Psychotic Symptoms in Some Marijuana Users Challenge Providers

Today's increasingly favored delivery systems for the psychoactive compound in marijuana have heightened the risk of psychotic symptoms among users, according to leaders in the treatment and research communities. An addiction treatment center medical director tells Addiction Professional that in a growing number of cases he encounters, the effects of vaping THC or using marijuana wax have become so pronounced that the individual cannot successfully be helped in a traditional substance use treatment setting.

“They can't engage,” says John Roberts, MD, medical director at Pavillon in Mill Spring, N.C. “We have to find them places that can manage people with persistent mental illness. There are not many options.”

The high concentrations of THC in marijuana wax (derived from oils in the plant) and in increasingly popular vaping products are having a dominant presence in many using communities. Roberts can quickly cite numerous case examples of young-adult users who had never shown prodromal symptoms of schizophrenia but are entering treatment exhibiting psychotic symptoms.

Many have become obsessed with delusional thoughts about family members, or feelings of persecution, Roberts says. “Most of the time, it takes several weeks for this to clear.”

Roberts wonders of these users, “Did they stress their brain and uncover a predisposition to psychosis?”

The risk of psychosis appears to be greater in individuals who had become regular users of marijuana at a younger age, he points out.

The situation overall reminds him of the period when synthetic drugs were growing in popularity and leading in the extreme to troubling, headline-grabbing behaviors among some users.

What the research suggests

Susan Weiss, PhD, director of the Division of Extramural Research at the National Institute on Drug Abuse (NIDA), tells Addiction Professional that while research has shown that marijuana use can cause acute psychotic symptoms, “such studies are unable to determine whether marijuana use causes psychotic disorders, such as schizophrenia, in someone who does not have other predisposing factors."

Weiss adds, “There is a growing body of evidence to show that the use of higher-potency marijuana and particularly the regular use of high-potency marijuana is associated with increased risk of psychosis.”

She advocates clear messaging to young people about the risks of marijuana use, without venturing into overstatement that might endanger youths' engagement with prevention messages.

Treatment options

Roberts says he has been leaning toward use of the antipsychotic aripiprazole (Abilify) to address psychotic symptoms in these patients, at a starting dose of 10 mg. “It is not as sedating and has fewer metabolic side effects,” he says. Another option is risperidone (Risperdal), though it is associated with a greater risk of extrapyramidal effects.

Effective behavioral treatments for marijuana use include cognitive-behavioral therapy, motivational enhancement therapy and reward-based contingency management approaches, adds Weiss.

The answers to a question Roberts will ask a group of his patients illustrate the overall lack of knowledge about the risks associated with the delivery methods for THC. He will ask them which drug carries the highest potential for psychotic effects, and most will incorrectly answer methamphetamine instead of marijuana, he says.

Perception of risk from marijuana continues to decline as opportunities to use the drug legally proliferate, he says. “More people are willing to try it,” he says.

Marijuana also appears to be the one constant for many individuals who otherwise might switch to or from other substances, Roberts says.

Yet he also sees the lack of awareness about risk extending well beyond the drug-using community. “The word hasn't gotten out, even in the field among the older professionals,” he says.