The Kenosha Trial

 

I watched the Rittenhouse trial closing arguments on 11/15/2021.  Let me preface these remarks by saying that this post is not a commentary on the guilt or innocence of the defendant.  It is not a commentary on his behavior, speech, or mental status.  It has absolutely nothing to do with psychiatric evaluation or treatment. This post is all about common sense and how that has been suspended in the United States - especially over the past 10-20 years.

This post is about open carry laws in the United States. Open carry laws make it possible for people to carry firearms publicly without risk of arrest or search for merely having possession of those firearms. The original intent of these laws was to reduce the risk to hunters and target shooters when they were transporting their firearms home.  There are still regulations in many states about how those firearms need to be transported but the original open carry laws were to make sure that there was not a problem carrying the firearms to the home where they would be stored.

Over the past 10 years, we have seen a striking change in how firearms are carried in public and it is the direct result of these open carry laws. The most striking change has been the appearance of heavily armed men open carrying military style semi-automatic rifles and handguns. They were also often wearing bullet proof vests, body armor, and helmets. In some cases, they were also disguised so that their facial appearance was obscured.  Some of these groups were self-identified as militias or paramilitary groups.  Militias always have a sacred role in firearm debates in the United States because when the Second Amendment was written and approved 230 years ago – this was the wording:

“A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.”

The Second Amendment is interpreted unambiguously by gun advocates as a Constitutional right to own firearms and the most open interpretation is firearms of any kind and as many firearms as a person wants.  The sheer number of firearms possessed by Americans is a matter of public record available in many places so I do not plan to repeat it here. Record gun violence in the United States is also a matter of public record due to suicides, homicides, and accidental deaths.  The United States also has record number of mass shootings each year that can also be found in the public record and I will not repeat it here.   

For now, I want to briefly focus on the concept of militia and the idea that it is well regulated.  Militias are defined as able bodied residents between the ages of 17 and 45 years old who can be called to defend a specific state or the United States.  Private militias acting outside of the federal code definition are illegal.  That includes all groups who are not called to duty by a state governor or the federal authorities.  Even if these groups appear to be uniformed and operating under some command structure, they are illegal organizations.  All 50 states prohibit private militias from doing what state authorized militias do.  They are also prohibited from engaging in paramilitary training and in some states brandishing firearms in a way that it could be construed as threatening. Apart from these laws about militias, states also have terroristic threat statutes, and statutes that restrict firearm access to anyone with a history of domestic violence. There is a patchwork of additional law regarding background checks, safe storage of firearms, and collecting statistic data on firearm violence.  There is a currently a loophole in background checks because unlicensed private gun sellers are exempt from conducting background checks on potential purchasers.    

For at least 20 years, gun advocates and lobbyists have pushed open carry and concealed carry laws to the point that they are both unnecessary and a threat to public safety. There is no better example than when groups of private militias or heavily armed private citizens show up at public events or protests. History illustrates that these events can lead to confrontations, injuries, and even deaths when they are managed by law enforcement or the state militia – the National Guard. Is it realistic to think that untrained private citizens or illegal militias will do a better job?  Is it reasonable to have open carry laws on the books so that these individuals or groups can potentially function in a number of ways that contradict other laws about assuming police functions or threatening other citizens?

The only logical conclusion you can come to is that both heavily armed private citizens or unregulated militias with a stated purpose of assuming the function of well regulated militias or law enforcement have no standing at all and are much more likely to add more heat than light to the situation.  They knew that in Tombstone, Arizona back in 1881, when they passed the ordinance at the top of this post. This ordinance (in one way or another) precipitated the Gunfight at the OK Corral. We need to recognize that heavily armed citizens roaming around in our communities is unnecessary and a recipe for disaster.  Open carry laws need to be rolled back to 1881 or about 130 years after the Second Amendment was passed.

I anticipate plenty of blowback about that opinion. My only goals are public health/public safety and preventing both unnecessary deaths and the kinds of confrontations that led to this trial in Kenosha. I also wanted to get this opinion out there before there was a verdict by the jury, because at that point those opinions on what happened will fall along partisan lines. Few people seem to recognize the seriousness of this issue – both in terms of the high personal and financial cost of gun violence – but also the destabilizing effect it has on the country.      

I also realize that there is a sense of hopelessness in the United States that we will ever have sensible firearm rules resulting in safer communities.  For a generation there has been a massive misinformation campaign about gun rights. It is possible to have a Second Amendment the way it is written and have safer communities.  Rolling back open carry laws is the place to start. 

 George Dawson, MD, DFAPA

 

References:

Transcript Prosecuting Attorney Closing Remarks

https://www.rev.com/blog/transcripts/kyle-rittenhouse-trial-prosecution-closing-statement-transcript

 

Transcript Defense Attorney Closing remarks

https://www.rev.com/blog/transcripts/kyle-rittenhouse-trial-defense-closing-statement-transcript

 

Supplementary 1: (posted on 11/19/2021 @ 12:49 PM):

I just saw the news that the defendant in this case was found not guilty on all charges.  Staying with the theme of this post that verdict is all the more reason why open carry laws need to be rolled back. I expect the usual posturing about the need for firearms to be used for self protection, but the public health issue remains - people bringing firearms to public gatherings or even to the local supermarket is a setup for violent confrontations and their outcomes. I encountered a statistic today that armed demonstrations are six times likely to turn violent than unarmed demonstrations.  If physicians and their professional organizations don't feel they can change the law - they can advocate for common sense measures and provide the supporting data.  Primary prevention of gun violence needs to start long before there are any court proceedings. 

Supplementary 2: 

I recalled today that I took an NRA Hunter's Safety Course when I was ten years old in a remote northern part of a state.  That course was taught by a military veteran who vetted us before we could even get in to the course.  He made us promise that we would no longer play with toy guns.  The main rule of the course was "Never point a gun at another person whether you think it is loaded or not."  Somewhere along the line that rule seems to have been lost by modern gun advocates. 

What is Psychotherapy and What’s in A Code?

 

After a recent discussion about psychotherapy done in psychiatric treatment – I decided to write this post in order to capture the complexity of some of these sessions. I hope that this post serves multiple purposes including a demonstration about how business management affects psychiatric care and the range of services that people receive in psychiatric follow up appointments. The audience for this post will be people seeking psychiatric services, psychiatrists of all orientations, and anyone interested in quality psychiatric care.

The fundamental unit of psychiatric care comes down to what tasks need to be completed in a set time frame and there are a lot of variables. Rather than list those variables – it is probably easier to describe a limited or rationed task scenario and compare that to an abundant task scenario.  Most peoples experience with psychiatrists in the US will fall somewhere between the extremes.  From a scheduling perspective there are no assurances that what a patient needs on a particular day will be the session they are scheduled for.

In the most limited care, the patient is seen for follow up or “medication management”.  These visits developed as part of a coding scheme that suggested that psychiatrists could see patients for very brief (5’-15’) periods of time with an exclusive focus on the medication a person was taking, whether it was effective, and whether they were experiencing any side effects. To speed up the process, many clinics have templates that are rapid checklists of symptoms and side effects.  In some cases, as the patient speaks the psychiatrist is checking off items on the list so that at the end of the session, a couple of sentences can be typed and the note is complete. Depending on the setting, additional information that might be acquired in the rooming procedure during a standard medical appointment (like pulse and blood pressure) may or may not be collected. Before psychiatrists started using standard billing codes like the rest of medicine, there were codes that assumed this limited care could be completed in anywhere from 5’-15’.  As far as I know - no other medical specialty had codes that were as restrictive.  In some clinics patients would be seen for that period of time every 6 months.  That duration and frequency of medication focused visits might work well for some people, but there is an understandable concern about quality when it is applied on a population wide basis. That concern is amplified where patients have more medical and psychiatric complexity (high risk for medical or psychiatric complications).   

At the other extreme, a psychiatrist may see a patient for 30-60 minutes in follow-up. A psychiatrist who typically sees people for 30 minutes would review the efficacy and side effects of any psychiatric medication.  They also may cover more medical or neurological considerations and following another condition like the patient’s problem with hypertension, diabetes, or neurological conditions.  In the remaining time, there is a detailed discussion with the patient.  In the case of a 50'- 60’ appointment, the psychiatrist is most certainly providing psychotherapy in addition to medical treatment. They may be providing psychotherapy exclusively.  Standard billing codes can be used, there are also psychotherapy add on codes and a separate psychotherapy code. Over the years, a lot has been written about the financial incentive for seeing many more of the briefer visits per hour than longer sessions involving psychotherapy. Practice setting tends to be the overriding factor.  If you are employed in a clinic or hospital, there is some administrator telling you how many people you need to see in a day.  That number is referred to as physician productivity.

There is a lot of confusion about what constitutes psychotherapy. At its core, psychotherapy is a teaching experience where the therapist attempts to assist the patient in solving problems that complicate their psychiatric disorder or affect their ability to adapt to life situations.  That can cover a lot of ground including inflexible thought patterns, stressful relationships and current or past stressors. It can also be a very focal problem that might require some directive education like sleep hygiene, diet, and exercise modifications. The teaching needs to occur in the context of a relationship that is both empathic and collaborative.  That collaboration is often referred to as the therapeutic alliance to indicate that the physician/therapist and the patient are aligned to focus on and resolve a mutually agreed upon set of problems. The common view of psychotherapy is that it needs to be long in duration and that the therapist “analyzes” the patient during that time. That description comes from psychoanalytic therapy that is a very specific therapy done be relatively few psychiatrists and it does not represent most of the brief psychotherapy done in treatment sessions.

There has not been a lot of study of psychotherapy in psychiatry in the real world. The best single study by Mojtabai and Olfson (1) and it is the most often quoted.  The most notorious quote is:

“ …..third-party reimbursement for one 45- to 50-minute outpatient psychotherapy session is 40.9% less than reimbursement for three 15-minute medication management visits.”

That led to the expected provocative articles about psychiatrists abandoning psychotherapy or being too motivated by money.  The reality of what it takes to keep a practice open in the face of paltry reimbursement was never mentioned. Some articles got so extreme they called for the end of psychiatry, replacing the greedy psychiatrists with therapists trained to prescribe. The authors of the article provide a much more balanced perspective including their opinion that many psychiatrists were still providing some kind of therapy and that their measures of what constituted therapy may have undercounted the therapy provided.

Polarized viewpoints of what actually occurs when a psychiatrist sees a patient probably described very little of what happens in real life sessions. From working in various settings with psychiatrists of three generations, there are many styles of practice and how psychotherapy is integrated – even into very brief sessions.  I was fortunate enough to work with a psychiatrist who ran a clozapine clinic and a separate clinic for long-acting injectable medications.  Both clinics were probably the largest in the state. He would typically see people in 20’-30’ appointments based on the complexity of the care they needed on that particular day. He was an expert in psychopharmacology and medicine as it applied to that patient population. But more than that he was empathic and knew the relevant life details of all of his patients. There was obviously a high degree of patient satisfaction and engagement in treatment.  One of the obvious markers of his success was patient interest in this physician after he made a career change.  His former patients would approach me in the hallway and ask me how he was doing or if I had heard from him. They would talk about him in the most positive terms. I don't recall seeing that happen with any other psychiatrist who moved on.

Papers on the minimum time needed to provide a psychotherapeutic encounter have been written for the past 40 years now. With the advent of managed care – many of them emphasize how the rationing aspect has reduced the time for both verbal and medical interventions. The latest guidelines for residency training emphasize the need to learn psychotherapy but beyond advanced interviewing techniques cognitive behavioral therapy or CBT seems to be the predominate paradigm – even though residents are still exposed to a variety of paradigms from their supervisors and mentors. 

The best single paper I have found that describes the psychotherapeutic aspect of medical treatment within the confines of a “medication management” session and its considerable constraints was written in 2018 (2).  The authors argue for the need for a human-to-human connection consistent with the existential orientation in psychiatry in order for treatment with medications to work.  The main features described are empathic listening and alliance building. One of the primary ways they are realized in the sessions is a focus on the patients own description of the problems or progress. 

As I read through this paper, I realized that I had been conducting outpatient visits in this manner over the course of my career but that nobody had previously described it in these terms or suggested why it had been so successful.  But even as I read this brief paper – I realized that the description was incomplete. It did not describe the many active psychotherapeutic interventions that I had used over the years.  I learned most of them as supportive psychotherapy in residency and they include interventions that would now be described as behavior therapy, cognitive behavioral therapy, and brief psychodynamic therapy and they all happened in the constraints of brief sessions that were generally 20-30 minutes long – in addition to whatever I needed to cover about the medications and other medical conditions.

These 20’-30’ sessions are currently No Man’s Land in the field of psychiatry. It is easy to extremely pessimistic about them.  As I previously noted they can be a political football – since any bias can be projected onto them. That is probably why there has been so little research in the area. It is as if the managed care and CMS template for these codes is an inescapable reality. Everything on the template is all that occurs in one of these sessions. I would propose a thought experiment to counter. If you are a psychiatrist seeing patients in these sessions and billing these codes – do you cover more information than what is in the bullet points for these sessions? Is the patient predictable from session to session – is more lengthy clarification needed? Are there any sessions where the entire session has very little to do with medications?  Are there any sessions dedicated to crisis intervention and only verbal interactions about that crisis? Do you see family members during these sessions and discuss their concerns? When you assess whether a person is experiencing suicidal thoughts do you know how to discuss them in a therapeutic manner?  If the answer to any of these questions is yes – it is highly likely that some form of psychotherapy is happening – even if you do not consciously pull up a psychotherapy technique that you learned and used in the past.  That psychotherapy happens whether you decide to record it on a template or not.

I think this area requires a lot more study. The information transfer between two people that can occur in 20’-30’ minutes is vast – even if it is semi-structured. The first step is determining what really happens in these brief sessions.  If anyone does that study, I think we will find out that the treatment that happens is much more than medication management.

 George Dawson, MD, DFAPA

 

References:

1:  Mojtabai R, Olfson M. National trends in psychotherapy by office-based psychiatrists. Arch Gen Psychiatry. 2008 Aug;65(8):962-70. doi: 10.1001/archpsyc.65.8.962.

2:  Ghaemi SN, Glick ID, Ellison JM. A Commentary on Existential Psychopharmacologic Clinical Practice: Advocating a Humanistic Approach to the "Med Check". J Clin Psychiatry. 2018 Apr 24;79(4):18ac12177. doi: 10.4088/JCP.18ac12177.

Graphics Credit:

Photo by Eduardo Colon, MD

 

When did Asylum Directors and Alienists Become Psychiatrists?

 

I am very interested in the answer to this question.  Readers of this blog will recognize the timeline (click to expand) at the top of this post as one I originally did to disprove any connection between psychiatry and drapetomania.  Several books and about 20 papers later, I am very interested in knowing more about this transition.  When the Association of Medical Superintendents of American Institutions of the Insane (AMSAII) was founded in 1844, there were only 13 Asylum Directors at that time. There was no formal education.  After completing medical school, physicians either spent some time working in an asylum or announced their interest and were appointed to these positions. In some cases, sons followed fathers into these positions after they attended medical school.  There was no residency training at that time.  Over time, additional physicians were employed at asylums but there was still no formal psychiatric education and none in medical school.

The American Medico-Psychological Association (AM-PA) was founded in 1892 primarily to accommodate the increasing number of asylum physicians who were not directors.  This organization began publishing the American Journal of Insanity in July 1844 and it was continued until May 1943 when it became the American Journal of Psychiatry.  The AM-PA transitioned to the American Psychiatric Association in 1921.  Between 1880 and 1920 there was a journal Alienist and Neurologist that I am using as a proxy for alienists in the US.  The literature at the time reflects the use of both terms (alienist and psychiatrist) in the same literature – even though the term psychiatrist was coined by Reil in 1808.

So the questions remain.  How did this transition between asylum directors, alienists, and psychiatrists occur?  When did modern psychiatric training start? Another indicator is the early establishment of psychiatric hospitals and clinics.  I recently added the New York State Psychiatric Institute (NYSPI) and Johns Hopkins to the timelines for establishing education and research program in 1895 and 1913 respectively. Johns Hopkins is considered to have established the first residency programs in Internal Medicine, Surgery, and Gynecology in 1889.  The Phipps Clinic opened at Johns Hopkins in 1913 under the leadership of Adolph Meyer.  It was described by Shorter as a German-style psychiatric clinic. I was having some difficulty getting adequate documentation on the first residency programs in psychiatry until today.    

Today I got the first solid information on psychiatric residents from NYSPI.  In July of 1930, there was an initial reference to 3 psychiatric “internes” being appointed. I was very grateful to receive that information from a colleague on Twitter who was kind enough to ask an archivist at this institution about this information.  The American Board of Psychiatry and Neurology was formed in 1934 so there were probably several residency programs at that time.

If you are a residency director, archivist or historian for a large medical school program and have similar information on the first residency program at your institution – I am very interested in hearing about it and will place your program on the timeline.

I am also very interested in the actual numbers of asylum directors, alienists, and psychiatrists at all points in time across the span of this timeline.  I have very accurate information for the past several decades.  I am very interested in any historical information on how the numbers of these subgroups varied in the late 1880s to mid 1900s.  I appreciate any data that can add to this timeline.

 

George Dawson, MD, DFAPA  

Shorter E.  A History of Psychiatry.  John Wiley & Sons; New York; 1997: p 111.

The problem with inpatient units…

 

Why are many psychiatric units in the United States such miserable places?  That question came up today on Twitter and there was a consensus by the responders.  It is a chronic question that comes up episodically and there are never any good formulations or solutions. I started working on an inpatient unit in 1988 after three years as the medical director of a community mental health center. At the mental health center, I travelled twice a week to an inpatient unit in a small town where I provided the only psychiatric coverage. Without those visits the inpatient unit would have closed. The new position was at an acute care hospital that accepted all of the emergency psychiatric admissions on the east side of St. Paul, Minnesota.  I was on the unit that accepted the most aggressive patients triaged through the emergency department. Over the next 22 years, a number of factors came into play that made that job impossible to do and resulted in my resignation and moving on to an outpatient job. What follows are my observations about what went wrong.     

1:  Management is strictly on a financial basis with minimal to no psychiatric input and no consideration of quality care.  That means administration typically has no expertise in managing the environmental aspects of care apart from blaming inpatient psychiatrists for any complications that occur. The most glaring deficiency is management of violence and aggression.

When I first started out – there was a psychiatrist who headed the department and set all of the administrative policies. There was a business manager who reported to the head of the department. With the advent of managed care, financial managers replaced psychiatrists as department heads and set administrative policy.  The only variation on that theme is a psychiatrist who carries out administrative decisions from the managed care company administration. The expectation is that the psychiatrists working on inpatient units have minimal to no input on administrative decisions that affect them. There is no discussion of the multiple failed administrative policies from business administrators.

2: Financial management dictates that the admission indication and reason for ongoing care is dangerousness loosely defined as a danger to self or others.  Reviewers aligned with the financial interests of the insurance company make this determination using proprietary guidelines by looking at documentation.  At their discretion they can stop payment for any patient who they determine is not dangerous or suicidal enough to be treated on an inpatient unit. That patient is often immediately discharged.

The clearest sign of failed policy from financial administrators is the current standard for inpatient care. That indication is dangerousness. That means a reviewer can say at any time that a patient will no longer be funded because they are no longer dangerous. This criterion is problematic at many levels. First, it is an inappropriate admission standard that makes it more difficult to assess people in the emergency department. Most people in need of psychiatric admission are in distress but not dangerous. It is not appropriate to turn them away if nothing has been done to alleviate their distress.  Second, dangerousness is stigmatizing and perpetuates the myth that people with psychiatric problems are dangerous. Third, there is no objective way to draw a clear line on a day-to-day basis in order to make a rational discharge decision.

3:  As a direct result of #1; aggressive patients are often triaged to the 5-10% of community hospitals in each state that might be able to contain aggression.

This only applies to states with multiple psychiatric hospitals and in some states that is not true.  Even in states with multiple community hospitals, only a minority of those will have psychiatric units. A select few will admit and treat highly aggressive patients. The reason again is financial. It requires specialized and more intense staffing that costs money.

4:  Length of stay (LOS) is short (3-5 days) to optimize profits.

One of the most perverse incentives are DRG payments. The theory is that the average cost and LOS for a specific diagnosis can be estimated by a group of experts. To financial managers that means, the patient must leave by that duration or less and less is much better. During my tenure in acute care reviewers would call me demanding to know “where is the dangerousness?” that necessitated ongoing inpatient care. Carefully explaining that the patient was not stable enough to function outside of a hospital did not count.  As time went by and managed care companies acquired hospitals this review process was internalized. Inpatient psychiatrists now faced case managers in their team meeting who were basically acting like external reviewers. That impacted not only patient care but the morale and enthusiasm of the inpatient team.

5:  The units are managed to keep all of the beds full irrespective of patient need and there are no private rooms.  This often leads to very incompatible roommate and one of them wanting to leave as a result.  The ability to admit patients is often out of the control of the psychiatric staff and is run by administrators.

Since all inpatient psychiatric beds are rationed in the US and kept at an artificially low aggregate number, these beds are at a premium. In any large hospital the emergency department, the consultation liaison teams, and psychiatric outpatient clinicians are all competing for bed space.  From the minute inpatient psychiatrists arrive in the morning they are pressured to discharge people.  The triage system for admissions is often out of control of the psychiatrists. That results in room mate mismatches and patients not being admitted to their desired specialty units. In both of those situations the inpatient staff and psychiatrists have to address the resulting complaints from patients and families including frequent demands for discharge because of these problems.

6:  Patients are discharged before they are stable to optimize profits.

Severe psychiatric problems rarely respond adequately to treatment in 3-5 days. No medication or psychosocial therapy works that fast. In order to meet the artificial time constraints people are treated aggressively with medications – increasing the risk of side effects.  The ability of the patient to care for themselves in a stable environment is less of a priority.

7:  Many inpatient environments are markedly deficient relative to medical/surgical units (less modern, poor air quality, more crowding, different food service)

This may be changing to some extent with the continued closure of inpatient units. Many of them are dated facilities.  In hospitals where medical surgical patients have private rooms that may not exist on psychiatric units.  In hospitals where there is an ala carte food service for medical surgical patients those choices may not exist on inpatient psychiatric units.  There are many rationalizations for these discrepancies, but when you see the glaring deficiencies in person there is clearly a lack of equal treatment.

In addition to the lack of privacy, practically all acute care units in the US are locked. That certainly reduces the elopement risk and may be necessary from a legal standpoint for involuntary patients, but it is possible to have more liberal policies and allow people off the ward for exercise and passes with their family or friends.  Some research suggests that people may do better on an unlocked unit. The overriding financial oversight comes in to play - with many companies saying that if a person doesn't need to be on a locked ward they don't need to be in a hospital.  Another variation on the dangerousness theme. 

8:  Follow up care is typically lacking in availability and intensity.

For a lot of people, quality inpatient assessment and treatment is their one good shot at stabilization and adequate care. There are many people who have severe mood disorders, bipolar disorder, episodes of psychosis, and postpartum mental illness who have never been stabilized on an outpatient basis. Many have been ill for decades.  Adequate inpatient care can make a significant difference but it will not happen in the span of 3-5 days.  Once adequate care has been established, follow up care is a problem. It is more of a problem if the patient is forced to leave before they are stabilized.

9:  Some units have a disproportionate number of involuntary patients undergoing civil commitment. If committed they may face a very long LOS waiting for transfer to a state hospital in a unit that was not designed for long term care.

The most obvious deficiencies of an inpatient unit come into the light when a patient ends up stranded there for a month or two. They start to experience the cramped quarters and lack of leisure time activity as imprisonment. There has been no work done on how to redesign units for people who have to remain there for extended periods.

10:  Even though substance use disorders are a common comorbidity – they are often seen by the insurance company as a reason for immediate discharge from a psychiatric unit, even when relapse is imminent, it is a life-threatening problem, and no residential beds for the substance use disorder are available.

Insurance company reviewers often insist that patients with severe depression and alcoholism or some other substance abuse problem be discharged the next day. That can even occur if the patient was exhibiting suicidal behavior while intoxicated.  Appropriate detoxification and adequate treatment were not a priority – only the reviewer’s idea that the directly observed suicidal behavior was due to acute intoxication. Most inpatient units do not have immediate access to substance use treatment facilities and it is imperative that these patients are detoxed and stabilized prior to discharge. Business and financial pressure backs up all the way through the psychiatric unit to the emergency department where the message becomes – “people with substance use disorders should not be admitted to psychiatric units.”  This can result in high-risk home detox scenarios and continued relapse with less chance of recovery.  Some counites have "non-medical detox" that patients are transferred to.  They are sent back to the hospital in the event that they have continued significant detox symptoms and may be admitted to a medical service or intensive car unit at that time. 

11:  There is often minimal to no contact with the outpatient staff who were treating the patient prior to admission.

Many outpatient psychiatrists are very cynical about inpatient care. First, they have no control over admissions. They may know inpatient colleagues but realize that it is futile to call them in order to admit one of their patients. They have to tell the patient to go to the emergency department and get assessed for admission. Second assuming that goes well – inpatient staff often do not have the time or energy to consult with outpatient docs about the plan. Finally, they receive many of their patients back who have not improved, are still in crisis, but are now taking higher doses of medication. They typically do not get discharge summaries or other paperwork form the hospital including the discharge medications. 

12:  There is often minimal communication with the family and federal privacy regulations are often given as a reason.

Acute inpatient care is often associated with a family crisis and family members want communication with inpatient staff and the inpatient psychiatrist. Work intensity on the inpatient unit along with staff burnout often results in either a lack of communication or a perceived lack of caring by the family. That can add more conflict to the treatment environment.

13:  The psychiatrists working in these settings have an intense work load and get minimal administrative support. In many cases there is a policing attitude on the part of administrators rather than an affiliative effort.  The psychiatrists are policed on the basis of productivity, LOS, and complications – none of which are under their control.  Staff splitting often occurs because of siloed administration that is commonly used by administration to elicit criticism of specific staff psychiatrists.

Instead of being treated like valuable experts with acknowledged expertise, inpatient psychiatrists are treated like production workers. Administrative staff make decisions that lead to the environment seriously deteriorating and often manage that by becoming more authoritarian and rigid.

14:  Medical coverage is not standardized and emergency department triage is often not enough.

Medical coverage varies greatly depending on the hospital and staff availability. Psychiatrists may not ever touch a patient in some settings or in the case of my inpatient unit – they may be responsible for the complete medical and psychiatric care of the patient.  In some settings there are free standing psychiatric hospitals where ill patients have to be sent by ambulance to an emergency department. In other hospitals there is complete access to all medical and surgical specialties.  In recent years another managed care innovation – the hospitalist has come to inpatient psychiatrist units. That basically means the same psychiatrist works 7 days shift on and 7 days off. Medical coverage is still contingent on local conventions. I have not seen it formally studied, but interviewing Internal Medicine hospitalists left me with the impression that cognitive performance dropped off significantly after 5 days.

Whoever is working the acute care units as a psychiatrist the risk for unrecognized physical illness and destabilized medical problems is always very high. In a chaotic, stressful, unpredictable environment a psychiatrist needs to be at the top of his or her game.

15:  There is intense regulatory interference at all levels.

It is often not obvious that all of the factors I am mentioning here are the direct result of government intervention. The federal government invented the rationed managed care system and early in this century turned the reins over to the insurance industry. It is the single largest conflict of interest interfering with quality care in psychiatry today.  Managed care alone is responsible for many inpatient psychiatric units closing. State sponsored units are rationed on the same principles by human services departments. Both have resulted in a large influx of psychiatric patients into jails where most people do not receive adequate care. Further initiatives like regulating the number of ligature points on an inpatient unit have resulted in further unit closures.

16:  Staff turnover:

It takes a mature and often experienced person to work on an inpatient psychiatry unit – irrespective of their profession. The best inpatient units are held together by a team of psychiatrists, nursing staff, social workers, and occupational therapists. I am convinced that I have worked with some of the best folks from all of those professions. But being the best and being mature enough to be empathic with a unit full of people in extreme distress is not enough. The staff have to be supported and given what they need to be successful. Without that support crises start to happen among the staff. How does that look?  It looks like a social worker who has spent all day on the phone calling 25 nursing homes in order to get a patient placed and being told that they are not doing enough and need to work on placing other patients.  It looks like nursing staff having complex patients taking care of too many patients with high acuity and complicated medical problems with not enough staffing. It looks like nursing assistants being falsely accused of wrongdoing and not being supported.  It looks like various staff members experiencing homicidal threats and nobody knowing what to do about it. Those are just a few examples of what leads to staff turnover.

The staff I worked with knew that we were short of resources. They did everything they could to make the environment more supportive for patients and families. At the Christmas Holiday the occupational therapists would organize a celebration and every patient there got a present and was able to participate. Nursing staff organized a used clothes closet so that patients could be resupplied with clothing if necessary. In some cases we raised cash and transportation on the spot for patients who were leaving abruptly, had no way to get back home, and had no money to buy food.  The inpatient staff is a significant human resource but they can’t compensate for decades of rationing and the irrational polices that play out on their units every day.

17.  Competing forces that increase length of stay that are never addressed by managed care companies:

There are many. The most obvious are probate court polices that affect patients being treated on an involuntary status. Any probate court procedure adds about 2 weeks to the length of stay in the place where I worked.  During that time the patient had no obligation to follow treatment recommendations. That could allow any insurance to refuse payment based on the fact no treatment (apart from containment and psychosocial therapies) was being given.  That creates a number of pressures from administrators and an associated bed shortage. If civil commitment does occur that patient may be waiting for weeks to months for transfer to a state hospital. A more proactive approach in this situation would be to do the hearings on an outpatient basis in the context of community treatment.  I never saw that happen.

Many patients need a therapeutic environment to be discharged to.  They are either homeless or not able to function well enough for independent living. The responsibility of insurance and managed care companies ends at the hospital door. If the inpatient staff cannot find a suitable county or charity funded setting many of these patient are discharged to the street.

Even standard discharge planning to an outpatient clinic can be a problem. Many organizations use a guideline that the patient must be seen in clinic 1-2 weeks post discharge. It is difficult if not impossible to get those appointments even if the inpatient unit and outpatient clinic are in the same organization.  In some cases the appointments are months out with no flexibility in the system to accommodate discharged patients.

All of the factors prolonging inpatient stays by delaying treatment or discharge magnify the pressure on inpatient staff.  Ineffective administrators who cannot negotiate contracts or other arrangements with these outside sources of inpatient utilization transfer that burden directly to the inpatient staff.  The only way to compensate is greater patient turnover and more admissions.  That typically is not possible and the inpatient staff are the obvious scapegoats.

18. Lower reimbursement for equivalent service.

In large metropolitan hospitals psychiatry is an invaluable service in terms of patient flow and discharge planning. Patients with overdoses on medical units and various injuries associated with their psychiatric diagnosis on surgical units – need to be rapidly assessed and transferred or discharged from those primary admitting services.  The emergency department needs to admit psychiatric emergencies to inpatient units. These processes are critical to the function of large hospitals.  Despite that fact, psychiatry is reimbursed at much lower levels for the equivalent amount of care provided by other services. This is an artifact of the long standing carve-out mentality of managed care companies.  In the 1980s they made a decision that psychiatric services were not like the rest of medicine and could be paid for by a separate and lower level of reimbursement. Some of my friends in other specialties, know this and they know that in a hospital setting the high margin services (generally proceduralists) transfer at least part of their profit to cover psychiatric services.  This could all be avoided with equitable reimbursement. Without it funding depends on this transfer of funds and generating as much turnover as possible on the inpatient units.

19:  Psychiatric units in hospitals are the only specialty services that are supposed to be all things to all people.

Most specialists have the luxury of admitting people with a fairly well-defined set of problems. Even if the people are diverse – their problems are not and that specialty service is set up to focus on that set of problems. In the case of inpatient psychiatric units – those rules no longer apply. If the patient has a significant medical or surgical problem and a significant psychiatric problem and the staff psychiatrist has no input into the admission decision – that patient may be admitted to psychiatry. As a result, there are a large group of patients on any unit with significant medical problems that are often acute and need close monitoring. Those problems can interfere with both the patient’s ability to participate in any available programming and also make is difficult to assess any treatment progress focused on their primary psychiatric disorder. The array of these problems can range from acute delirium to a terminal illness requiring intensive nursing care. Since psychiatric units are rarely designed, equipped or staffed to provide this level of care these situations place additional stress on the inpatient environment.  Managed care companies may deny reimbursement for this care on the basis that “the patient should be on a medical unit”.  But of course the medical unit sent the patient in the first place.

20:  Decades of admission avoidance has led to a non-functional admission procedure that is focused on hospital administration needs over outpatient staff and patient needs.

Many outpatient psychiatrists have complained to me over the years that it is impossible to get their patients admitted on a timely basis. On the inpatient side it makes complete sense since the inpatient units are managed to maintain full capacity, there is a chronic bed shortage, and the admissions are not in control of the inpatient psychiatrists. That means the only practical way to get a patient admitted is to send them to the emergency department.  That is true even if the outpatient psychiatrist has consulted with inpatient staff who agree with the admission.  The backlog in the EDs is legendary and there are rules in lace to send the patient to a remote hospital even if that hospital is hundreds of miles away.  There are very few people who want to be voluntarily admitted to a psychiatric unit and even fewer who want to be sent to a remote hospital. 

This conflict plays out in other ways.  In the case of patients with severe depression requiring electroconvulsive therapy (ECT) - they typically cannot be directly admitted and may have to go through the emergency department.  Patients with complicated detoxification related problems - like benzodiazepine detoxification prior to surgery with an associated severe psychiatric problem may not be admitted at all.  There are frequent conflicts about admission and discharge times, because the inpatient staff may end up working long hours (12-13/day) indefinitely due to the timing of the admissions and discharges. In some cases, a hospital may close down their bed capacity and divert all of their admissions to a nearby hospital to avoid this problem.  

21:  Admission Avoidance: This has always been a goal of managed care organizations on both the psychiatric services and medical side of the operation.  There has been a long series of interventions to try to compensate for what amounts to a lack of service and spin it in the most positive light.  About 25 years ago in the New England Journal of Medicine there was an article describing what were essentially crisis units that were supposed to divert potentially short stay psychiatric admissions and house them in a less intensive settings with psychiatric services.  Many counties have this kind of service that is paid for by the county so the cost has been shifted away from managed care companies or federal payers.  I recently attended a conference on a “new” model where a large open hospitable room and psychiatric services are provided. Each patient gets their own lounge chair (the photos I saw showed gerichairs).  There were no beds on the unit. Patients were expected to sleep in those chairs if they had to stay overnight.  Nobody on a 72 hour hold or requiring any significant degree of medical care would be admitted to this unit.  The expectation is that most people would be discharged in about 6-8 hours.  The only real difference from the ED is that patients had more immediate access to psychiatry staff and were not just sitting there waiting to be seen at the next transfer. I suppose some might see this as an innovation. I don’t think you can focus on what is needed on an inpatient unit and what those patients need if you are constantly focused on an artificial admission avoidance concept and putting resources into that.  If anything, it suggests that there are not enough staff and resources on inpatient units.

22.  There is a lack of collaboration with outpatient staff:  Good inpatient care proceeds from the assumption that the main focus of treatment is with the primary psychiatrist or treatment team. For me that attitude goes back to an attending physician I worked with as an intern on an Internal Medicine rotation. He let us know about the term “local MD” and why that was a pejorative. He pointed out that it was arrogance and assumed that the inpatient team who had brief contact with the patient knew more about the care of that person than the outpatient physician.  I did not have enough experience at the time to know one way or the other, but over the years have developed a nuanced view of the problem. But I have no doubt that the inpatient process needs to support outpatient care and that unilateral plans from the inpatient side are by definition suboptimal.

By more nuanced there are a number of reasons for a lack of communication. The only acceptable reasons are that the patient does not have outpatient care, the patient refuses to consent to the communication, or the outpatient physician or their proxy cannot be contacted with a good faith effort. Being on both ends of that call - a good faith effort to me means leaving a cell phone number with the message to “call me at any time.”  I have found that effort is required in an era of overproduction and no set times in the outpatient clinic for necessary phone calls.

In addition to the outpatient psychiatrist, consultants also need to be contacted. I have found that direct communication with the patients cardiologist, endocrinologist, nephrologist, primary care physician, and neurologist is necessary. In fact, there are cases where I do not make any changes to the patient’s medications until I have talked with one of these specialists.

In terms of specific outpatient care, a lot of history needs to be reviewed in the case of complex care.  The outpatient clinic can more efficiently send the records after a brief call. What the outpatient psychiatrist wants to see happen and the endpoint of inpatient care are very important areas that need to be covered. On occasion, the patient expresses dissatisfaction with outpatient care and that conversation can occur in a way that does not split care providers.  For example, one common scenario is the patient with a first manic episode after being treated for years for depression in the outpatient clinic.  A neutral discussion of the difficulty of making a bipolar disorder without a clear manic episode may facilitate transition back to the outpatient psychiatrist.  These problems highlight inpatient psychiatrists needing to maintain a realistic outlook on what has been done and what can possibly be done in the future. 

23:  All of the above factors translate to a chaotic and poorly run inpatient units.  There is no overall clinical guidance because it is typically taken away from psychiatrists and placed with administrators who clearly know nothing about inpatient psychiatry.  

Many inpatient units are nerve wracking places. The first order of business for me after a team meeting was to address as many crises on the unit as possible.  That could include agitated and aggressive patients, patients actively harming themselves, patients refusing medical care for a life-threatening illness, patients refusing surgical care for an obvious problem, and instability due to detoxification from alcohol or benzodiazepines. By addressing these crises, I always hoped to bring a measure of comfort and reassurance to the patient and everyone else who was distressed. I hoped to bring the noise level down. I hoped to have all of the biohazardous material cleaned up.  It is without a doubt a very tough job – made tougher by the fact that you only have the illusion of control. The people really responsible for this bedlam are out of touch. I actually had an administrator tell me to imagine that there was a firewall between me and the administrators who made all of the decisions affecting me, my staff, and the patients. That firewall was there to block my input and the input of my colleagues.

I had planned to do inpatient psychiatry until I retired, but I could not take it anymore. The interpersonal dimension was the most draining. Rather than dwell on that I often think about a deluxe psychiatric hospital that I visited instead. Several years out of residency, I was invited down to this campus by the former chief resident from the program I graduated from. It was a modern campus connected by broad boardwalks running to the compass points. My friend’s office was modern, open and airy. He told me about all of the services and activities available to his patients including excellent cuisine in the cafeteria. At the time the length of stay at his hospital was 2-3 months.  He had no concerns that his patients were unstable at the time of discharge and described none of the stressors that were impacting me on a daily basis. He had set office hours and left at a predictable time every day.  In the subsequent blur of my inpatient tenure, I never found out what happened to this hospital. My suspicion is that managed care eventually shut them down.

I don’t believe for a second that psychiatric inpatient units need to be miserable places that patients and their families want to avoid. I don’t believe for a second that they can’t be therapeutic and stimulating for the dedicated staff that work there.    

But that transformation clearly can’t happen if it is run by business administrators empowered by government edicts.

 

George Dawson, MD, DFAPA

Supplementary 1:

Almost exactly 10 years ago, I had an interview about my thoughts on managed care and psychiatry published in the MetroDocs periodical.  You can read it here but it will probably require adjusting the screen view.

Supplementary 2:

 I have also been interviewed on this theme by Awais Aftab, MD for his series Conversations in Critical Psychiatry.  You can read that interview at the following link.

The Bureaucratic Takeover of American Psychiatry

Is Medical Cannabis Overly Promoted In Minnesota?

 

Karl Marx wrote his famous metaphor about religion being an opiate for the proletariat in 1843:

“Religious suffering is, at one and the same time, the expression of real suffering and a protest against real suffering. Religion is the sigh of the oppressed creature, the heart of a heartless world, and the soul of soulless conditions. It is the opium of the people.”

He suggests in the next paragraph that the abolition of religion would rid people of the illusory happiness and it would be more consistent with the goal of real happiness for the people.  Marx’s formulation has not withstood the test of time. There is no more happiness now with widespread secularism than there was in Marx’s day.  Despite that fact - his metaphor survives and I thought about it quite a lot as I read through the Minnesota Medical Cannabis Program Report (MMCP) Anxiety Disorder Review.  The main difference of course is that cannabis is an equivalent metaphor only at the level of the idea of what medical cannabis can do.  When some writers suggest that religion can cause people to sleep and dream unrealistically, cannabis can physically do the same thing.  But it is promoted as doing many other things for many people – despite a profound lack of evidence.

The MMCP has been around for a number of years. I have taken the longstanding position that the medical cannabis concept is basically a way to legitimize cannabis and eventually get it legalized. I have also taken the position that physicians should not be involved in what is essentially a political maneuver.  The grandest aspect of that political maneuver has been the MMCP acting as a mini-FDA and coming up with their own indications for cannabis use. Initially, the idea was to use cannabis for the treatment of chronic pain and hospice care. I attended one of the early CME courses where most of the speakers were pain doctors and oncologists. Psychiatric input on these decisions has generally been minimal, despite the fact that psychiatric populations are at the highest risk from cannabis exposure and psychiatrists typically see most of the complications of cannabis.  The initiative to treat anxiety (in all forms) has not been approved by the MMCP and they state that was the reason for a more detailed look at the literature on cannabis as a treatment for anxiety and producing the report. 

Reading the report is an interesting exercise. It is not written very much from a scientific standpoint. They are very explicit about what they are considering as evidence.  For example they consider a literature search, a small panel of experts that does not really come to any consensus, and the experience of other states with medical cannabis and the indication of anxiety to be the basis for the report.  There are significant problems with all of those sources. 

 

The Research Matrix

At first the Research Matrix of papers included in the appendix looks impressive. There are 30 papers listing the reference, study type, total number of participants, dose and results.  Reading through the studies - some are single person case reports, some are reviews, and there are 15 studies listed as randomized controlled trials (RCTs). Looking at the RCTs there are probably one or two studies with an adequate number of participants to be adequately powered to show a statistical difference. Additional problems include the lack of an actual anxiety diagnosis.  In fact the diagnoses involved were frequently not anxiety related at all. Three observational studies at the end probably had the most merit and their results were equivocal. So the research studies really add nothing toward answering the question of whether medical cannabis should be used to treat anxiety and certainly nothing about the dose, delivery, or cannabis subtype.

Experience of Other States

Tables 1 summarizes the information about how other states have handled the question about medical cannabis and anxiety.  The states listed are Nevada, New Jersey, North Dakota and Pennsylvania.  In Nevada and North Dakota, the legislatures were petitioned to add anxiety (as DSM-5 Generalized Anxiety Disorder) to the medical cannabis formulary.  In New Jersey and Pennsylvania it was a commissioner decision. The Pennsylvania Secretary of Health was described as being “proactive” by suggesting that medical cannabis for anxiety was a “tool in the toolbox” and recommended duration of use, specific formulations, and avoidance in teenagers.  In all 4 states where cannabis was approved, anxiety quickly rose to the top or second most frequent indication for prescribing medical cannabis. None of the states collects any outcome data. 

What about other countries with more experience with cannabis like the Netherlands?  I contacted a colleague there who forwarded my questions to 2 other psychiatrists who were anxiety experts and doing active research in the area.  They responded that medical cannabis was not prescribed for anxiety and that there was a medical cannabis site for the Netherlands.  The site suggests that a CBD product is recommended. They had the same concerns about THC causing anxiety and psychosis.  A direct comparison of the indications for medical cannabis use comparing the Minnesota program to the Netherlands is included in the following table and linked directly to the respective web sites.

Medical Cannabis Qualifying Conditions

Minnesota   Cancer associated with severe/chronic pain, nausea or severe vomiting, or cachexia or severe wasting Glaucoma HIV/AIDS Tourette syndrome Amyotrophic lateral sclerosis (ALS) Seizures, including those characteristic of epilepsy Severe and persistent muscle spasms, including those characteristic of multiple sclerosis Inflammatory bowel disease, including Crohn’s disease Terminal illness, with a probable life expectancy of less than one year* Intractable pain Post-traumatic stress disorder Autism spectrum disorder (must meet DSM-5) Obstructive sleep apnea Alzheimer's disease Chronic pain Sickle cell disease Chronic motor or vocal tic disorder

The Netherlands   Pain, muscle cramps and twitching in multiple sclerosis (MS) or spinal cord injury; nausea, loss of appetite, weight loss and weakness in cancer and AIDS; nausea and vomiting due to medication or radiation treatment for cancer, HIV infection and AIDS; long-lasting pain of a neurogenic nature (cause is in the nervous system) for example due to damage to a nerve pathway, phantom pain, facial pain or chronic pain that persists after shingles has healed; tics in Tourette's syndrome; treatment-resistant glaucoma

 Expert Consensus

In terms of the professional consensus, the participants were described as  3 psychiatrists, a pediatrician, a person in recovery, a primary care physician, and a marriage and family therapist. On a scale of recommendations, there was one vote for non-approval, one vote in favor of a limited pilot study and follow-up outcomes, one vote for neutral not opposed, three votes in favor of considering for generalized anxiety disorder, panic disorder, and agoraphobia. No consideration is given to the experience of the physicians or the asymmetry of expertise. It appears to be a political approach to neutralizing the opinion of the group of physicians (psychiatrists) who essentially are left treating the complications of cannabis use disorder.  Those complications include acute mania or psychosis, anxiety and panic, chronic depression and amotivational syndromes, and significant cognitive problems.  Cannabis obscures whether the patient has a true psychiatric diagnosis or not.  It also destabilizes psychiatric disorders. That is the common theme I noted above.  This is really not expert consensus – it is a man-on-the street poll.

Apart from the very weak lines of evidence, some of the conclusions in this document are even worse.  There are basically 6 common themes:

1:  Protect the brain: There are longstanding concerns about the new timetable for brain development extending into the mid to late 20s. This is a peak period for drug experimentation and heavy use of alcohol and most substances. There appears to be consensus on this theme and I would agree.

2:  Safer alternative to benzodiazepines: the rationale here is much rockier.  The authors in this case cite the increase in benzodiazepine overdose deaths in the state of Minnesota, but the quality of this data is not clear.  I took a look at the data and contacted the Minnesota Department of Health about it – specifically if opioids were excluded as a primary cause along with fentanyl being sold as benzodiazepines. I was informed by an epidemiologist that a T42.4 code was present and the coding is not mutually exclusive. In other words, more drugs may be involved and fentanyl may have been involved. The death certificates and toxicology confirmations are dependent on the county medical examiner. The accuracy of the data is therefore in question. There are clearly ways to safely prescribe benzodiazepines.  Benzodiazepines are research proven alternatives for severe anxiety when conventional treatments have failed as a tertiary medication and cannabis is not.

In terms of addiction risk, the risk with cannabis is 8-12% overall and 17% for people who start using cannabis in their teens (1-6).  That compares with an addiction liability of about 10% with benzodiazepines (7).  Benzodiazepines are used by people who are taking multiple addicting drugs to amplify the effect, treat withdrawal symptoms, and treat the anxiety and insomnia that accompanies chronic substance use or opioid agonist therapy.  This population is often acquiring benzodiazepines from non-medical sources. There is no real good evidence that medical cannabis will replace non-medical use of benzodiazepines in that setting, since benzodiazepines are easily acquired from non-medical sources.

3:  Therapy is the standard:  Therapy is not the standard. The standard is whatever works for a particular practice setting.  Psychiatrists see people who have already seen a therapist and quite probably a primary care physician where their anxiety was diagnosed with a rating scale. That means they will have failed therapy and at least one or two medication trials. Psychiatrists are not going to start treatment by repeating ineffective therapies. In many cases, substance use including cannabis use is the main reason for the anxiety disorder in the first place.

4: Health Equity:  This was perhaps the most unlikely reason for cannabis use. To emphasize how far this document goes off the rails I am going to quote this section directly:

 “Known disparities exist in the level of care available for anxiety disorder among historically disadvantaged communities. Medical cannabis may offer these individuals the option for an alternative to current medications, however this view was not shared by all participants.” (p.15)

Are the authors of this document really suggesting that disadvantaged communities should settle for a substance that has been inadequately studied, has known severe medical and psychiatric side effects, and is associated with higher rates of suicidal ideation and suicide attempts in these disadvantage communities (14) rather than providing them with standard care? That statement to me is quite unbelievable. It is the first time I have seen a recommendation to use a prescription substance to address a social problem.  It may happen by default – but if you really want to promote health equity equivalence evidence based treatments are the only acceptable standard.

When  "an alternative to current medications" is mentioned cost is not discussed as a factor. In my discussions with people who have received medical cannabis from the Minnesota dispensaries, high cost was often mentioned as a limiting factor. This current price list from one of the dispensing pharmacies shows that nearly all of their products are much more expensive than the generic antidepressants used to treat anxiety disorders.

5: Limited research:  Cannabis advocates point to the lack of research due to the fact that cannabis is a Schedule 1 compound. That means there is no known medical use and a high potential for abuse. Since certain compounds have been FDA approved for specific indications, I anticipate that these compounds will be rescheduled.  That is one of many hurdles in researching cannabis.  A few of the others would include the issue of subject selection (cannabis naïve or not), placebo controls, specific form (THC:CBD ratio), type of drug delivery, and a general methodology that would capture a good sample of persons with an anxiety disorder in adequate numbers for the trial.

6: Harm Reduction:  The authors suggest that medical cannabis could serve to limit exposure to other more harmful drugs obtained on the street to treat anxiety like benzodiazepines. There is no evidence that this would occur given the availability and preference for non-prescribed benzodiazepines.  The issue of polysubstance dependence is complex.  A significant number of opioid users also use benzodiazepines. Despite a black box warning about respiratory depression from using that combination, the FDA has been clear that the medications can be prescribed together. Further, a recent study suggests that retention in a methadone maintenance program was twice as likely if the patients received prescription benzodiazepines as opposed to non-prescription benzodiazepines (10).  No such data exists for cannabis.

In terms of substituting cannabis for benzodiazepines the only study I could find was a retrospective observational study of new patients in a cannabis clinic. Over the course of 2 months 30.1% were able to stop benzodiazepine use and at 6 months that number had increased to 45.2%.  These authors (11) conclude

“Without dependable safety data and evidence from randomized trials for this cohort, cannabis cannot be recommended as an alternative to benzodiazepine therapy.”

 The conclusion of this paper suggests the options of maintaining the status quo or no approval for anxiety, approve for a limited number of “subconditions” defined as specific anxiety disorders, or approve for anxiety disorders.  They list the pros and  cons associated with each approach but not much was added relative to the above discussion.  There are a few comments that merit further criticism. The risks of maintaining the status quo are seriously overstated.  From reviewing previous tabulated data from the MN Medical Cannabis program, it is unlikely that any meaningful real world data will be collected. It is not possible to collect non-randomized, uncontrolled data on a substance that is highly valued and reinforces its own use that has any meaning. The results will predictably be like the comments solicited by this program that are 96% favorable. There are similar speculative predictions of the direct consequences of not providing medical cannabis in terms of not seeking therapy if using cannabis off the street, suicides due to not tolerating SSRIs, and patient harm from “illicit use”. Similar speculation occurs throughout the remaining bullets points and there seems to be a strong pro-medical cannabis for anxiety disorders bias.

To summarize, I am not impressed with the Minnesota Medical Cannabis Program report on the use of medical cannabis for anxiety. It clashes with my 35 years of clinical experience where cannabis has been a major problem for the patients I treated in community mental health centers, clinics, substance use treatment centers, and hospitals. It suggests a great potential for a substance that has been around and used by man for over 7 millennia.  You would think with that history, man would have realized by now that it was a panacea for his most common mental health problem – anxiety. The report also ignores the commonest role of cannabis in American society and that is as an intoxicant and not a medication.  Physicians should not be prescribing intoxicants.  You don’t need a prescription to go to a liquor store and purchase alcoholic beverages. If the real goal is to get cannabis out to the masses, the option is legalization of cannabis not medical cannabis.

 

George Dawson, MD, DFAPA

 

References:

1:  Anthony JC, Warner LA, Kessler RC. Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the National Comorbidity Survey. Exp Clin Psychopharmacol. 1994;2(3):244-268. doi:10.1037/1064-1297.2.3.244

2:  Lopez-Quintero C, Pérez de los Cobos J, Hasin DS, et al. Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug Alcohol Depend. 2011;115(1-2):120-130. doi:10.1016/j.drugalcdep.2010.11.004

3:  Anthony JC. The epidemiology of cannabis dependence. In: Roffman RA, Stephens RS, eds. Cannabis Dependence: Its Nature, Consequences and Treat:ment. Cambridge, UK: Cambridge University Press; 2006:58-105.

4: NIDA. 2021, April 13. Is marijuana addictive?. Retrieved from https://www.drugabuse.gov/publications/research-reports/marijuana/marijuana-addictive on 2021, September 13.

5:  Moss HB, Chen CM, Yi HY (2012). Measures of substance consumption among substance users, DSM-IV abusers, and those with DSM-IV dependence disorders in a nationally representative sample. J Stud Alcohol Drugs 73: 820–828

6:  Perkonigg A, Goodwin RD, Fiedler A, Behrendt S, Beesdo K, Lieb R et al (2008). The natural course of cannabis use, abuse and dependence during the first decades of life. Addiction 103: 439–449 discussion 450–451.

7: Becker WC, Fiellin DA, Desai RA. . Non-medical use, abuse and dependence on sedatives and tranquilizers among U.S. adults: psychiatric and socio-demographic correlates. Drug Alcohol Depend. 2007; 90 2-3: 280- 7. DOI: 10.1016/j.drugalcdep.2007.04.009 PubMed PMID: 17544227.

 

Harm Reduction:

8: Okusanya BO, Asaolu IO, Ehiri JE, Kimaru LJ, Okechukwu A, Rosales C. Medical cannabis for the reduction of opioid dosage in the treatment of non-cancer chronic pain: a systematic review. Syst Rev. 2020 Jul 28;9(1):167. doi: 10.1186/s13643-020-01425-3. PMID: 32723354; PMCID: PMC7388229.

9: Shover CL, Davis CS, Gordon SC, Humphreys K. Association between medical cannabis laws and opioid overdose mortality has reversed over time. Proc Natl Acad Sci U S A. 2019 Jun 25;116(26):12624-12626. doi: 10.1073/pnas.1903434116. Epub 2019 Jun 10. PMID: 31182592; PMCID: PMC6600903.

10: Eibl JK, Wilton AS, Franklyn AM, Kurdyak P, Marsh DC. Evaluating the Impact of Prescribed Versus Nonprescribed Benzodiazepine Use in Methadone Maintenance Therapy: Results From a Population-based Retrospective Cohort Study. J Addict Med. 2019 May/Jun;13(3):182-187. doi: 10.1097/ADM.0000000000000476. PMID: 30543543; PMCID: PMC6553513.

11: Purcell C, Davis A, Moolman N, Taylor SM. Reduction of Benzodiazepine Use in Patients Prescribed Medical Cannabis. Cannabis Cannabinoid Res. 2019 Sep 23;4(3):214-218. doi: 10.1089/can.2018.0020. PMID: 31559336; PMCID: PMC6757237.

 

Cannabis and Psychosis:

12: Kuepper R, van Os J, Lieb R, Wittchen H, Höfler M, Henquet C et al. Continued cannabis use and risk of incidence and persistence of psychotic symptoms: 10 year follow-up cohort study BMJ 2011; 342 :d738 doi:10.1136/bmj.d738

13: Murray RM, Mondelli V, Stilo SA, Trotta A, Sideli L, Ajnakina O, Ferraro L, Vassos E, Iyegbe C, Schoeler T, Bhattacharyya S, Marques TR, Dazzan P, Lopez-Morinigo J, Colizzi M, O'Connor J, Falcone MA, Quattrone D, Rodriguez V, Tripoli G, La Barbera D, La Cascia C, Alameda L, Trotta G, Morgan C, Gaughran F, David A, Di Forti M. The influence of risk factors on the onset and outcome of psychosis: What we learned from the GAP study. Schizophr Res. 2020 Nov;225:63-68. doi: 10.1016/j.schres.2020.01.011. Epub 2020 Feb 6. PMID: 32037203.

 

Cannabis Use and Suicide:

14:  Kelly LM, Drazdowski TK, Livingston NR, Zajac K. Demographic risk factors for co-occurring suicidality and cannabis use disorders: Findings from a nationally representative United States sample. Addict Behav. 2021 Nov;122:107047. doi: 10.1016/j.addbeh.2021.107047. Epub 2021 Jul 12. PMID: 34284313; PMCID: PMC8351371.

 

Cannabis Use and Life-Threatening Medical Problems:

15:  Ladha KS, Mistry N, Wijeysundera DN, Clarke H, Verma S, Hare GMT, Mazer CD. Recent cannabis use and myocardial infarction in young adults: a cross-sectional study. CMAJ. 2021 Sep 7;193(35):E1377-E1384. doi: 10.1503/cmaj.202392. PMID: 34493564.

16:  Parekh T, Pemmasani S, Desai R. Marijuana Use Among Young Adults (18-44 Years of Age) and Risk of Stroke: A Behavioral Risk Factor Surveillance System Survey Analysis. Stroke. 2020 Jan;51(1):308-310. doi: 10.1161/STROKEAHA.119.027828. Epub 2019 Nov 11. PMID: 31707926.

17:  Shah S, Patel S, Paulraj S, Chaudhuri D. Association of Marijuana Use and Cardiovascular Disease: A Behavioral Risk Factor Surveillance System Data Analysis of 133,706 US Adults. Am J Med. 2021 May;134(5):614-620.e1. doi: 10.1016/j.amjmed.2020.10.019. Epub 2020 Nov 9. PMID: 33181103.

18:  Desai R, Fong HK, Shah K, Kaur VP, Savani S, Gangani K, Damarlapally N, Goyal H. Rising Trends in Hospitalizations for Cardiovascular Events among Young Cannabis Users (18-39 Years) without Other Substance Abuse. Medicina (Kaunas). 2019 Aug 5;55(8):438. doi: 10.3390/medicina55080438. PMID: 31387198; PMCID: PMC6723728.

Pharmacokinetics and Adverse Effects of Cannabis:

19:  Schlienz NJ, Spindle TR, Cone EJ, Herrmann ES, Bigelow GE, Mitchell JM, Flegel R, LoDico C, Vandrey R. Pharmacodynamic dose effects of oral cannabis ingestion in healthy adults who infrequently use cannabis. Drug Alcohol Depend. 2020 Mar 21;211:107969. doi: 10.1016/j.drugalcdep.2020.107969. Epub ahead of print. PMID: 32298998; PMCID: PMC8221366.

20: Spindle TR, Cone EJ, Goffi E, Weerts EM, Mitchell JM, Winecker RE, Bigelow GE, Flegel RR, Vandrey R. Pharmacodynamic effects of vaporized and oral cannabidiol (CBD) and vaporized CBD-dominant cannabis in infrequent cannabis users. Drug Alcohol Depend. 2020 Jun 1;211:107937. doi: 10.1016/j.drugalcdep.2020.107937. Epub 2020 Apr 1. PMID: 32247649; PMCID: PMC7414803.

21:  Spindle TR, Martin EL, Grabenauer M, Woodward T, Milburn MA, Vandrey R. Assessment of cognitive and psychomotor impairment, subjective effects, and blood THC concentrations following acute administration of oral and vaporized cannabis. J Psychopharmacol. 2021 Jul;35(7):786-803. doi: 10.1177/02698811211021583. Epub 2021 May 28. PMID: 34049452. 

22:  Spindle TR, Cone EJ, Schlienz NJ, Mitchell JM, Bigelow GE, Flegel R, Hayes E, Vandrey R. Acute Effects of Smoked and Vaporized Cannabis in Healthy Adults Who Infrequently Use Cannabis: A Crossover Trial. JAMA Netw Open. 2018 Nov 2;1(7):e184841. doi: 10.1001/jamanetworkopen.2018.4841. Erratum in: JAMA Netw Open. 2018 Dec 7;1(8):e187241. PMID: 30646391; PMCID: PMC6324384.

Vaping and Pulmonary Toxicology:

23:  Meehan-Atrash J, Rahman I. Cannabis Vaping: Existing and Emerging Modalities, Chemistry, and Pulmonary Toxicology. Chem Res Toxicol. 2021 Oct 8. doi: 10.1021/acs.chemrestox.1c00290. Epub ahead of print. PMID: 34622654.

24:  Tehrani MW, Newmeyer MN, Rule AM, Prasse C. Characterizing the Chemical Landscape in Commercial E-Cigarette Liquids and Aerosols by Liquid Chromatography-High-Resolution Mass Spectrometry. Chem Res Toxicol. 2021 Oct 5. doi: 10.1021/acs.chemrestox.1c00253. Epub ahead of print. PMID: 34610237.

25:  McDaniel C, Mallampati SR, Wise A. Metals in Cannabis Vaporizer Aerosols: Sources, Possible Mechanisms, and Exposure Profiles. Chem Res Toxicol. 2021 Oct 27. doi: 10.1021/acs.chemrestox.1c00230. Epub ahead of print. PMID: 34705462.

Epidemiology:

26: Lim CCW, Sun T, Leung J, et al. Prevalence of Adolescent Cannabis Vaping: A Systematic Review and Meta-analysis of US and Canadian Studies. JAMA Pediatr. Published online October 25, 2021. doi:10.1001/jamapediatrics.2021.4102

Prevalence of cannabis vaping by adolescents has recently increased for lifetime use, use in the past 30 days and use in the past year.

Maternal Cannabis Use and Anxiety in Offspring:

Rompala G, Nomura Y, Hurd YL. Maternal cannabis use is associated with suppression of immune gene networks in placenta and increased anxiety phenotypes in offspring. Proc Natl Acad Sci U S A. 2021 Nov 23;118(47):e2106115118. doi: 10.1073/pnas.2106115118. PMID: 34782458.

LaSalle JM. Placenta keeps the score of maternal cannabis use and child anxiety. Proc Natl Acad Sci U S A. 2021 Nov 23;118(47):e2118394118. doi: 10.1073/pnas.2118394118. PMID: 34789581.

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