From the Editor
Last week, the Senate voted 52 to 29 in favour of Bill C-45, clearing the last hurdle for marijuana legalization. The federal government is aiming for implementation in the fall.
So, what now?
In the first selection, the University of Toronto’s Tony P. George et al. discuss a “framework” for cannabis policy post-legalization. This Canadian Journal of Psychiatry perspective paper is prescriptive, aiming to reduce the negative effects of the legal change. They make six recommendations, including a national strategy for education.
Also, in this week’s Reading, we consider the life and psychiatric contributions of Charles Krauthammer, who died last week at age 68. Dr. Krauthammer is best known for his political commentary, but he had a career in psychiatry before becoming a prominent essayist, and penned a classic paper on “secondary mania.”
Please note that there will be no Reading next week.
Cannabis and Public Policy
“Cannabis Legalization and Psychiatric Disorders: Caveat ‘Hemp-tor’”
Tony P. George, Kevin P. Hill, Franco J. Vaccarino
Canadian Journal of Psychiatry, 26 February 2018 Online First
Rates of cannabis use in Canada are among the highest in the Western world. Past year use among Canadian youth is estimated to be approximately 25%, with up to 28% of children aged 11 to 15 years reporting cannabis use, the highest rate among developed countries. Moreover, 43% of Canadians currently endorse lifetime cannabis use. In contrast, rates of cannabis use disorder (CUD) appear to be lower (∼2.0–2.9%) but may be increasing. The scientific literature suggests that people with mental health and addictive disorders have higher rates of cannabis use and CUD compared to the general population. While it is not clear whether chronic cannabis use is detrimental to physical health and may in fact have some modest benefits, cannabis use is known to be associated with lower motivation; problematic co-use of alcohol, tobacco, and opioids; and poorer psychiatric outcomes notably in people at risk for or with pre-existing psychosis and in people with mood and anxiety disorders. In Canada, the federal government is moving ahead with plans to effect the legalization of cannabis nationwide, which is scheduled to begin in July 2018. There are some notable potential benefits to this nationwide policy change, including a reduced burden on law enforcement and increased tax revenues. However, there are considerable concerns that the legalization of recreational cannabis use may be detrimental to vulnerable populations such as those with mental health and addictive disorders and to youth. It is also clear that more data are needed to assess the impact on these populations. Accordingly, the collection of such data before and after cannabis legalization is imperative if we are to understand fully any consequences of a national policy change such as cannabis legalization. Moreover, it is well known that children begin to first use cannabis during adolescence when most psychiatric disorders also have their onset. Furthermore, there is preliminary evidence that cannabis legalization in the United States may increase youth access; after legalization, Washington State experienced an increase in cannabis use among students in Grades 8 and 10 (cannabis use prevalence in Grade 12 students already exceeds 20%). This may be related to a reduced perception of cannabis risk, and therefore, efforts to increase knowledge about the risks of cannabis in the general public, and youth in particular, are of paramount importance. As such, this information would have clear implications for the mental health of young people. Moreover, in American states that have approved commercial sales of cannabis, rates of cannabis use and CUD have increased compared to states that have not approved commercial cannabis sales. This perspective article reviews the topic of cannabis legalization and psychiatric disorders (including substance use disorders) and provides a framework for clinicians and policy-makers to approach these concerns going forward.
Tony P. George
So begins a paper by George et al. They focus on six areas and make six recommendations:
A Clear Need for a General Population Education Strategy
While noting potential benefits of legalization including a reduced burden on law enforcement, they argue that “given the concerns about cannabis and pregnancy, brain development, and fetal and child well-being, there is a clear need for a strategy directed to children and their parents…”
Recommendation: Create a national strategy for public education about the benefits and risks of cannabis and its constituents based on the available evidence that promotes open and sensible conversations on the topic and ensures that such information is updated on a regular basis.
Limits on THC Potency and Clearer Product Labelling
Noting that others have called for product labelling, they comment: “the potential dangers as it relates to people with mental illness need to be clearly emphasized by mental health and public health agencies at local, provincial, and national levels.”
Recommendation: A robust program of public and physician education is needed about the risks of high THC products for youth and those at risk for or diagnosed with mental health conditions.
Minimal Age for Legal Recreational Cannabis Use
They note that brain development occurs into people’s mid-20s, and “increases in the legal age for alcoholand tobacco are associated with reduced prevalence and the mitigation of morbidity and mortality.”
Recommendation: Convene a national working group of physicians, scientists, and policy-makers to regularly review the scientific evidence and data on longitudinal health outcomes after legalization to provide guidance on adjustments to the legal age limit for recreational cannabis use.
The Need for a National Surveillance Strategy Before and After Cannabis Legalization
They argue: “There is much at stake here, and a pre-post legalization surveillance approach needs to be robust and comprehensive.”
Recommendation: There should be a system developed for the regular and accurate monitoring of health outcomes and cannabis use prevalence data, which can be used to inform subsequent evidence-based real-time policy decisions with respect to Canada’s cannabis legalization framework.
Developing an Enhanced Treatment Capacity for Problematic Cannabis Use Including Those With Psychiatric Disorders
They write: “Should rates of cannabis use, and CUD, increase after legalization, there will be a need to provide treatment to those who seek help for problematic use. Without further resources for this purpose, this will place an additional burden on the addiction (and mental health) treatment system.”
Recommendation: Investment of resources into treatment development and provider capacity building to provide meaningful strategies aimed at addressing problematic cannabis use is of critical importance to the health and well-being of Canadians.
The Role of Physicians in Endorsing “Medical” Cannabis and the Need for Provider Training
Though there is much commercial enthusiasm for legalization, the authors state: “evidence supporting the therapeutic effects of cannabis and its constituents (e.g., THC, cannabidiol) is developing, but to date, high-quality evidence for the therapeutic effects of cannabis is only present for chronic pain, neuropathic pain, and spasticity associated with multiple sclerosis…”
Recommendation: Provide robust medical education for physicians at medical school and postgraduate education and continuing medical education levels about the science of cannabis and its potential therapeutic effects so that physicians can provide evidence-based advice and care to patients wishing to use recreational and medicinal cannabis.
There are strong reasons to approach cannabis legalization cautiously, given that long-term mental health outcomes in Canada may be impacted. Canada already has one of the highest rates of cannabis use, and CUD, in the Western world, and the legalization of cannabis for recreational purposes may increase this burden.
A few thoughts:
- This is a good piece.
- Overall, the recommendations are thoughtful. People hold different views on legalization, and the authors of this paper clearly have hesitation based on their interpretation of the literature. But their recommendations should sit well with both sides of the larger debate.
- Since this was published in the winter, the debate has evolved (for example, on the minimal age). It should be noted as well that the federal government has already committed some money for awareness activities, such as drug-impaired driving. The 2018 budget includes additional money for marijuana education and study ($82.5 million over five years) – a good, if modest start. Still the central themes of their recommendations – education and research – are relevant today and moving forward.
- One point not made in this paper is the possible impact of different provincial implementation strategies (for example, with public vs. private cannabis stores). From a public-policy perspective, we could see ten plus laboratories of experimentation – adding to our ability to understand and learn from it, but also adding in the challenges of studying the full impact of legalization.
“Charles Krauthammer’s Quiet Contribution to Our Understanding of Bipolar Disease”
Daily Beast, 21 June 2018
Charles Krauthammer, the Pulitzer Prize-winning columnist at The Washington Post, died Thursday afternoon from cancer.
While best remembered for his thoughtful essays in many of the country’s top publications, Krauthammer’s first career was as a physician—one that, while short-lived, deeply influenced his prose and approach and was, by all accounts, groundbreaking.
It wasn’t easy, however. During Krauthammer’s first year at Harvard Medical School, he had a devastating accident, the type that might have stymied many people from pursuing a career. Jumping off a diving board, his spinal cord got severed at C5. Krauthammer proceeded to spend 14 months in the hospital. It was an accident that confined him to a wheelchair, but one that he rarely discussed.
He simultaneously attended school, graduating on time in 1975 with a degree, then pursued a residency in psychiatry at nearby Massachusetts General Hospital, earning the top spot of chief resident his final year.
That year turned out to be an important one that would establish Krauthammer as someone who not only had a voracious capacity for learning but also a unique sense of discovery.
So begins a short essay on Dr. Krauthammer.
She notes several contributions to psychiatry.
- “In November 1978, Krauthammer and his co-author, Gerald Klerman, published a paperin the Archives of General Psychiatry, in which they identified that what was at the time called ‘mania’ could actually be indicative of other mental disorders. This “secondary mania,” as he called it, was a variant that was distinct from bipolar disorder, something that could eventually signal dementia in older adult…”
- “The following year, Krauthammer published again, this time a deep dive into the epidemiology of bipolar disorder.”
- “His innate fluency with words and his knowledge of psychiatry made him a natural contributor to the third edition of the Diagnostic and Statistical Manual of Mental Disorders, which had published a couple editions by then, categorizing mental disorders and their neurobiological symptoms.”
In a time when mental illness had yet to achieve public-health recognition and was still viewed through heavy handed stereotypes… Krauthammer’s recognition of the disease as a fundamental neurochemical imbalance was unusual and striking.
A few thoughts:
- This is a good essay.
- Dr. Krauthammer is best remembered for his political commentary and for his time as a speech writer to US Vice President Walter Mondale. But before there was a Pulitzer Prize, and before there was his nationally-syndicated column and time in the White House, he was a psychiatrist. It’s worth noting that he suffered his catastrophic injury – leaving him as a quadriplegic – after his first year of medical school. He completed the rest with his disability, and then went on to complete his residency in psychiatry.
- “Secondary mania: manic syndromes associated with antecedent physical illness or drugs” is a classic. You can find its abstract here: https://www.ncbi.nlm.nih.gov/pubmed/757997.
- This essay notes Dr. Krauthammer’s academic work in psychiatry. He was also active in the debates of the 1970s, perhaps most famously challenging Thomas Szasz, the psychiatrist who championed strong anti-psychiatry views. In a New Republic essay, he begins: “Like the atheist who cannot stop talking about God, Thomas Szasz cannot stop talking about psychiatry.” The essay is worth remembering for that sentence alone. And though time has passed and Dr. Szasz has faded from memory, the overall criticism of anti-psychiatry remains relevant.
- For a consideration of his political views – a Mondale speech writer turned neoconservative turned voter who didn’t support either presidential candidates in 2016 – see The New York Times obituary, which you can find here: https://www.nytimes.com/2018/06/21/obituaries/charles-krauthammer-prominent-conservative-voice-dies-at-68.html.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.