Clinical Psychiatrist’s Thoughts on Medical Marijuana Treatments

Psychiatrist Norton A. Roitman, MD spent some time with us at Cannabis Magazine to talk about the medicinal use of marijuana in psychiatric patients, especially with youth who are supervised in the juvenile justice system. Although he does not prescribe or administer medical marijuana, he has learned some tips for medical marijuana patients to help find their correct dose and effectively treat their symptoms.  Dr. Roitman is a highly credentialed medical practitioner, so getting a chance to pick his mind just a bit was a worthy venture.  Here’s what he had to say…

Tell me a little bit about your background and your credentials.

Psychiatrist Dr. Roitman: I have wanted to be a psychiatrist since I was 12 years old. I went to the University of Wisconsin during the late sixties and majored in psychology. I then went to the University of Illinois for medical school, then residency training and a psychopharmacology research fellowship at the University of California in San Diego. Being a glutton for punishment, I then took a fellowship in child and adolescent psychiatry and psychoanalytic psychotherapy at the Reiss–Davis Child Study Center that is now associated with UCLA in Los Angeles.

I’ve been in private practice since 1995 after a stint as a state hospital medical director in Reno, and becoming the founder and director of a major psychiatric and substance abuse outpatient clinic in Las Vegas. I’ve been a regular practitioner and consultant to governmental agencies including the County’s Department of Family Services, School District, Nevada’s Child and Family Services and the Department of Juvenile Justice and Nevada Youth Parole. My practice now consists of mostly expert testimony as a forensic psychiatrist. I testify on civil cases, often involving:  trauma, brain injuries, PTSD, liability and causality, as well as capital criminal cases when the defense needs an expert opinion about the defendant’s mental state and criminal culpability when they were violent.

Medical School

Very nice. You are very well qualified and an expert in your field! In your private practice or in your other professional experience, have any of your patients ever used cannabis?

Psychiatrist Dr. Roitman: I have seen quite a bit of use of cannabis in the youth I’ve examined through Juvenile Justice Services and Youth Parole. Young people kept telling me how much more effective their cannabis was than any of their counseling or psychiatric treatment, in both inpatient and outpatient settings. Most told me their use of cannabis was far superior to their psychiatric medications and was free of some of the side effects that psychotropic medications routinely produce. This was the report of youth with a variety of diagnoses, including Bipolar Disorder, ADHD, PTSD and other trauma related disorders, anxiety or depression. These people found that marijuana was by far their  most effective treatment and had no problem with compliance because it actually helped. Marijuana calmed them and slightly rewarded them instead of numbing them. It did not interfere with their sexual function. Some youth smoked before they went to school because it helped them focus and concentrate, and those who routinely lost their temper reported being less apt to be provoked.

With cannabis being legal in some states do you feel like it gives patients a sense of control of their life and their health care? Particularly control over their medicine?

Psychiatrist Dr. Roitman: Although I don’t have as much experience with adults who are using medical marijuana for psychiatric reasons as I do with the juveniles, I know this to be true: for years people have used alcohol for self-regulation, but opposed to cannabis products, alcohol generally does not reduce violent tendencies and emotional reactivity in people prone to these reactions.

Being able to adjust the dose and time of administration, without worrying about medically consequential overdosing, as can be the case with benzodiazepines like Xanax or stimulants like Adderall, empowers people to take care of their problems with a safe substance when they have yet to develop coping mechanisms. By self-regulating their emotions with a safe substance, psychiatric patients do not have to be locked into what a doctor’s prescription says and wait till their next appointment to get their treatment adjusted.

Justice-involved youth feel like they are taking care of their own problems instead of being told what to do and what to take, which rebellious teenagers hate. Of course it is not legal for them, and I can’t and won’t prescribe it. I am just saying, from what I’ve observed, medical marijuana has had distinct advantages over main stream psychiatric treatment. I suspect once pediatric psychiatrists have more research to legitimize cannabis, establish its medical indications, establish its long term safety, and once laws can accommodate treatment of a younger population we may see it used as a treatment for youth more frequently. Of course we have to determine an age cut-off. There have been reports of doctors and parents medicating very young children with antipsychotics off label, which can have tremendous long term risks. I hope we take relative risks when we are at the stage to consider who should and shouldn’t use cannabis products.

The young people are still being arrested. It’s sad. Here they find a safe substance that helps them function in society, and they get punished for it. 

Do you feel like there has been an increase in juvenile’s being punished for cannabis use?

Psychiatrist Dr. Roitman: No, I don’t think so. I’ve been examining juvenile justice children for  20 years. The majority have been adjudicated  prior to legalization. I am not in the loop, but from the outside it seems that even though cannabis is  illegal, leaders in the juvenile justice system could de-emphasize violation of parole based on marijuana use. They have discretion, just like the federal government does. I think some of that de-emphasizing violation of parole based on marijuana use is happening, which is a move in the right direction.

What do you think is behind the popularization of marijuana use for people who find it useful for their pain and other problems?

 Psychiatrist Dr. Roitman: My sense is that we are undergoing a cultural transition. The progress in marijuana laws reflects this transformation and marijuana use seems to be more accepted across the board. Also main stream medicine has not always delivered on its promises and people have found medical benefits of marijuana on their own outside the medical establishment. Not to mention the sometimes ridiculous restrictions imposed by insurance companies turning people away from mainstream treatments.

In your experience in clinical psychiatry, what’s the most popular ailment or illness that adolescents suffer from, which they find cannabis to be a preferable treatment for?

Psychiatrist Dr. Roitman: Patients use cannabis for recreational purposes and for life enhancement. Some are very specific about how they treat their symptoms of  Post Traumatic Stress Disorder, Anxiety Disorders, Sleep Disorders, and even suicidal depression. Many youth use cannabis to subdue their anger and loss of temper. I feel very grateful on behalf of people I see who have been suffering but haven’t been able to find relief through standard treatment methods. While some people are prone to addiction, others use their marijuana products conscientiously.

Psychotropic medications

I have heard from patients that their doctors are suggesting they stop using their addicting sleep aids such as Ambien, which is really only supposed to be prescribed for 14 days running, and instead encourage them to go talk to their dispensary bud tenders and ask them for advisement on the use of more sustainable sleep remedies.

Let’s shift a  bit into more mainstream medical marijuana. – Do you think that the medicinal cannabis industry is going to disrupt health care? Cannabis is being used as an alternative to opioids and prescription medications.  Do you think that’s going to cause any stirs in the traditional mainstream medicine?

Psychiatrist Dr. Roitman: I think there’s a fight for territory right now. I’m no expert on this, but I think as big pharma moves in, as represented by the recent FDA approval, and the legitimization of Epidiolex the stage is being set for more aggressive capitalization and commercialization. I have mixed feelings about it. I hope there is still room for the small famers and traditional marijuana interests who have sustained the culture up until now. I’m not sure how it’s going to shake out, but cannabis legalization has definitely influenced health care, and will likely continue to do so. It is just too popular and too many of our patients are using it.

It wold be irresponsible for medical research not to turn towards studying marijuana and psychedelics too.

I know you are a clinical professor in medical school departments of psychiatry in Nevada. Are any of the doctors or medical professionals being trained or educated about cannabis at the University level?

Psychiatrist Dr. Roitman: I’m at a distance from most of the curriculum. Mostly I supervise residents near the end of their studies. I don’t detect that marijuana education is ready for prime time yet, though. I see occasional articles in the formal and informal psychiatric literature. In my opinion, it does not have the consensus or research foundation to integrate into mainstream medicine yet. However, I do know the younger psychiatrists are more interested in alternatives to the psychotropic medications.

Since I graduated medical school there have been just a couple of developments in psychotropic medications that have made any significant difference. Where I think the most serious research needs to point is whether marijuana is a detriment to people who have problems maintaining a consistent perspective of consensual reality. It could be that cannabis might loosen a vital connection to functional reality if it is too strong, used too often, or maybe it shouldn’t be used at all. I hope we can find out the answer to that question soon,

There’s this idea that medicines are not supposed to be pleasurable. I guess the belief is that if you’re sick you have to suffer and you should not be attracted to your medicine. I think that’s ridiculous.

Based on what you’ve read, and your expertise as a psychiatrist, do you have any advice that you would give to a medical marijuana consumer?

Psychiatrist Dr. Roitman: The best medical information is for patients to use cannabis as they would many other substances:

1. If you’re using medical marijuana for therapeutic purposes, clearly identify why you’re using it. Be specific! Identify in your words the nature of the problem. Clarify for yourself the typical time variables, such as: when do symptoms typically start, what time of day, what are the triggers and circumstances and how long symptoms last. Get to know yourself first.
2. Some people use ratings of some kind, like number scales or words that represent symptom severity, for instance, “I’d call this: mild, bad, really bad, intolerable!”
3. Aim your treatment at your problem areas, one at a time.
4. Choose a strain or product that is likely to address the specific nature of your problem area based on your reading or advice received. But remember, everyone is different .
5. Decide how useful your strain and delivery system is at a low dose. Then, rate your symptoms after the dosage is expected to take hold. For instance, oils are faster than edibles. Don’t rate yourself a half hour after an edible, and don’t increase the dose before the prior dose ends if you want a good gauge of how much you need.
6. Don’t gobble or smoke in panic.
7. Base assessment on pre-marijuana use rating of symptoms, versus post use results.
8. Use the minimal effective dose for symptom relief so you don’t accommodate rapidly to your treatment thus having to increase use to get the same level of relief.

That consciousness about structuring your cannabis use scientifically to see whether it’s effective or not. That’s what’s important.

It’s a scientific approach to trying to figure out what’s right for you, what the right amount is, and to do no harm. That’s true with cannabis, as with psychotropic medication.

 When it comes to any medicine, including medical marijuana, every individual should be their own study subjects, and should be the leader of their personal research.

Though, sometimes it’s helpful to have somebody outside yourself to discuss treatment with and to keep some record on how it’s going.

With that first step of  “Identify why you’re using cannabis” do you mean a general reason, or something more specific?

Psychiatrist Dr. Roitman: If cannabis is being used to control symptoms, the symptoms should be clearly identified on an estimate of severity, duration, and nature. Then, see if a dose does affect the identified symptom(s), and over what course of time. Once efficacy is established, a patient can be more  specific with how and when they use their medicine.  For instance, a patient may find that they can use an Indica strain for immediate sedation, in combination with an edible, to maintain sleep through the night. It’s the same as using a certain sleeping pill to get to sleep, and another one to stay asleep.

I don’t want to be the man who says this is the formula of use that will work for everyone.

Medical marijuana patient

Absolutely not, I don’t think that you’re saying it’s for everyone. It’s pretty clear that cannabis effects everyone differently. There’s no one size fits all. There’s no cookie-cutter treatment for anybody that is using medical cannabis or even using it recreationally. I do believe people have to have standpoint where they are experimenting but also regulating themselves to find that happy medium between: what’s the purpose and goals of consuming cannabis as medicine. What’s the proper equation to support the objective.

Psychiatrist Dr. Roitman: That’s right. It’s exciting. It’s like watching the internet develop in the 80s and 90s. Oh, I can get music on my computer. What, I can take my desk top? It was very exciting.

Well, thank you so much for taking the time out of your day. This is a very enjoyable conversation.

Psychiatrist Dr. Roitman: Oh, good.  Thank you for having me.