Illegal or Legal, Marijuana Remains a Gateway Drug

Reviewing the Clinical Landscape

Welcome to our second annual review of the clinical landscape. This year we asked Focus editorial board members and section editors to identify the most important article they had read in the past year, in any journal, and briefly explain why they would recommend it to the general psychiatrist. This exercise came about after the American College of Psychiatry meeting, where I was talking to my friend David Katzelnick. He was raving about a book he had just finished, Designing Your Life: How to Build a Well-Lived, Joyful Life, by Bill Burnett and Dave Evans (1). Professors Burnett and Evans teach design theory at Stanford University. Several years ago, they created an undergraduate elective class that applies design principles to thinking about one’s life. One of the key concepts in the book is that a variety of successful work and life options are available to every person. Professors Burnett and Evans then describe a deliberate process that facilitates people prototyping several different life paths, thus testing multiple creative options for their life course without requiring them to commit to only one path. David was so enthusiastic about the book that I decided to read it. I hate self-help books, but this work added tremendous richness to my thinking about life options and life. I have been so impressed by the work that I bought hard copies for my children, and my wife and I have been recommending it to patients and colleagues. In that vein, our editors were asked to provide similar sources of inspiration. The responses ranged from the heady (neurobiological signatures and biomarker-based research) to what approximates a home remedy (hot showers for hyperemesis brought about by heavy marijuana use) while also touching on works discussing depression, trauma, opioids, suicide, and burnout. We hope you find these enjoyable and that they inspire you to seek and share your own source of scholarly inspiration.

Mark Hyman Rapaport, M.D.

Editor, Focus

REFERENCE

1. Burnett W, Evans DJ: Designing Your Life: How to Build a Well-Lived, Joyful Life. New York, Alfred A. Knopf, 2016

Because I continue to be concerned about the impact of marijuana legalization, two articles related to this topic caught my eye. In the first article, Hasin and colleagues (1) investigated whether increases in adult illicit cannabis use and cannabis use disorders followed implementation of medical marijuana laws. The authors used three national cross-sectional adult surveys, one from 1991–1992, one from 2001–2002, and one from 2012–2013. Over the entire 20-year period, the predicted prevalence of illicit use and disorders increased to a greater degree in the states that passed medical marijuana laws than in other states. Medical marijuana laws seem to have contributed to increasing adult use and cannabis disorders.

In the second article, Olfson and colleagues (2) examined the speculation that cannabis might help to curb or prevent opioid use disorders, which arose from reports that annual death rates caused by opioid overdoses were significantly lower in states that permit medical marijuana. Olfson and colleagues (2) used data from the National Epidemiological Survey on Alcohol and Related Conditions (wave 1 in 2001–2002 and wave 2 follow-up in 2004–2005). They found that cannabis use was strongly associated with subsequent onset of nonmedical prescription opioid use and opioid use disorder (nonmedical prescription use was defined as using analgesics “without a prescription, in greater amounts, more often, or longer than prescribed, or for a reason other than a doctor said you should use them”). Thus, cannabis seems to increase rather than decrease the risk of developing nonmedical prescription opioid use and opioid use disorders.

Legalization of marijuana leads to an increase in cannabis use and risk of cannabis use disorders, and cannabis use is associated with an increase in nonmedical prescription opioid use and opioid use disorders. These findings seem to confirm rather than refute the old observation that marijuana is a gateway drug. They also suggest the fallacy of medical marijuana laws and predict more work for addiction specialists and physicians in general.