplies and he is pissed.
 
GroverPsychMD said:
He has been seeking benzos from many other docs. I'm starting to cut off his supplies and he is pissed.
Click to expand...

You can't really mandate drug tests for benzos anyways because there are legal ones he can order online. I'm out of ideas. As he cuts back on the benzos he is going to get rebound anxiety and smoke more.
 
JesusSaves said:
You can't really mandate drug tests for benzos anyways because there are legal ones he can order online. I'm out of ideas. As he cuts back on the benzos he is going to get rebound anxiety and smoke more.
Click to expand...

As a physician, I can mandate any drug tests for anything I want to for patients under my care.
However, you do make a great point regarding the rebound anxiety.
 
GroverPsychMD said:
As a physician, I can mandate any drug tests for anything I want to for patients under my care.
However, you do make a great point regarding the rebound anxiety.
Click to expand...

What I meant is that even if you were to require drug tests for him to get his benzo rx, he would likely just start ordering the legal benzos online. Plus you would still have to taper him off even if you were to cut him off.
 
JesusSaves said:
D-amp produces less anxiety than mixed salts (adderall). Dexedrine. In fact, d-amp has a calming effect on a lot of people. I wouldn't give up yet because if you find a stimulant he likes, he won't want to keep smoking marijuana. Was he smoking marijuana with the stimulant? That could definitely cause bad anxiety.

I don't think giving him a benzo would benefit him. While you could mandate drug tests with that, the benzo addiction would be harmful in the long run. Probably worse than the marijuanna.

Anxiety can have a lot of causes. Dietary issues, gastrointestinal issues, sinus issues, toxins etc.. maybe look into that stuff... At least he is not using liquor.

There are a lot of nootropics and prescription drugs that help with anxiety but is the issue his anxiety or that he simply doesn't want to stop smoking marijuana? If he is set, in his mind, on continuing to smoke it (regardless of what he is telling you), there is nothing you can do if you can't find a way to mandate drug tests.
Click to expand...
Poor coping skills... etc.
 
whopper said:
This post is evidence as to something that I've found to be a significant trend and it is very upsetting. This is not against anyone on this thread because I too have my own problems that can be pointed to me.

The medical education curriculum is heavy biased towards FDA approved meds and commercialization.

What am I talking about?

N-Acetylcysteine has good data showing it helps one go off marijuana.
Click to expand...
Sorry, whopper, I may be missing something here, but several of us mentioned NAC specifically for THC withdrawal symptoms. I'm not clear what you're pointing to?
 
I hope this is not taking away from the thread, I will move it if it is, but I am curious about the perception of marijuana from practicing psychiatrists. Anyone here seen the recent documentary The Culture High? It features several psychiatrists including addiction psychiatry on the accuracy (or rather, inaccuracy) of our views on marijuana especially compared to the psychotropics currently used.
 
Psychczar said:
I hope this is not taking away from the thread, I will move it if it is, but I am curious about the perception of marijuana from practicing psychiatrists. Anyone here seen the recent documentary The Culture High? It features several psychiatrists including addiction psychiatry on the accuracy (or rather, inaccuracy) of our views on marijuana especially compared to the psychotropics currently used.
Click to expand...

I think most psychiatrists know it has potential to help with some symptoms. But using marijuana to treat anxiety, for example, is a bad idea that I would compare to using neuroleptics to treat autism. In both situations, it is going to make things much worse.

I think marijuana would be useful for people with severe PTSD such as people who were abused as children. Now if something like that is causing their anxiety, marijuana would be useful. I also think it would be useful for the suicidal depressed. That is not the mainstream opinion, but I think it will be within the next few decades.

Marijuana's medicinal effects were never fully explored.

I also believe that the CBDs, not the THC, would be useful in cases of psychosis. Far more useful than neuroleptics. But that is not technically marijuana. I wish that would be explored more. I think it is promising.

One thing about marijuana is, and this is a cliche, there is no money in it for the big pharmaceutical companies. So it will be a while before it is fully considered.
 
"Doc, Sanjay Gupta has a lecture online about marijuana...he totally saw the light...and he is a well respected neurosurgeon...."
 
whopper said:
This post is evidence as to something that I've found to be a significant trend and it is very upsetting. This is not against anyone on this thread because I too have my own problems that can be pointed to me.

The medical education curriculum is heavy biased towards FDA approved meds and commercialization.

What am I talking about?

N-Acetylcysteine has good data showing it helps one go off marijuana. There are faults with the study, but it is a very good study w/ over 100 people and it was double-blinded.
http://www.ncbi.nlm.nih.gov/pubmed/22706327

This IMHO should start a new trend among physicians to consider N-Acetylcysteine for the treatment of cannabis abuse but 1-there's no pharm company that will profit off of this so they're not sending drug reps to us 2-how many practicing clinicians actually read journals? I'm not talking about people on this forum or in academia, I'm talking doctor in the community? I've rarely ever had a conversation with one where they could point to a recent journal study.

It is the only pharmaceutical agent I know of that could have a benefit here. Another issue is this same agent could help in mental illness across the board but again, no pharm company will push it because it's available OTC.

Of course there's other things too such as motivational interviewing, making sure the person doesn't have a comorbid mental illness that the cannabis could be relieving (e.g. pain disorder, an anxiety disorder, etc).

While we're on the topic, I recommend everyone here start looking into SAM-E for depression and joint related pain, milk thistle for liver diseases, SAD lamps for SAD, Vitamin D for autoimmune/cancer/depression/psychosis, and fish oil for mental illness. All of these have tremendous amounts of data supporting their use but few psychiatrists are utilizing them, some more than others but in the case of Vit D and fish oil the price and risk factor are almost non-existent, pushing that even weak to moderate data should factor in their use.
Click to expand...

I have noticed this, but it goes beyond what you're talking about.

For example, I for years had tachycardia in spite of being treated for anxiety. I had seen umpteen psychiatrists. They knew my pulse would get to the 180s from walking around and that I had really low stamina. It's just anxiety they would tell me. Except as I would continually point out, I was not anxious about the act of standing. I wasn't anxious about playing tennis, which I had to stop. You can't make your pulse go from 90 to 180 from anxiety. My primary care doctor finally recognized it as POTS. The treatment for me is selective use of a low-dose beta blocker and lots and lots of water. But this is too much of a bother to figure out for some doctors and the solution maybe too pedestrian for some.

Another example is that my psychiatrist ordered a $3,000 genetic test to see if I had the MTHFR mutation so she could prescribe Deplin. I had already declined Deplin because I am not diagnosed with depression and I could see no point in taking it when I take a multi-vitamin already. So, I did the test. Based on me looking at the results (which included results other than the MTHFR), I found out that I have a different genetic variation that does significantly impact the blood concentration of one of the medicines that I do take. My psychiatrist never mentioned this was in the results (I found it on my own) and even after I pointed it out, she was disinterested. She did however, continue to push Deplin.

I don't know why beta-blockers aren't looked at more often, or why no one thought to look into physical causes of me losing my stamina when I was 15. Looking back on it, the explanation of anxiety for why I had to very suddenly quit the tennis team in high school makes no sense. I was anxious about how I felt yes, but no one looked into why I felt the way I did. I was given Ativan, which is not a solution to POTS. Anxiety is simple to diagnose (partially because it's such an ambiguous term) and easier to treat than a more complicated issue like POTS (not that Ativan is easy to manage--but that's not the original prescribing doctor's problem after he moves on).

I know that these are not common practices among the psychiatrists on this board. But I have experienced a very clear pattern of doctors wanting to push certain drugs/prescription-supplements for every issue. My psychiatrist wanted me to stop taking my magnesium, multivitamin, and fish oil and take Vayarin and Deplin instead. She wasn't interested in the fact that I have found magnesium to help with anxiety or that I need a multivitamin with iron and have taken one for years because of being vegetarian. She wasn't even interested in the really interesting information in the genetic test report because it wasn't the information she was hoping for. I was skeptical of the MTHFR test (and still am), but in the end am glad she did it because of the CYP results that came back with it.

She has expressed before a displeasure with reimbursements, there are often drug reps in the office (including ones representing Deplin and Vayarin), and she bragged about a free trip to Israel she got to go on from the people at Vayarin, so I am pretty sure she is getting kickbacks somehow (beyond the ones I know about).

So not only are people eschewing supplements in place of pharmaceuticals, but the supplements are being made prescription only—and then those prescription supplements are being pushed for everything under the sun off-label to the exclusion of OTC supplements (and the ones like fish oil which actually have more evidence behind them than the new designer prescription-supplements). I don't see any reason why Deplin should be a prescription, for example. St. John's Wort is OTC and has far more interactions and psychoactive effects than Deplin. These prescription-only supplement companies also make really broad claims and seem to be held to very few standards and are governed by the Orphan Drug Act. Vayarin is even sold in other countries OTC by the very same company that makes Vayarin but under a different name. And the people pushing these prescription-supplements are every bit the same as the other pharmaceutical reps. I've seen them. They all have a certain look that walks the line between flight attendant and prostitute.
 
Anyone here from a newly legalized area? I'd love to hear what they are seeing since laws changed.
 
When I run into situations where a patient has chronic depression or anxiety, smokes marijuana on a daily basis, and despite having spoken to them about the possibility that their chronic use could be maintaining their depression they remain pre-contemplative about quitting, I say something like, "So I just want us both to be clear - what you are saying is that right now your depression (or anxiety) is not enough of a priority to you for you to be willing to try stopping marijuana for 2-3 months in order to find out if it could help your mood or anxiety improve, is that correct?"

Then, each time we try a new antidepressant, I couch expectations by saying, "I'm willing to continue trying to help you with your depression with medications. But remember, to whatever extent marijuana is maintaining your anxiety and depression, it doesn't really matter what antidepressant we try, and we won't really get a sense of how effective the medication could be as long as you continue using."

I find that some patients, after several months, come to a position where they either are willing to try stopping or else already have.
 
VMSmith said:
When I run into situations where a patient has chronic depression or anxiety, smokes marijuana on a daily basis, and despite having spoken to them about the possibility that their chronic use could be maintaining their depression they remain pre-contemplative about quitting, I say something like, "So I just want us both to be clear - what you are saying is that right now your depression (or anxiety) is not enough of a priority to you for you to be willing to try stopping marijuana for 2-3 months in order to find out if it could help your mood or anxiety improve, is that correct?"

Then, each time we try a new antidepressant, I couch expectations by saying, "I'm willing to continue trying to help you with your depression with medications. But remember, to whatever extent marijuana is maintaining your anxiety and depression, it doesn't really matter what antidepressant we try, and we won't really get a sense of how effective the medication could be as long as you continue using."

I find that some patients, after several months, come to a position where they either are willing to try stopping or else already have.
Click to expand...

After a few session of similar MI techniques, I follow-up with "Do you feel you're addicted to it?" and many have reluctantly said they have problems with it.
 
The last patient I got who was on fish oil ended up needing an antipsychotic and had two inpatient hospitalizations...Fish oil was not enough..
Click to expand...

I don't mean fish oil and nothing else. Getting OT but a meta-analsysis that I saw at a poster-presentation shows it is very helpful in prodromal and first-break schizophrenia but the benefit tends to peter-off in patients that have had it for years.

As for Vitamin D and fish oil having risks, of course they do. Nothing, even water, is without risks, but if anything I've seen most patients have vitamin D deficiencies that aren't treated. This problem I suspect is sunlight related . I do not think people in Hawaii would be having a deficiency but in Ohio and Missouri I've seen it often.

As for people pointing N-Acetylcysteine before my post, that is my fault for not observing it. It is the only pharmacological agent I know of that has any evidence to back it's use, yet I see no one other than myself (and people here on this forum) talking about it.
 
milesed said:
Anyone here from a newly legalized area? I'd love to hear what they are seeing since laws changed.
Click to expand...
Some cases of marijuana induced psychosis. At least as best as I can tell. Usually people in their early 20's smoking hash oil.

Many patients tell me that now it is readily available they smoke more because prior they relied on friends giving/selling it to them, which often meant using only once a month. Now they can smoke everyday.
 
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milesed said:
Anyone here from a newly legalized area? I'd love to hear what they are seeing since laws changed.
Click to expand...

We go legal this summer, and I'm curious about what we'll see. We already have medical marijuana, though, which a huge proportion of our population has (like 1% or something), and marijuana is super prevalent as it is here. I would be surprised if legalization makes much of a difference, but I could be wrong. We'll see.
 
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