Residents’ Corner

Do you talk about marijuana with your patients?


Do you talk about marijuana with your patients?

In medical school, I had a roommate. He was a smart law school graduate, good looking, outgoing, had lots of friends, was funny, and he was a great cook.

Dr. Yehonatan Shilo, a second-year PGY in the department of psychiatry at Einstein Medical Center, Philadelphia.

Dr. Yehonatan Shilo

And yet, he failed to pass the bar exam, frequently argued with his brother, and his room was always a mess. In his 30s, he was still very dependent on his parents in several ways and mostly unemployed. When he did work, it was for his friend, for a few hours a day, 3 times a week. I really liked him, and we became friends who have lots of deep conversations. We keep in touch to this day.

I should tell you another thing about my friend: He was a heavy, daily user of marijuana.

I believe that most of us, at a certain point of our lives, have met someone like my friend. The combination of a high-stress lifestyle, high self-expectations, and lack of appropriate skills to tackle life’s obstacles when encountered with failure frequently leads to addiction or a behavioral problem. In most cases, that will cause a pathological relationship with an outside substance or stimuli (Internet overuse/shopping too much/overeating or drinking, and so on).

Living a life filled with severe trauma and pain, especially at a developmental stage, often leads to an addiction. We frequently see people escape to the sweet narcotic-induced sleep via opioid abuse. On the other hand, for people who did not suffer trauma and are highly functional, marijuana offers a means of emotional detachment from pain, in its different form, and existential depression. That is the main benefit my patients who live with marijuana addiction get.

My friend serves as a rather stereotypical – and some may say – subjective, simplistic example of what is becoming more and more common in our society. I’m willing to bet that a good number of clinicians who read this have a similar example in mind.

With its intoxication state perceived as benign and the limited medicinal advantages, marijuana rapidly is gaining more and more legitimacy in the eyes of the general public (Addict Behav. 2008 Mar;33:397-411), (Monitoring the Future: National Results on Drug Use: 1975-2016). The risk of addiction is perceived as negligible and often nonexistent.

Almost no one knows about the potential risk of addiction (around 9%) (Drug Alcohol Depend. 2011;115:120-30). No one knows about about tolerance and withdrawal states – or about the real risk of psychosis (N Engl J Med. 2014 Jun 5;370:2219-27) or about the possible risk of schizophrenia in vulnerable populations (Schizophr Res. 2016 Mar;171:[1-3]:62-7). No one talks about the fact that it’s often used with tobacco. (How many times have you been told during history taking that a patient doesn’t smoke tobacco, only to find that in drug history he smokes 3-5 joints with tobacco daily?)

Throughout my journey in the psychiatric world (studying and working on three different continents) another typical marijuana user is the patient living with chronic mental illness. My Israeli mentor often complained about not having a single “clean” patient with schizophrenia anymore. I now see the same phenomena in Philadelphia and was also exposed to the same reality in Europe during medical school.

As physicians, and especially as psychiatrists, I believe we are obligated to educate our patients by telling them about the risks in their behaviors. Educating patients about marijuana in today’s atmosphere can be a very important preventive measure, and awareness is an important step toward change.

The current generation of psychiatrists is dealing with an opioid epidemic. Let’s educate ourselves and our patients so this current epidemic won’t be followed by another, severe cannabis epidemic.

Dr. Shilo is a second-year PGY in the department of psychiatry at Einstein Medical Center, Philadelphia.

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