Washington Center For Psychiatry

American Journal of Clinical Psychiatry

August 2004

By Alen J. Salerian, MD

Sir: There have been numerous reports of the sexually enhancing effects of tetrahydrocannabinol (THC) (1), and this letter reports positive outcome in a female bipolar patient after dronabinol use. Dronabinol, a medication currently labeled as Schedule III, is approved by the US Food and Drug Administration (FDA) for treating nausea and increasing appetite. Δ9-tetrahydrocannabinol is the sole synthetic psychoactive ingredient of dronabinol. While dronabinol may still require additional supervision needed for a controlled substance, because of its Schedule III classification in the controlled substances list of the Controlled Substances Act, the medication is not as restricted as a medication from the Schedule II list. In practical terms, dronabinol may be prescribed by telephone with up to 6 refills in a 6-month time period.

Case report. Ms. A, a 43-year-old married African American woman employed as a midlevel manager for a federally funded organization, had a history of bipolar disorder, mixed type (DSM-IV criteria), with numerous hospitalizations triggered by noncompliance with her medications. After her last relapse, she had readily admitted that the single most important factor in her noncompliance was sexual dysfunction secondary to her psychotropic medications (olanzapine, valproic acid, and paroxetine). In the past, buproprion, methylphenidate, and yohimbine had been tried, but the patient had experienced no relief from her major complaint of anorgasmia. She had no history of substance abuse.

In November 2001, Ms. A was instructed to use dronabinol 10 mg prn 1 hour before sex. She was advised that she should not drive a vehicle for 24 hours after using dronabinol and that treatment of sexual dysfunction was a non-FDA-approved use of dronabinol.

Ms. A completed self-rating of her sexual function on a scale from 0 to 10, with 0 representing the worst and 10 representing the best, and her ratings after two and a half weeks showed remarkable overall improvement. Dronabinol improved the patient’s sexual function on all of the domains assessed, including libido, arousal, lubrication, orgasm, and overall quality of her sex life.

Two years after her last hospitalization, Ms. A remains functional, employed, fully compliant with her medication, symptom-free, and sexually satisfied. There is no evidence that she has abused dronabinol. She has been using dronabinol an average of two times weekly.

An interesting and potentially serious complication occurred during the course of treatment. In routinely administered testing at her workplace, Ms. A tested positive for THC and was immediately suspended from work, but, fortunately, after a second opinion from a university-based colleague and a medical report from me addressing the rationale for her pharmacotherapy, the medical director of her company ruled in her favor, and she resumed her job.

Dronabinol’s potential for producing sexually enhancing effects that reverse psychotropic-induced sexual dysfunction is probably multifactorial. Dronabinol caused euphoria and relaxation, and because these emotional states promote sexual pleasure, it is likely that the positive sexual response is due in part to this very avenue. Most likely, there are other unknown mechanisms involved in dronabinol sexually enhancing effects. Particular attention must be paid to patients with bipolar disorder due to the greater risk of substance abuse among bipolar patients. Further double-blind, placebo-controlled studies are needed to establish the efficacy of dronabinol as an enhancer of sexual dysfunction. The potential for abuse is a risk and must be considered. Further, because Δ9-thc is the sole psychoactive ingredient of dronabinol and cannabis, clinicians must remain aware of the adverse physiologic consequences of cannabis use (2-5), and the clinical decision to prescribe dronabinol should rest on the overall risks and benefits of side effect management of bipolar patients.

Dr. Salerian has served as a consultant for and received honoraria from Eli Lilly, Pfizer, Janssen, Wyeth-Ayerst, SmithKline Beecham, and Shire.

References

1. Powell J, Fuller WR. Marijuana and sex: strange bed partners. J Psychoactive Drugs 1983;15:269-280
2. Kolodny RC, Masters WH, Kolodner RM, et al. Depression of plasma testosterone levels after chronix intensive marihuana use. N Engl J Med 1974;290:872-874
3. Besch NF, Smith CG, Besch PK, et al. The effect of marijuana on the sevrection of luteinizing hormone in the ovariectomized rhesus monkey. Am J Obstet Gynecol 1977;128:635-642
4. Smith, CG, Moore, CE, Besch, NF, et al. The effect of marijuana on the secretion of sex hormones in the mature rhesus monkey. Clin Chem 1976;22:1120
5. List A, Nazar B, Nyquist S, er al. The effects of Δ9-tetrahydrocannabinol and cannabidiol on the metabolism of gonadal steroids in the rat. Drug Metab Dispos 1977;5:266-272