An honest perspective on Cannabis in therapy
I enjoyed Dr. Nasrallah’s editorial “Maddening therapies: How hallucinogens morphed into novel treatments” (From the Editor, Current Psychiatry. January 2017, p. 19-21). In this world, physicians still regard “street” drugs as issues of morality and criminality rather than a health issue, so it is refreshing when respected physicians take fearless, evidence-based approaches to potential therapeutic use of such drugs. Dr. Nasrallah did not glorify or condemn their effects; he simply described them.
As a psychiatrist specializing in bipolar and psychotic disorders—as well as the founder and Board President of Doctors for Cannabis Regulation—I appreciate his reservations about the potential of Cannabis to trigger psychosis in vulnerable individuals. My reading of the literature is there is good evidence for marijuana as a trigger—not as a cause—of the disease. However, what is the evidence for hallucinogens?
Cannabis can have adverse effects on brain development, but it is not clear whether those effects are worse than those caused by alcohol. In the absence of any head-to-head studies, how can we proceed?
David L. Nathan, MD, DFAPA
Clinical Associate Professor
Rutgers Robert Wood Johnson Medical School
Director of Continuing Medical Education
Princeton HealthCare System
Princeton, New Jersey
Dr. Nasrallah responds
LSD can cause psychosis, paranoid delusions, and altered thinking in addition to vivid visual hallucinations in some individuals but not all, because vulnerability occurs on a spectrum. I postulate that the recently discovered inverse agonist of the serotonin 5-HT2A receptor, pimavanserin (FDA-approved for visual hallucinations and delusions of Parkinson’s disease psychosis), might be effective for LSD psychosis because this hallucinogen has a strong binding affinity to the serotonin 5-HT2A receptors.
Studies show that marijuana can induce apoptosis, which would adversely affect brain development. Patients with schizophrenia who abuse marijuana have a lower gray matter volume than those who do not abuse the drug, and both groups have lower gray matter volume than matched healthy controls. I strongly advise a pregnant woman against smoking marijuana because it could impair the fetus’s brain development.
Henry A. Nasrallah, MD
Professor and Chair
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine
St. Louis, Missouri
Self-administering LSD: Solution or abuse
Dr. Nasrallah’s editorial (From the Editor, Current Psychiatry. January 2017, p. 19-21) gave an interesting update about the potential therapeutic uses of LSD. However, he did not mention the growing self-prescribed usage of microdoses of LSD, which is said to reduce anxiety and depression with less risk than usual dosages.
H. Steven Moffic, MD
Retired Tenured Professor of Psychiatry
Medical College of Wisconsin
Milwaukee, Wisconsin
Dr. Nasrallah responds
I am not aware of any systematic data about self-prescribed use of microdoses of LSD to reduce anxiety and depression. Among persons with anxiety and depression who have not had access to psychiatric care, self-medicating with agents such as alcohol, stimulants, ketamine, or LSD is regarded as substance abuse. It also is questionable whether people can determine which microdose of LSD to use. Finally, most drugs of abuse are not “pure,” and many are laced with potentially harmful contaminants.
Henry A. Nasrallah, MD
Professor and Chair
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine
St. Louis, Missouri