Friday, December 15, 2006


Cannabinoids, neurodevelopment, and treatments of difficult children: part I

Recently I've been reading a lot about cannabis and the endogenous cannabinoid system in regards to schizophrenia. A quick Google search got me to the Journal of the California Cannabis Research Medical Group, and an interesting case report of prescribing medical marijuana to an adolescent to treat behavioural problems (by Tod H. Mikuriya, M.D):

"Alex and Barbara P. were seen by the author at a follow-up visit in February 2006. Alex reported dramatically improved mood and functionality with only one migraine attack in the past year, not severe enough to require a trip to the hospital for a Dilaudid injection. He is in an independent study program at a small public school and getting straight As and Bs. “They love me at school,” Alex asserts. His teacher is aware that he medicates with cannabis with a physician’s approval. He smokes approximately one ounce per week and would use 50% more if it were cheaper to obtain. He does not vaporize because a vaporizer is “too expensive” (although he has taken up the guitar and purchased several models). He summarizes his status thus: “I use(d) to use a lot of medication like Klonopin and other pain medication but I haven’t had to since the use of cannabis.”"

According to the article, Alex had started using cannabis at the age of 11. At this age, he was also diagnosed with ADD for apparent concentration difficulties in school and prescribed Ritalin. The article doesn't state whether cannabis use preceded diagnosis or vice versa. According to his mother, Alex "wasn't acting wild in school"; however, he befriended some older peers with whom he shared his stimulants, smoked marijuana and stole a car. Following arrest, he "began a four-year sojourn through institutions of the Central Valley juvenile justice system and Kaiser-affiliated hospitals and clinics". During this time, Alex was prescribed, at various times, a cocktail of stimulants, antidepressants and anticonvulsants that I find simply horrifying.

"Alex P., accompanied by his mother, first visited my office in February 2005 at age 15 years, 6 months. At that time he had been prescribed and was taking Fioricet with codeine (30 mg, 3x/day); Klonopin (1 mg, 2x/day); Ativan (1 mg, 2x/day); and Dilaudid “as needed” to treat migraine headaches (346.1), insomnia (307.42), and outbursts of aggression to which various diagnoses —including bipolar with schizophrenic tendencies- had been attached by doctors in the Kaiser Healthcare system.
Alex had previously been prescribed Ritalin, Prozac, Paxil, Maxalt, Immitrex, Depacote, Phenergan, Inderal, Thorazine, Amitriptaline, Buspar, Vicodin, Seroquel, Risperdal, Zyprexa, Clozaril, Norco, and Oxycodone."

The outbursts of aggression that Alex suffered are noteworthy because they appeared after he began taking the different drug combinations. According to his mother,

"They put him on all these medications and not only couldn’t he sleep at night, but he started having rampages, hitting —mainly me. He fought with his brother and his dad, too. He beat up the truck. He couldn’t remember afterwards what he actually did. He seemed like a completely different person. I don’t think that’s because of who he is. I think it was because of the medications he was taking.”"

In a New York Times article, discussing the difficulties and uncertainties inherent in combination drug treatments of adolescent mental disorder (found via Mindhacks) , one of the children seems to suffer from the same bouts of uncontrolled aggression as Alex, and furthermore, these outbursts also appear to be connected with medication.

"Despite the medications, Michael’s behavior has grown increasingly disruptive. He has kicked and punched holes in almost every wall of the Igafo-Te’o home. He wrenched the sink off the wall in the upstairs bathroom and pulled two bedroom doors off their hinges, damaging the frames. The family no longer fixes the damage."

Anecdotal evidence does not a theory make, but these two cases raise the possibility that heavy medication, or perhaps combination therapy, of adolescents could actually precipitate psychotic symptoms and worsen the condition of the children treated. In the case of Alex, one wonders if he would have been diagnosed with schizophrenia had he not been subjected to all the different drugs listed above.

According to the case report, Alex's mood and overall functionality has drastically improved since he was prescribed to smoke approximately an ounce of marijuana daily. He performs well in school and no longer needs the menagerie of medications he was prescribed. All's well that ends well? I'm not really sure.

I'd like to use this case to discuss the neurodevelopmental effects of cannabis use, for which I will need a separate post. But for now, I'll finish with this observation: Is it ethically defensible to experiment with combined medication on children, given what is known about brain plasticity and development? Or rather, not known: there's not a lot of research going on about this.
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