Is there such a thing as a marijuana use disorder? I think it often begins with us looking at the diagnostic criteria for substance use disorder and often what I will hear patients say is, well, it's legal. So I can use it and this diagnostic criteria don't talk about whether a substance is legal or not legal. It doesn't talk about the quantity a person uses, doesn't talk about route of administration for use. It's really assessing as you've mentioned several times now a loss of control and ways in which the substance is interfering in their functioning, in their interpersonal relationship, in their physical well-being, in their mental health that there are multiple domains across which the substance use is having a negative impact on their life. So marijuana use as alcohol and opioids and cocaine and all substances that we think of can have similar interfering, the potential to interfere in people's functioning. So because it's being made legal or because it's being studied or because it can even be useful in some applications doesn't mean that there's no risk of developing a substance use disorder with it. I think it's controversial in part because whereas we know the perturbations and permutations that harder drugs cause with repeated use, we really don't know enough about what is really occurring in the growing adolescent brain when chronic marijuana use is on-board and until we know that, I think to classify it in a category as starkly as stimulant use disorder or opiate use disorder may be overstating the problem a bit. I'm not saying that there may not be a time when we are able to say that definitively, but I think right now the jury's out on that a little bit because we just don't know enough about what THC and other cannabinoids are really doing in terms of hampering maturation of the brain. So we might get at some evidence of a loss of control but even with that loss of control, is it as severe or the manifestations generally as severe as other substances? Is marijuana the cause or the symptom? Tell us more what you're thinking Robert. Well, it may be that excessive marijuana use is a form of self-medication rather than the cause of the problem why the adolescent isn't thriving, isn't doing well in school, is cutting himself out of his previously fairly reasonable social circumstances. Or is it potentiating? Is it potentiating or is it just a symptom of self-medication. Which we'd say we consider with regard to all substances and often there's that discussion about self-medication, which speaks to that need to really do a full assessment to address the psychiatric co-morbidity and that people who have any underlying condition, mental illness are significantly higher risks. So I think that's always a question for us. Yes, but certainly for stimulants and for certain conditions, stimulant drugs like Adderall and ritalin are used therapeutically and actually help make people better. The question is, is there a way that for the people who are self-medicating with marijuana we can make that marijuana use beneficial for them rather than detrimental? Does it vary by person? We do have increasing data that daily heavy marijuana use from an early age increases the risk of development of a psychotic disorder and many people use stimulants to good effect and others use them in a way that demonstrates loss of control, and actually ends with some negative consequences of use. So it might not be as easy as deciding if there's a marijuana use disorder, but is there a marijuana use disorder evident in this person in this context. Helen I thought that the data pointed to early and chronic marijuana use in teens not necessarily leading to increased psychotic disorders, but that it might bring on a psychotic disorder earlier and of course the problem is with psychotic disorders. The earlier the onset, the worst the prognosis. So that itself seems to be a reason for me to suggest to my patients for instance to avoid using marijuana at a teenage years because if you have a potential of developing a psychotic disorder, it might happen earlier. I didn't know the evidence was really pointing the other way that the use could actually create a psychotic disorder where there wasn't one otherwise. So I think determining causality is very difficult. Yeah. But evidence is mounting that there might be a causal association. Okay. But the verdict is the jury's out. I think that is true or I'll go to [inaudible] That's why we need more research. But there's certainly genetic variations too. Sure. Which some people being very prone to it even just using a single time, right. So I think and that's what that complicates things, but yeah the adolescent brain and really understanding how substances play a role in that all substances is something we need a lot more evidence before we as providers can necessarily counsel definitively. Our bottom line is to talk about risks, explore benefits with patients and decrease harm, and that's all I think. Also on this topic of marijuana use disorder, I will say that it is a substance use disorder that I treat not infrequently. Patients do come in and they feel like they've lost control, they are having marijuana withdrawal which has been a well researched and identified syndrome. We don't have any medication treatments at this point for marijuana use disorder. So we use things like motivational interviewing and cognitive behavioral therapy and some of the other evidence-based psychotherapies, but it is something that's bringing patients into treatment. Is there any reason to think that Marinol or anything would be useful in the replacement? So there's been some research using Dronabinol in marijuana use disorder. I don't know that it's certainly is a strength of evidence to suggest that this should be used at this point. Okay. There's also some studies looking at an acetylcysteine. Yes. Adolescents, right? Again strength of evidence. Its more effective in an adolescent. Right, than adults.
