In 1996, California legalized cannabis as a treatment for "any... condition for which marijuana brings relief." Although the law does not constrain physicians from approving the use of cannabis by children and adolescents, the state medical board has investigated physicians for doing so, exerting a profoundly inhibiting effect.
Even doctors associated with the Society of Cannabis Clinicians have been reluctant to approve cannabis use by patients under 16 years of age, and have done so only in cases in which prescribable pharmaceuticals had been tried unsuccessfully. The case of Alex P. suggests that the practice of employing pharmaceutical drugs as first-line treatment exposes children gratuitously to harmful side effects.
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.
A history taken from Alex and a separate interview with his mother, Barbara P., were in full accordance. The mother described Alex as a healthy baby who was "never a good sleeper." She had "a rocky relationship" with Alex's father, who had three children from a previous marriage. Alex, their second son, "always saw himself as the peacemaker when there was arguing... I think that's why, when it was time for him to go to school, he never wanted to go. He just didn't like to leave the house."
Although Alex showed facility communicating verbally, his reading and writing skills disappointed his teachers and prior to going to middle school he was evaluated for an Individual Educational Plan.
According to his mother, "They didn't say he was dyslexic, they said he 'had trouble processing things.' He wasn't acting wild in school. He was always well behaved. But they said he had ADD because he couldn't concentrate and process things." At age 11, Alex was prescribed Ritalin for attention deficit disorder.
In middle school Alex befriended some 13- and 14-year-olds, with whom he was caught stealing a car (and with whom he had shared his stimulant medication, and who introduced him to marijuana). Thus began a four-year sojourn through institutions of the Central Valley juvenile justice system and Kaiser-affiliated hospitals and clinics.
In this period, according to Barbara P., "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." Barbara P. expresses remorse that she obeyed court orders to force Alex to take his prescribed medications.
At age 13 Alex made a serious attempt at suicide by hanging himself from a tree outside his house. He was rescued by his brother returning home unexpectedly. He reports making other attempts to overdose on pills.
Alex had known since age 11, when he first smoked cannabis with his older friends, that it had a calming effect. Many of his encounters with the juvenile justice system were for marijuana possession. His mother says, "He was aware that it helped him not feel stressed out and not have headaches. It helped him concentrate. It helped him sleep. All the things he needed. But I wasn't for smoking it." She reports feeling social pressure from her Central Valley community and pressure from her husband to oppose Alex's attempts to obtain and use marijuana.
"Alex went through three rehabs--two inpatient and one outpatient, all court-ordered, all for marijuana. He could not do inpatient and I told them that. It's not that Alex wanted to be out there doing drugs, he wanted to be home! He had a thing where he didn't want to be put in an institution where he didn't know anybody. That would drive him more crazy. He ended up running from one rehab house and getting kicked out of another."
Perceiving that Alex's mental state was worsening, and in response to his repeated requests to be allowed to smoke marijuana, Barbara did research on the internet that alerted her to similarities between cannabis and Marinol (dronabinol), a legally prescribable drug. Her request that a Kaiser physician prescribe Marinol for Alex was rejected.
Through the internet she identified the author as a specialist in cannabinoid therapeutics and arranged an appointment for Alex.
A prescription was written in February 2005 for Marinol (10 mg), along with a recommendation to use cannabis by means of a vaporizer. Alex has consistently maintained he prefers smoking cannabis to ingestion by other means, due to rapidity of onset and ability to titrate dosage. ("It works great and you can use just as much as you need," he says.)
When a drug test ordered by the Probation department turned up positive for cannabinoids, Alex had a hearing at which a Superior Court judge declared that because Marinol use could mask marijuana use, he would not allow it. He explicitly refused to recognize the validity of a specialist in the field of cannabis therapeutics and ordered Alex to take only drugs prescribed by Kaiser.
Barbara P. says: "I guess judges have authority over anything. He thought Alex had a drug problem with marijuana because he had smoked it before." At a subsequent hearing another judge rescinded the order. When Alex's Probation ended in May, 2005, he began medicating exclusively with smoked cannabis.
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."
His mother reports: "We knew after about three months on Marinol that he was going to be okay. He started doing a lot better. He sleeps well, he's not on any of the other medications, I haven't had to take him to the emergency room for migraine since he first went on Marinol. He's been totally fine. He walks the dog, cleans up his room, does chores for the family. And I know that he's going to be okay. Before, I never knew what was going to happen. I couldn't picture him getting a job." Alex's father has relented in his disapproval of Alex's cannabis use, having seen its effects on the household.
The case of Alex P. is one of iatrogenic illness in which drug-oriented school counselors and administrators played a harmful role. In a previous era, psychologists would have put more emphasis on examining the family constellation. An adequate work-up would have identified Alex's insomnia as the likely cause of his poor scholastic performance. Failing an adequate work-up, the quasi-diagnosis "inability to process" led to a prescription of methylphenidate, a stimulant, for an 11-year-old with persistent insomnia. The resulting disinhibition led in turn to trouble with law enforcement, a cycle of extreme anxiety and distress, and the prescription of more drugs, irrationally chosen to counteract drug-induced symptoms.
As a result of the federal prohibition, there exist no official guidelines governing when and how cannabis should be used by patients suffering from a given condition. The Institute of Medicine Report of 1999 acknowledges the feasibility of cannabis being used to treat certain conditions when all pharmaceutical options have failed. The case of Alex P. suggests that employing pharmaceutical stimulants, antidepressants and anti-psychotics exposes children gratuitously to harmful side effects in violation of Hippocratic principles. The first-line treatment for any condition, efficacy being equal, would be the drug or procedure least likely to cause harm. Given the benign side-effect profile of cannabis, it should be the first-line of treatment in a wide range of childhood mental disorders, including persistent insomnia.
Physicians and parents both face stigma and take risks in authorizing cannabis use by children, but the risks are legal and social rather than medical. The case of Alex P. exemplifies this reality.