Taxing Cannabis

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Monday, 26th June 2017

Cannabis

Cannabis and Paranoia

 


Paranoia is a symptom long associated with use of cannabis, indeed ‘acute hashism’ was one of the main reasons for banning the drug given to the international convention which first introduced international controls on cannabis.  However conclusions as to causality need to reflect the illegal status of the drug and the techniques used by enforcement agencies to detect and punish users, such as the use of undercover officers and informants.  In such an atmosphere there is a thin dividing line between self-preservation via exaggerated caution at one end of the scale and clinical paranoia at the other.  However it is rare for a regular user of cannabis not to have felt paranoid, by their own reports, at some stage.

 

For this report a Medline search using keywords Cannabi* and Paranoi* identified a total of 95x scientific papers, this review concentrates on human studies.

 

Case Histories & Anecdotal Reports

Case reports suggesting adverse reactions attributed to cannabis use have appeared in the scientific literature since 1967[i], with reports of psychotic symptoms[ii][iii], suggestibility[iv], and paranoid ideation[v][vi]. In a study of 5 chronic users in Spain, Farini-Duggan & Aust[vii] reported “In all cases, marked depression, and anxiety, schizoid features, and poor control were detected. In four patients self-aggresion, inversion of sleep cycle, weakness of will and mental confusion were registered. In four subjects a definite psychotic profile was detected through Rorschach tests. Three patients suffered from visual hallucinations, and trends to sexual promiscuity. Memory failure and gaps were apparent in two cases. One patient developed a short-lasting paranoid delusion.”

 

Chaudry et al[viii] described psychosis in Pakistan after drinking Bhang – a cannabis beverage, stating “Presenting symptoms of bhang-induced psychosis found in patients included grandiosity, excitement, hostility, uncooperativeness, disorientation, hallucinatory behavior and unusual thought content... The presenting symptoms of bhang-induced psychosis are consistent with a brief mania-like disorder with paranoid psychotic features, and cognitive dysfunction.”

 

In Jamaica, a country associated with particularly heavy levels of cannabis use, Knight[ix] reported “One-third of male admissions to the psychiatric hospital have used cannabis. Of 74 males admitted to another psychiatric service over a 12-month period, 29 had used cannabis. Ten of these patients were diagnosed as "ganja psychosis," and four others were classified as "marijuana-modified mania." At another psychiatric service, 54 of 223 admissions (24.2%) for functional psychosis presented with cannabis usage as a comtributory factor. These 54 patients included 14 and seven cases of hypomanic and depressive reactions, respectively. At three other rural general hospitals, psychiatric admissions for psychosis showed 11 of 51, seven of 18, and 39 of 75 patients, respectively, in whom cannabis was considered directly responsible.”  Solomons et al[x] described psychosis among ‘dagga’-using black men in South Africa, with symptoms including “schizophrenia (42%), paranoia (26%), maniform psychosis (16%) and organic psychosis (16%).”

 

De Lucas Taracena et al[xi] report the case history of a “17-year-old woman with family history of OCD, starting with panic symptoms after cannabis use, but suddenly developing OCD with avoidant behavior and delusional ideas of self-reference and persecution”  Dalby & Duncan[xii] described a “socially isolated married couple who developed a shared paranoid disorder preceded by their cannabis abuse with the wife initiating the delusions. After the couple were separated the wife feared that she would be killed and assaulted her child and mother. Delusions in the pair ceased quickly and a return to cohabitation did not result in relapse in the absence of cannabis abuse.”

 

Thakor & Shulka[xiii] observed “patients with cannabis psychosis substantially differed in terms of behavioral manifestations. Most of these patients were violent and panicky and demonstrated bizzare behavior, but they possessed some insight into the nature of their illness. Schizophrenic patients manifested these disturbances and characteristics less frequently. Subjects with cannabis psychosis showed rapid ideation and flight of ideas, whereas the characteristic schizophrenic thought-disorder was found mostly in schizophrenic patients.” Negrete[xiv] reported “The most frequently observed complication of cannabis inebriation, however, is a short-lasting acute psychological disturbance with symptoms of panic, paranoid apprehension and personality disorganization.”  Hollister[xv] reported “Cannabis may produce directly an acute panic reaction, a toxic delirium, and acute paranoid state, or acute mania. Cannabis use may aggrevate schizophrenia, but it is much less certain whether it can lead to sociopathy or even to "amotivational syndrome".

 

Psychiatric patients

In a controlled study matching patients receiving treatment for cannabis dependence with non-drug psychiatric outpatients and healthy controls, Bravo de Medina et al[xvi] reported “Cannabis-dependent patients were specifically characterized by low educational level and by the presence of paranoid ideation; they were also more impulsive and sensation-seeking than those from the other two groups.” Katz et al[xvii] compared schizophrenics who used and did not use cannabis, finding “statistically significant (increases) for hallucinatory behavior, excitement, grandiosity, and hostility” among the cannabis-using group, concluding “Cannabis possibly produces some antidepressive and anxiolytic effect on psychotic and affective inpatients. The "price" of this effect is often an exacerbation of psychotic and some manic symptoms.”

 

Boydell et al[xviii] compared young schizophrenia patients who did or did not use cannabis, finding “no statistically significant effect of cannabis use on the presence of [distractibility, bizarre behaviour, positive formal thought disorder, delusions of reference, well organised delusions, any first rank symptom, persecutory delusions, abusive/accusatory hallucinations, blunted affect, negative thought disorder, any negative symptoms (catatonia, blunted affect, negative thought disorder, or deterioration), lack of insight, suicidal ideation and a positive family history of schizophrenia]. There remained however a non-significant trend towards more insight (OR 0.65 p=0.055 for "loss of insight") and a finding of fewer abusive or accusatory hallucinations (OR 0.65 p=0.049) of borderline significance amongst the cannabis users

 

Jockers-Scherübl[xix] concluded “First-episode schizophrenic patients with long-term cannabis consumption were significantly younger at disease-onset, mostly male and suffered more often from paranoid schizophrenia (with a better prognosis) than those without cannabis consumption in our investigation.” In males with personality disorder, Watzke et al[xx] reported use of cannabis to be associated with more severe symptoms, including paranoia in over half the cannabis-using group. Mathers & Ghodse[xxi] warned that a tendency to diagnose cannabis psychosis may mask symptoms of true schizophrenia, noting “A short-lived psychotic episode does occur in clear consciousness after cannabis intoxication, but chronic cannabis-induced psychosis was not found.”

 

Self-Medication?

Buadze et al[xxii] noted that most cannabis-using schizophrenia patients do not regard cannabis as a causal factor in their disease progression, many self-medicating to reduce anxiety and tension.  However Stefanis et al[xxiii] reported “Use of cannabis was associated positively with both positive and negative dimensions of psychosis, independent of each other, and of depression. An association between cannabis and depression disappeared after adjustment for the negative psychosis dimensions. First use of cannabis below age 16 years was associated with a much stronger effect than first use after age 15 years, independent of life-time frequency of use. The association between cannabis and psychosis was not influenced by the distress associated with the experiences, indicating that self-medication may be an unlikely explanation for the entire association between cannabis and psychosis.”

 

Arendt et al[xxiv], examining the ‘self-medication’ hypothesis, reported “Subjects with lifetime depression used cannabis for the same reasons as others. While under the influence of cannabis, they more often experienced depression, sadness, anxiety and paranoia, and they were less likely to report happiness or euphoria.”

 

Population studies

In a general population study of mental health in England, Freeman et al[xxv] reported “The prevalence of paranoid thinking in the previous year ranged from 18.6% reporting that people were against them, to 1.8% reporting potential plots to cause them serious harm”, noting[xxvi]Paranoia and insomnia were both strongly associated with the presence of anxiety, worry, depression, irritability and cannabis use. In a path analysis the association of paranoia and insomnia was partially explained by the affective symptoms, and, to a much lesser degree, cannabis use.”  Kalashiri et al[xxvii] found adolescent cannabis use increased the risk of paranoid reactions to cocaine.

 

IDMU Survey data:

In my 1984 survey of 607x drug users at UK festivals[xxviii] 74% admitted experiencing ‘paranoia’ at some stage, a response most strongly associated with the number of drugs tried by respondents, but also with a statistically significant association with the frequency of cannabis use.  In our 1994-1998 surveys with results analysed for the House of Lords cannabis enquiry[xxix], ‘paranoia’ (156x reports, 5.6%) was second only to ‘memory problems’ (170x reports, 6.1%) in open-response reports to “have you suffered physical or mental health problems from cannabis use – if Yes what problems?”  There was no relationship between incidence of paranoia and age of initiation to cannabis use, although users of home-grown cannabis were more likely to experience paranoid symptoms than those using soap-bar resin.

 

In our 1999 survey (Table 10), respondents were asked to rate the severity and frequency of named problems, for Paranoia although 47% of respondents reported experiencing paranoia to some degree, only 4% reported severe problems, 6% reporting regular bouts of paranoia and 1.4% reporting continual problems.  Under 5% reported lifetime incidence of psychotic episodes, but for 20% of these such episodes were a regular occurrence and severe in nature.

 

Frequency & Severity of Paranoid Symptoms among Regular Cannabis Users (1999)

Frequency

n

%

Severity

n

%

Once or twice

382

17.6%

Mild

526

24.2%

Occasionally

477

22.0%

Moderate

337

15.5%

Regularly

138

6.4%

Severe

83

3.8%

All the time

30

1.4%

Total

946

43.5%

Total ever

1027

47.3%

Base

2173

100.0%

Frequency & Severity of Psychotic Episodes

Frequency

n

%

Severity

n

%

Once or twice

57

2.6%

Mild

49

2.3%

Occasionally

25

1.2%

Moderate

30

1.4%

Regularly

8

0.4%

Severe

18

0.8%

All the time

9

0.4%

Total

97

4.5%

Total ever

99

4.6%

Base

2173

100.0%

Other studies of Therapeutic & Recreational Users

Following a randomized double-blind clinical trial of the cognitive effects of Sativex® in cannabis-naïve MS patients, Aragona et al[xxx] concluded “Cannabinoid treatment did not induce psychopathology and did not impair cognition in cannabis-naïve patients with MS. However, the positive correlation between blood levels of Delta-9-tetrahydrocannabinol and psychopathological scores suggests that at dosages higher than those used in therapeutic settings, interpersonal sensitivity, aggressiveness, and paranoiac features might arise, although greater statistical power would be necessary to confirm this finding.”  In a study of cannabinoids on nausea and vomiting associated with chemotherapy, Tramer et al[xxxi] found patients treated with cannabinoids to be 8 times as likely to report depression or paranoia and 6 times as likely to report hallucinations compared to patients treated with antipsychotic drugs.

 

In a study of long-term cannabis users in Australia, Reilly et al[xxxii] found “The most commonly reported negative effects were feelings of anxiety, paranoia, or depression (21%), tiredness, lack of motivation and low energy (21%) and effects of smoke on the respiratory system (18%).” Melges[xxxiii] reported “THC induced greater difficulties with tracking information over time, greater disruptions of self-other interpersonal perceptions, and more persecutory ideation that did alcohol or placebo

 

Summary – Cannabis & Paranoia

Paranoia is one of the most commonly-reported adverse effects of cannabis use. Acute intoxication with cannabis, particularly that with high THC content and low or no CBD, increases psychotomimetic symptoms in healthy users, including distortions of perception, delusions and paranoid ideation, however these tend to be short-lived.

 

For most users paranoia when experienced is mild and short-lived and recognised as an effect of the drug which will wear off (insight).  For a small minority of users paranoid symptoms are severe and frequent and/or prolonged and may reflect an underlying psychosis, particularly where there is absence of insight.


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[xvii] Katz G, Durst R, Shufman E, Bar-Hamburger R, Grunhaus L. [2010] Cannabis abuse and severity of psychotic and affective disorders in Israeli psychiatric inpatients. Compr Psychiatry. 51(1):37-41.

[xviii] Boydell J, Dean K, Dutta R, Giouroukou E, Fearon P, Murray R. [2007] A comparison of symptoms and family history in schizophrenia with and without prior cannabis use: implications for the concept of cannabis psychosis.Schizophr Res. 93(1-3):203-10

[xix] Jockers-Scherübl MC. [2006] [Schizophrenia and cannabis consumption: epidemiology and clinical symptoms].[Article in German] Prax Kinderpsychol Kinderpsychiatr. 55(7):533-43.

[xx] Watzke AB, Schmidt CO, Zimmermann J, Preuss UW. [2008] [Personality disorders in a clinical sample of Cannabis dependent young adults].[Article in German] Fortschr Neurol Psychiatr. 76(10):600-5.

[xxi] Mathers DC, Ghodse AH. [1992] Cannabis and psychotic illness. Br J Psychiatry. 161:648-53.

[xxii] Buadze A, Stohler R, Schulze B, Schaub M, Liebrenz M. Do patients think cannabis causes schizophrenia? - A qualitative study on the causal beliefs of cannabis using patients with schizophrenia. Harm Reduct J. 28;7:22.

[xxiii] Stefanis NC, Delespaul P, Henquet C, Bakoula C, Stefanis CN, Van Os J. [2004] Early adolescent cannabis exposure and positive and negative dimensions of psychosis. Addiction.99(10):1333-41.

[xxiv] Arendt M, Rosenberg R, Fjordback L, Brandholdt J, Foldager L, Sher L, Munk-Jørgensen P. [2007] Testing the self-medication hypothesis of depression and aggression in cannabis-dependent subjects. Psychol Med. 37(7):935-45.

[xxv] Freeman D, McManus S, Brugha T, Meltzer H, Jenkins R, Bebbington P. [2010] Concomitants of paranoia in the general population. Psychol Med. 24:1-14.

[xxvi] Freeman D, Brugha T, Meltzer H, Jenkins R, Stahl D, Bebbington P. [2010] Persecutory  ideation and insomnia: findings from the second British National Survey of Psychiatric Morbidity. J Psychiatr Res. 4(15):1021-6

[xxvii] Kalayasiri R, Gelernter J, Farrer L, Weiss R, Brady K, Gueorguieva R, Kranzler HR, Malison RT. [2010] Adolescent cannabis use increases risk for cocaine-induced paranoia. Drug Alcohol Depend. 107(2-3):196-201.

[xxviii] Atha  M.J. (1987).  Quantitative Assessment of Illicit Substance Use.  Birmingham University - unpublished MSc thesis.

[xxix] House of Lords Select Committee of Science & Technology. [1998] Cannabis the Scientific and Medical Evidence. [Volume of Evidence] 9th Report, Session 1997-98.  HL Paper 151.  London:  The Stationery Office.

[xxx] Aragona M, Onesti E, Tomassini V, Conte A, Gupta S, Gilio F, Pantano P, Pozzilli C, Inghilleri M. [2009] Psychopathological and cognitive effects of therapeutic cannabinoids in multiple sclerosis: a double-blind, placebo controlled, crossover study. Clin Neuropharmacol. 32(1):41-7.

[xxxi] Tramèr MR, Carroll D, Campbell FA, Reynolds DJ, Moore RA, McQuay HJ. [2001] Cannabinoids for control of chemotherapy induced nausea and vomiting: quantitative systematic review.BMJ. 323(7303):16-21.

[xxxii] Reilly D, Didcott P, Swift W, Hall W. [1998] Long-term cannabis use: characteristics of users in an Australian rural area. Addiction. 93(6):837-46.

[xxxiii] Melges FT. [1976] Tracking difficulties and paranoid ideation during hashish and alcohol intoxication. Am J Psychiatry. 133(9):1024-8.