Parkinsonism and Related Disorders 20 (2014) 1293e1294

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Letter to the Editor

“Medical marijuana” use in a movement disorders clinic in Rhode Island To the Editors: Marijuana is currently legally available in 22 states plus the District of Columbia, with more likely to be added. To obtain the drug legally in the state of Rhode Island, patients must ask a doctor to sign a letter from the state formally allowing the patient to use marijuana for medical purposes to treat a “chronic or debilitating disease” which produces any of several syndromes, including cachexia or wasting, severe chronic pain, severe and persistent muscle spasms, as may occur in multiple sclerosis, or agitation related to Alzheimer's disease. It is, in general, unknown how medical marijuana (MM) is being used in movement disorders patients although possible benefits have been described for tics [1], Parkinson's disease (PD) [2,3] and neurodegenerative disorders in general [4]. The American Academy of Neurology guidelines panel on marijuana concluded that data existed to support its use only in multiple sclerosis [5]. The following results are from a survey of all patients attending one movement disorders clinic who had requested physician approval of MM. Patients who requested MM but were deemed poor candidates due to dementia or behavioral problems were dissuaded and did not ask again. No records were kept on the number of patients who were not given approval. There are a variety of MM formulations and preparations available and these were not controlled by the neurologist. For this report the term MM is used inclusively for all forms of the plant and its extracts. A protocol to administer a formal survey to all Butler Hospital movement disorders clinic patients who solicited approval for legal medical marijuana use was approved by the hospital IRB. After written informed consent was obtained, every patient who had received approval by the author for legally sanctioned use of MM was asked 10 questions related to marijuana use. Thirty three patients in the BH movement disorders clinic had been given written approval for use of MM over the past two years out of a total population of 1655 different patients. Three patients never tried MM and 4 could not be contacted. Of the 26 MM users who responded, 16 had idiopathic PD, 4 had Huntington's disease (HD), 2 with essential tremor, and 1 each with: Tourette's syndrome, myoclonic dystonia, chorea of unknown origin, and spinocerebellar ataxia type 3. The range in age for PD patients was 46e84 (median 63), and for HD 56e79 (median 65). Patients with the other disorders ranged in age from 35 to 65 (median 65). All 4 HD and 6 of the 8 other non-PD patients were men. Thirteen of the 15 PD patients were men. Ten patients had taken MM prior to legalization for 4e44 years. Sixteen smoked it; three used a vaporized form; 4 ate it, including one who used an oil extract; and 3 administered it in more than one way. Sixteen used it at least once daily. Fifteen of the 16 PD patients took MM http://dx.doi.org/10.1016/j.parkreldis.2014.07.006 1353-8020/© 2014 Elsevier Ltd. All rights reserved.

for non-motor problems, primarily anxiety, but also for sleep, appetite and pain. Only one PD patient used it for rigidity and mobility. Four PD patients reported improvement in tremor and 2 in gait. Eight PD patients reported some degree of euphoria. All 4 HD patients took MM for anxiety, sleep or other behavior problem (“it puts my mind right.”), one of whom also took it to reduce chorea. The 6 non-PD, non-HD patients took MM for anxiety, appetite, pain or sleep problems primarily, but also to reduce essential tremor or myoclonus. Most patients found the drug effective. One patient took it only 4 times to treat essential tremor, found no benefit and stopped. One with HD stopped due to cost and found that he didn't miss it. One PD patient reported worsened motor function when he increased his consumption dramatically, and another, who had used the drug for 40 years on a daily basis, developed hallucinations and paranoia, forcing him to stop its use. This study reflects patients' subjective perceptions of their experience on MM. It involves only people who asked for official approval. Many of the patients had been using the drug illegally for long periods of time and therefore knew its effects. Obviously patients who had tried the drug and did not benefit would not ask for it, making this a highly biased population. How many patients use the drug illegally is unknown. Patients were not examined on and off the drug. One open label study of PD patients reported motor benefit [2] and an anonymous survey from Europe [3] reported that most PD patients who used the drug did so for motor benefit. That was the opposite of the findings in this report, in which almost all patients, regardless of their movement disorder reported taking the drug for non-motor symptoms, and occasionally experiencing motor benefit, primarily in tremor, which may reflect reduced anxiety. Although anecdotal evidence suggests benefit of different forms of cannabis in treatment of various neurologic disorders, systematic reviews [5] have found limited evidence supporting its use. These findings, with an extremely limited and non-random population suggest that some preparations of MM are perceived as being useful in treating anxiety, sleep disorders, pain, and reduced appetite in a variety of different movement disorders. Financial conflicts of interest Consulting: Acadia; Lundbeck; Roche; Pfizer; Auspex. Research: NIH: EMD Serono; Teva; Schering Plough; Avid; Royalties: Demos Press. References [1] Muller Vahl KR. Treatment of tic syndrome with cannabinoids. Behav Neurol 2013;27:119e24.

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Letter to the Editor / Parkinsonism and Related Disorders 20 (2014) 1293e1294

[2] Laten I, Treves TA, Roditi Y, Djaldetti R. Cannabis (medical marijuana) treatment for motor and non-motor symptoms of Parkinson’s disease: an open label observational study. Clin Neuropharmacol 2014;37:41e4. [3] Venderova K, Ruzicka E, Vorisek V, Visnovsky P. Survey on cannabis use in Parkinson’s disease: subjective improvement of motor symptoms. Mov Disord 2004;19:1102e6. [4] Iuvone T, Esposito G, DeFilippis D, Scuderi C, Steardo L. Cannabidiol: a promising drug for neurodegenerative disorders? CNS Neurosci Ther 2009;15: 65e75. [5] Koppel BS, Brust JC, Fife T, Bronstein J, Youssof S, Gronseth G, et al. Systematic review: efficacy and safety of medical marijuana in selected neurologic disorders: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2014;82:1556e63.

Joseph H. Friedman* Butler Hospital, Dept of Neurology, Alpert Medical School of Brown University, Providence, RI 02906, USA *

Tel.: þ1 401 455 6669; fax: þ1 401 455 6670. E-mail address: [email protected] 13 May 2014

"Medical marijuana" use in a movement disorders clinic in Rhode Island.

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