JJ’s case highlights the reality that some clinical situations remain elusive and are haunted by clinical uncertainty. He exhibits a psychiatric syndrome, a complex set of behaviors for which there is no clearly described physiologic etiology/diagnostic criteria at this time. Although psychiatric classification can project a sense of “objective certainty,” it becomes less and less convincing that medicine is proceeding with certainty when three different DSM IV codes are required to diagnose a seven year old child’s behavior. In addition, the diagnosis of Bipolar Disorder in the youth is relatively new in the psychiatric literature, and it has often been linked as a co-morbid condition to impulse control disorder. Its diagnosis and treatment remain controversial.[1]^,[2] So, from a physician’s perspective, JJ’s case is located at the epistemological edge of medicine. There is no clear diagnosis or treatment plan for JJ. There is no “standard of care” within the profession for JJ’s 16 physicians to know how to proceed.

Without a “standard of care,” medicine often straddles the line between standard therapy and the “trial and error” approach of informal scientific research. A physician tries an agent that she believes will help the patient with their particular problem, and then she observes for evidence of benefit and for evidence of adverse effects. For four years, JJ’s hyperactive and aggressive behavior has been informally researched via 19 different psychiatric medications that only exacerbated his underlying behavioral problems. In short, within the known repertoire of the profession, no apparent benefit has been found despite multiple adverse effects. The best alternative that the psychiatrists offered his mother was a “strictly structured environment,” a vague and arguably ineffective long term strategy to help JJ integrate into the non-structured environment of societal life.

As a proactive surrogate of her son’s health and well-being, JJ’s mother researched other potential means to help her son. Staying within the established medical profession, she sought physicians who incorporated “alternative medicines” in their practice. Anecdotally, medical marijuana has provided JJ with the most beneficial behavioral results thus far, with no apparent adverse effects. If JJ had a rare form of cancer that evaded an exhaustive use of standard medications, few would question the parental search for research protocols, investigating alternative medications. So, why should this case be any different?

Social stigma still surrounds the use of marijuana. Historically, the “recreational” use of marijuana has been associated with a lack of morals, a lack of motivation, and a suspicion of leading users to more advanced illicit drug use; beliefs that have been refuted by recent research.[3] The clinical use of marijuana is also blocked by its federal classification as a Schedule I drug; those drugs listed in the Controlled Substance Act (CSA) with a high potential for abuse, no currently known medical use, or lack of an acceptable safety profile.[4]  In 1970, when the CSA was passed, there was very little research involving marijuana as a medicinal agent. Since then, there has been a tremendous amount of research questioning its abuse potential, supporting its use for nausea, AIDS wasting, chronic pain (particularly from spastic or amputated limbs), and other chronic clinical conditions.[5] The Institute of Medicine has recently reviewed the use of medical marijuana for multiple medical problems and has called for continued research on specific cannabinoids within marijuana.[6] Proposition 215 represents a states response to the IOM’s call and a challenge to the judgment of prior federal legislation.

Nonetheless, there are multiple reasons why JJ’s clinical management should be closely scrutinized. JJ suffers from a relatively rare condition, whose manifestation is severe. It is not well characterized, and there is no known “standard of care” for his condition. JJ is a vulnerable member of society as a young child, and since no available agents have proven beneficial, JJ is in a desperate situation. JJ’s mother/surrogate is faced with either no treatment beyond the “strictly structured environment,” or his experimental use of an unproven agent.

Now, multiple agents might be proposed by the professional community as a potential treatment option for JJ’s condition (including one of the cannabinoids of marijuana), but to protect the patient from the random whim or scientific hunch of a researcher, each agent must be methodically screened for evidence of both benefits and adverse effects. During the course of the research trial, if a disproportionate risk is identified, the patient/surrogate should be duly notified and given the opportunity to withdraw from the trial. Although JJ’s current pediatrician appears to have safely adjusted the oral dose of marijuana, he should remain accountable to the rest of the profession in detailing and reporting his clinical experience of marijuana, particularly in the pediatric population via an Institutional Review Board. Another dose of marijuana may be just as effective with an improved safety profile. Without proper regulation and oversight in researching unknown agents, physicians in their admirable desire to help the vulnerably ill may be unwittingly trespassing the ancient dictum, Primum, non nocere.

 

Works Cited:

Biederman J, Hammerness P, Doyle R, Joshi G, Aleardi M, Mick E. "Risperidone treatment for ADHD in children and adolescents with bipolar disorder." Neuropsychiatric Disease Treatments 4, no. 1 (Feb 2008): 203-7.

Harris, Gardiner. "Use of Antipsychotics in Children Is Criticized." The New York Times, November 19, 2008: A 20.

Joy, Janet E, Stanley J Watson, and John A Benson. Marijuana and Medicine: Assessing the Science Base. Institute of Medicine, 1999.

Medicine, New York Academy of. The La Guardia Committee Report: The Marihuana Problem in the City of New York. New York City, New York: Mayor′s Committee on Marijuana, 1944.

Shedler, J., and J. Block. "Adolescent drug use and psychological health: A longitudinal inquiry." American Psychologist 45, no. 5 (May 1990): 612-30.

 

Bibliography

Biederman J, Hammerness P, Doyle R, Joshi G, Aleardi M, Mick E. "Risperidone treatment for ADHD in children and adolescents with bipolar disorder." Neuropsychiatric Disease Treatments 4, no. 1 (Feb 2008): 203-7.

Harris, Gardiner. "Use of Antipsychotics in Children Is Criticized." The New York Times, November 19, 2008: A 20.

Joy, Janet E, Stanley J Watson, and John A Benson. Marijuana and Medicine: Assessing the Science Base. Institute of Medicine, 1999.

Medicine, New York Academy of. The La Guardia Committee Report: The Marijuana Problem in the City of New York. New York City, New York: Mayor′s Committee on Marijuana, 1944.

Shedler, J., and J. Block. "Adolescent drug use and psychological health: A longitudinal inquiry." American Psychologist 45, no. 5 (May 1990): 612-30.