The current approach to Cannabis is seriously impoverished. It needs to be much more focused. This is because where Cannabis use is particularly problematic is where there is comorbidity. Comorbidity refers to the combination of a substance abuse problem with an underlying psychiatric condition. First of all this comorbidity requires a more integrated/ holistic approach to the problem. Additionally, the demographic most at risk from Cannabis use is adolescent users. These adolescents are not caught by the mental health services and when they show up as users of addiction services it is already too late.
Cannabis abuse then is an issue that underscores the importance of the developing area of Primary Care in Ireland. Primary Care refers to health care at a basic level for people making an initial approach to a doctor of nurse for treatment. It is at this stage of initial approach that an earlier and targeted intervention may be achieved. A young or psychologically vulnerable patient may, for example, go to a General Practitioner (GP) presenting with respiratory difficulties long before approaching any addiction services.
Cannabis as a mental health issue
Cannabis use is associated with high rates of comorbid psychiatric disorders, notably mood and anxiety disorders. It is for this reason that it highlights the importance of an integrated approach between psychiatric services, addiction services and primary health care provision. Early marijuana use is associated with the development later in life of serious mental health disorders: addiction, major depression, anxiety and psychotic disorders such as schizophrenia.
Adolescents are the most at risk group when it comes to Cannabis abuse and they are often outside of the reach of addiction services or psychiatric services. John Knight MD, Associate professor of Pediatrics in Harvard Medical School,suggests that ‘[t]he earlier an adolescent starts smoking, the earlier the potential changes to brain structure and function’. THC, the main psychoactive property of Cannabis, acts on the endocannabinoid system which plays a critical role in brain development and normal function; it affects the growth, differentiation and final positioning of neurons as well as connectivity among neurons.
In a 2008 article in the Journal of European Child and Adolescent Psychiatry, G. Dorard et al, outline a study of Cannabis abuse in adolescents. Their study study involved thirty two adolescent and young adult cannabis users. In that study they found that there was a remarkably high 85% comorbidity rate. The main motivation for Cannabis use given by users in this study was to achieve detachment and anxiety sedation. The average age of users in the group was 17.2 years of age which the authors worrying remark is ‘almost 8 years younger than the mean age at the time of first consultation for drug withdrawal’.
The answer then to this problem is a continued emphasis of Primary Care in order to reach younger and more psychologically vulnerable users. This would involve the continued advancement of a shared care approach between primary care and specialist mental health services. When these vulnerable Cannabis users reach out for help there first point of contact is usually their General Practitioner (GP). GPs are described as ‘gatekeepers’ to the mental health service in the A Vision for Change.
In the HSE guidance document produced by the sub group on the mental health and primary care their role is stressed. In the guidance it is suggested that ‘[all staff including GP’s and Practice staff are particularly well placed to have a key role in mental health service delivery in primary care.’ It further suggests that ‘[t]he effect and impact of […] drug misuse on a person’s mental health needs to be highlighted’. It further recommends that the ‘preventive role of the Primary Care Team in this area needs to be supported by training and resources from Specialist Services.’
G. Drorard et al, ‘Affect dysregulation in adults and young adult cannabis users’, (2008) Eur Child Adolesc Psychiatry, 17: 274
Elaine Gottlieb, ‘ Cannabis: A danger to the Adolescent Brain – How Pediatricians address Marijuana use’, http://www.mcpap.com/pdf/Cannibis.pdf
‘A Vision for Change – Report of the Expert Group on Mental Health Policy’ – http://www.hse.ie/eng/services/Publications/services/Mentalhealth/Mental_Health_-_A_Vision_for_Change.pdf
‘Advancing the Shared Care Approach between Primary Care Specialist Mental Health Services’ – http://www.hse.ie/eng/services/Publications/services/Mentalhealth/Advancing_the_Shared_Care_Approach_between_Primary_Care_Specialist_Mental_Health_Services.pdf