Psychiatric Perspective: In conversation with Dr. Murray B. Stein, Senior Medical Consultant

Our recently appointed Senior Medical Consultant, Dr. Murray B. Stein, connected with us to discuss his body of work, expertise in psychiatry, and overall perspective of the role of pharmaceuticals in the treatment of anxiety.

Dr Murray Stein

Let’s begin with something foundational: why did you go into psychiatry, and how has that path evolved to where you are today?

I’ll have to take you back a long way. I’m from Canada. I attended the University of Manitoba in Winnipeg. I had no intention of being a psychiatrist, but on one of the medical student rotations I was assigned to a unit that was working with people with anxiety disorders. This was the first time I met people whose anxiety was completely disabling. At the time, thirty years ago, there was very little known about the reasons behind these conditions, or their treatment. This got me extremely interested and I made the decision to go into the field of psychiatry. Over the course of my career, I really came to understand how disabling these conditions could be and how they could lead to depression and be associated with suicide. But also, how very treatable they were, given the right kinds of treatments. Over the years I have consulted for pharmaceutical companies who were working on drugs for anxiety or depression. The opportunity arose to consult for EmpowerPharm and their development of cannabidiol (CBD) products, which is of great interest to me.

What is the current context in which you are treating your patients, and how does CBD play a role in that?

In the past 5-10 years, I have seen many more patients using cannabis. Either before it was legalized, [regulated] cannabis products, or medical cannabis. Most recently, people have told me they’re using products with CBD. And many, if not all who continue to use it, say it’s been helping. They say they’ve benefitted from these products. The difficulty for me as a psychiatrist is that I have no idea what is in the products, what the dose is, or what the quality is, particularly when it comes to CBD.

About a year ago I was seeing a new patient with anxiety problems and she was referred by her primary care doctor who was concerned about the dose of a benzodiazepine that she was taking. After spending an hour together, I determined that the dose that she was using was just fine. She wasn’t overusing the product or abusing it. We’re almost ready to complete the visit and she pulls something out of her purse and takes a puff. I asked her, “What is that?”, to which she replied, “My CBD puffer.” She hadn’t mentioned she was using it a half a dozen times a day for her anxiety. When I asked her where she got it, she responded that she purchased it legally in California. “Can I take a look at it? Is there something that says how you should use it, or what the dosage is?”, I ask her. Nothing. And this is what I encounter frequently now. Patients are using CBD, or sometimes cannabis-based products. They and I have no idea of the quality or the dose. I don’t know if the amount they are using is higher or lower than what they should be using. It’s an information void, and I can only describe it as the wild west out there in terms of what’s available.

I’m really keen on a company that wants to develop a pharmaceutical CBD product and prepared to do randomized controlled trials to find out if it works for a given condition and the proper dose. Assuming that the products work, that company can go out and market that product so that I, as a psychiatrist, will know what my patients are getting, and have the knowledge of available studies and safety information. This would be an absolute game-changer. Right now, it’s almost impossible for psychiatrists to know what CBD their patients are taking, how it interacts with other medicines, and if our patients are benefitting in any way.

“This would be an absolute game-changer. Right now, it’s almost impossible for psychiatrists to know what CBD their patients are taking, how it interacts with other medicines, and if our patients are benefitting in any way.”

How important is it that the products work, specifically in the field of anxiety treatment?

Assurance in the product is incredibly important. Not everything is going to work for everybody but knowing that the compound has gone through rigorous testing and it’s been shown to be beneficial for the condition overall, is required. We also need to have an idea about the dose. Some doctors will recommend medical cannabis or suggest purchasing a CBD product. But I don’t feel I can do that. I require a reason to believe those products are regulated in a way that I can be confident about whether or not their applications are safe. It’s absolutely critical that if I’m going to recommend a product, it’s going to be something I can prescribe, and have assurance about its quality.

Do you see the need for an alternative to current anxiety therapies, particularly in the context of highly-addictive pain management drugs that are widely available?

Yes, I do see the need for alternatives to current anxiety therapies. At least half our patients with anxiety disorders get some benefits from the things we’re doing and the medications we have right now at our disposal. But many have incomplete responses. Many don’t tolerate the existing methods, and that’s partly why people go out and look for products that that are regulated in the hope that they’re going to get the benefit they’re looking for. There’s definitely a need for new, efficacious treatments. That’s true for anxiety, and it’s true for depression.

Opioids aren’t something that we would prescribe for anxiety disorders, but that doesn’t mean that people aren’t getting them. If that’s the case, then you know there’s a mixing of emotional and physical pain, and some patients wind up getting opioids when they never should have in the first place. But it’s also medicines like benzodiazepines that can be very useful in anxiety disorders, and I definitely prescribe them. Some patients might be overprescribed or develop abuse problems with them. For those patients, CBD could be an important alternative.

In the context of covid-19 and the projected increase of anxiety cases, what should we be thinking about in terms of post-pandemic anxiety treatment?

In the studies I’m aware of, there are marked increases in both anxiety and depression in the general population. These are national studies in the United States, some showing an astronomical doubling of rates of anxiety and depression since March 2020. Whether or not that’s going to subside when vaccines come around, it’s still going to be a long-term recovery. It definitely seems like people who had preexisting anxiety problems or preexisting depression are the ones who are most prone to having it worsen.

Within legal recreational cannabis regions, some patients will self-manage their care using available cannabis products. Will prescription CBD change those habits?

I think that speaks to the fact that some people’s needs aren’t being necessarily adequately addressed from treatments that are out there now. Or it’s become so easy to access. I think there’s always going to be people who are just going to do their own thing, even if there are licensed cannabidiol products. But I also think there will be a whole lot of people much more comfortable taking something that they know is being prescribed for them at the right dose that somebody’s monitoring.

When treating anxiety, is a prescription-based product more appropriate to over-the-counter medications that may relieve mood or other similar indications?

There aren’t really over-the-counter products known to be effective for anxiety. But one exception is alcohol. A lot of people with anxiety use alcohol to relieve anxiety and I think we all know how well that works. Many people with anxiety problems develop substance use disorders and alcohol use problems. For people trying to treat their anxiety with unregulated substances like alcohol, they have an abundance of access, and there’s really no monitoring of their use. I think that’s what we’re starting to see with the legalization of cannabis. Many people are using it to try and treat their anxiety, and I don’t think we have any idea yet about how many people may develop cannabis-use disorder problems as a result.

What is the role of pharmaceuticals in supporting mental health illness?

Therapy is really important. Psychological interventions are extremely important. But there’s still a really important role for medications, both for anxiety and depression. Having an extension or an augmentation of the kinds of treatments that we have available for these problems is really important. There have been essentially no new classes of compounds approved for the treatment of anxiety in the last twenty years. There’s a real unmet need to come up with new kinds of treatments. The development of new treatments will hopefully benefit people who haven’t completely benefitted from the treatments that we have now.

EmpowerPharm isn’t the only company realizing this problem and CBD has been talked about at length in terms of its likely anti-anxiety effects. If you go into the literature to find studies backing that up, they’re few and far between. There’s been wider recognition of the need for prescription-grade cannabinoids, and studies to show the applications. EmpowerPharm, particularly with their focus on CBD, is going about this in a way where they’re developing a product that they believe is going to have good potency in terms of CBD properties. They are planning on studying it for anxiety conditions in a way that’s going be definitive. This will let them know what doses are helpful, how long to treat people for, and then also get a really good sense of safety. That’s a complete world of difference.