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6915-2 Cannabis Use Disorder Training for Inspira ...
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We appreciate you, uh, you know, doing this for us and we're really looking forward to it. And like I said, I'll give it like, maybe, what do you think, Adam, another minute or do you think we have everybody before we start? I'd say another minute, definitely. Okay. I'll give another minute. Great. Well, I'm, I'm really quite thrilled that you're interested in substance use disorders. It's, you know, I've been doing this work for 20 plus years. I finished residency in the last century. It's been so underserved and, and sort of in the, the dark corner of medicine for so long and I'm really quite relieved that, you know, there's an interest and a dedication to this. Yeah. Yeah, certainly. Um, so we definitely look forward to hearing all your insight, being that you've done this, uh, you know, for quite some time. Um, I mean, our, our population is pretty diverse. I mean, the, we, we see a lot of the rural population. We also see, uh, some of the urban populations, we have a very diverse mix of, uh, groups of patients we treat it, but across the board, we see a lot of, um, you know, patients with comorbid, you know, substance use and mental health, uh, disorders. So I think this will be really informative for the, for the entire group. Great. Um, should we get started? You think Adam? Yeah. Okay. Perfect. Um, so we have with us today, uh, Dr. Diana Martinez. She's a professor of psychiatry, uh, who specializes in addiction research at Columbia University Medical Center. Uh, she's also a consultant and trainer for the Opioid Response Network, uh, uh, who provides trainings on how, um, including education, uh, not just for trainees, but also for, uh, middle, high school students, parents, teachers, the community at large. And, um, as she said earlier, she's been doing this for a very long time, so a lot of expertise in this. So we welcome her to, um, our programs and, uh, look forward substance use, uh, presentation. So I'll let you take it away. I'll be in the background. If you need any, if you need any assistance, um, Adam or Dr. Hirsch is our, uh, one of our chief residents for this year. Uh, so he's also here to kind of help facilitate if there's anything that you need from us. Great. Great. Thanks. Um, I will admit I have like a ton of slides and not a huge amount of time, so I might, I talk fast too, but please feel free to interrupt me. Stop me. Ask questions. I don't mind just, you know, ask me anything along the way that seems unclear because, um, you know, it's a topic that I love, so I tend to try to cover a lot. Um, so let me share my screen and let me check. I hope you see the slideshow. We do. Okay. Perfect. All right. So let me start just, you know, to thank the ORN, the ORN is funded by SAMHSA. It really provides a lot of support for this work. You can always contact them. It's not just opioids. It's also alcohol, cannabis, any, anything that you would like training on, we can, we can provide. And if we need to develop something, we're happy to develop something for your group specifically. Um, so let's talk about, let's start with the endocannabinoid system. It's really quite an interesting system, you know, it's sort of one of these diffuse neurotransmitter systems that, you know, is we, we think about the brain, but really exists throughout the whole body, has a wide, huge range of different functions from modulating the immune system, stress response. Um, but you know, we're going to talk about the brain because we are psychiatrists and of course that's the most important organ. I'll leave the GI tract and liver to others. Um, you know, so the brain makes its own cannabinoids, uh, they're called anandamide and 2-AG, and these bind to the CB1 and CB2 receptors. I have a image of a PET scan here of the CB1 receptor, um, CB2 receptors are in very low concentration in the brain, unless it's some sort of inflammatory state. So we're really going to be talking about CB1 receptors. And here you just see a distribution of the CB1 receptors, and as you can see, it's widespread. So we have some receptor systems in the brain that are kind of very widespread. And when they're like this, if it's not glutamate and GABA, it tends, there tend to be modulatory, you know, glutamate and GABA really drive processing in the brain. So something like the endocannabinoid system kind of modulates this activity. I often liken the endocannabinoid system to, um, like the power strip for a computer, it sort of prevents overload of the brain. So when somebody uses cannabis, it has the effect of sort of slowing things down, like a movie in slow motion. And that's sort of how you're modulating the endocannabinoid system of the brain with cannabis use. So let's talk about cannabis use in psychiatric patients. So we all know cannabis use is on the rise in the United States. It's kind of everywhere now. I have, you know, a 21-year-old kid and a 17-year-old kid, so I have these discussions with them constantly. But you know, what is really at stake here is cannabis use among patients with psychiatric disorders. Substance use with patients with psychiatric disorders runs the highest risk of developing a cannabis use disorder. So even though rates are going up, we really need to focus on our patients. And here I just have the odds ratio of different psychiatric diagnoses of developing a substance use disorder to cannabis. As you can see, the highest risk is having another substance use disorder. So alcohol, tobacco, for example, run a very high risk of then developing a cannabis use disorder as well. But you know, really it runs the gamut. This is personality disorders, mood disorders, anxiety disorders. All of these increase the risk. This is an odds ratio down here of running, of developing a substance use disorder. So we need to be really mindful of this when it comes to our psychiatric patients. And today I'm going to really focus on two conditions. I'm going to focus a lot on ADHD and depression anxiety. I don't have a lot of time, otherwise we could go into bipolar, psychosis, PTSD, other types of disorders. But I'm going to focus on these today because they're the most common. So we have data showing that 53% of non-daily cannabis use disorders and 57% of daily cannabis use disorders meet criteria for ADHD. It's what I see constantly. So I do research in cannabis use disorder and I'm constantly asking about comorbidities and ADHD is really at this point top of the list. And the good news though is that we can do something about it, which I'll be talking about more in this talk. When it comes to depression anxiety, it's about 20 to 30% of cannabis use disorder patients have these disorders. So let's dive in. So I'm going to be talking a lot about self-medication. I'm a huge believer in self-medication. I can tell you part of the neuroscience community for a while sort of didn't really believe in this topic, find that a little odd. As clinicians, we know that this is really a major driver when it comes to substance use disorders. So when it comes to ADHD, cannabis really reduces a lot of the nervous energy and irritability and agitation that the patients feel. And when it comes to ADHD, we often think about the impulsivity and the distractedness and the moving. But when you talk to patients with ADHD, you will see that they have a lot, they report a lot of agitation, irritability, and just kind of nervous baseline energy. Cannabis really helps smooth that out. So it makes sense that it's a major issue when it comes to comorbidity. Certainly when it comes to depression, cannabis lightens mood, it can help us sleep, which is a major issue in patients with these disorders. Anxiety disorders, I mean, cannabis is sort of famous for lowering anxiety and fear, and it can really help with social stress, which is often common with patients with anxiety disorder. With PTSD, cannabis will reduce stress, heighten anxiety, schizophrenia can lighten mood, help with social situations, bipolar disorder, again, helps with agitation, irritability, and sleep. So all of these symptoms in psychiatric disorders contribute to the use of cannabis as self-medication. But as I'll discuss, cannabis doesn't really treat these disorders. I'll go into this more. It's not a treatment, and I'll explain why in this talk. I'm going to start with the case study. And this is a case study. This is something that I see on such a regular basis. All my research in cannabis use disorder is in participants who have this disorder. So it's all human subjects research. And this is just a scenario that I see constantly. So I'm going to describe a patient who is 25 years old. He had struggled in college. He attended five semesters between two universities. Now he's back at home working in a restaurant, and his parents want him either treated or to move out of the house because he has a cannabis use disorder. So when you talk to him, though, he had ADHD going back probably to middle school, high school, not diagnosed, not detected, which is common with what we see. He started using cannabis in high school, started early in ninth grade. Ninth grade is a little early to be starting cannabis use. And he found it helped with social issues. So when we think about ADHD, we often think about schoolwork and not making good grades. But patients with ADHD have a lot of issues with getting along socially, and it's a huge issue in high school. Socialization in high school is a big thing. And if you're having trouble with social situations and cannabis helps, it's incredibly reinforcing because that's kind of the major factor that happens in high school, right? Cannabis helped with the social issues. He went from high school to college. His grades were okay in high school. You know, in high school, there's a lot of guardrails. You get to college, there's none. And so his academics performance definitely suffered. He was diagnosed and treated with methylphenidate at age 20, so part of his hardship at college was addressed. Methylphenidate definitely helped. However, his cannabis use continued. At this point, you know, he's an adult, has to deal with his own medical issues. He's given a prescription for methylphenidate, however, it was stopped because his urine tested positive for THC. So he no longer had access to methylphenidate. Things went down from there, and he's required to take academic leave. So, you know, cannabis and ADHD, I'm not surprised. My patient comes into me. He tells me how, you know, cannabis is a treatment for ADHD, and so that's why he started using it and continued using it. There's a lot of advertising online that says cannabis can improve ADHD despite the complete lack of evidence. I'm going to talk about three websites here. One's called VeryWellHealth, another one VeryHeal and Healthline. Now these are fairly reputable sites. These are sites that honestly have a lot of vetting, and if you look up something on these sites with respect to cancer or heart disease, they don't have equivocal data. But when it comes to cannabis, they do. They have things like, you know, can marijuana treat ADHD? The answer is no. But why would you even consider this on a website that's giving health information? And just, you know, just so you know, I do have letters out to these organizations. I complain a lot about this. You know, here it's like, you know, can you use cannabis instead of medication? You know, like you can use cannabis instead of your ADHD medication. And you know, even VeryWellHealth, most of the time within these articles, it'll, you know, qualify, well, cannabis hasn't been treated. But the real answer here is that no, this is not a treatment. This is not a solution. So what does the data show? It shows absolutely no evidence of ADHD improvement with cannabis use. There's a study that's cited all the time. It shows that patients with ADHD who are using medical marijuana took less ADHD medication. Of course, we know that doesn't mean that medical marijuana replaced the ADHD medication. It means that people stopped taking the medication that they needed when they started using cannabis instead. Other studies are self-report. Patients reported that cannabis alleviated their symptoms and medication of side effects. And as I mentioned, I don't doubt that that's the case, but that doesn't mean that cannabis is a treatment. There is one randomized controlled study in the whole bunch of research that compared THC with CBD to placebo. So this is a well-done study. It was done within the UK. It's a spray. It's called Sativex. It's a one-to-one ratio of THC to CBD and compared it to placebo, and there was no improvement in ADHD. So this is really the only research that we can go by if we're trying to ask this question. So now let's back up in time. As I mentioned, my patient had ADHD as a teenager, and this is something that I see all the time. It's a significant risk factor, not only for addiction to cannabis, but all types of addiction. So this is data looking at children between the ages of 12 to 17 who have ADHD and the risk of drug use and substance use disorder down the road. So you can see here there's an increased risk. So one would be the general population. The odds ratio goes up from there. The highest risk, as you can see, is nicotine dependence. We also have cannabis or marijuana. I use cannabis instead of marijuana. Cannabis use, any drug or alcohol dependence, marijuana drug dependence, nicotine use, cocaine, alcohol, and alcohol use. So what this shows overall is that teenagers who have ADHD are at a high risk for using alcohol and all drugs in high school and at a higher risk of developing an addiction down the road. And this is just incredibly common. This is what I see all the time. And I will also add, even when it comes to opioid use disorder, the prevalence of ADHD either in childhood or as an adult is very common, and it's a high risk. And the more severe the ADHD, the greater the cannabis use and the higher the risk of a cannabis use disorder. However, the news is we can change this. We can treat this. If we're able to go back in time, this is why I give a lot of talks to high schools, parents and students, is because the data shows that if we treat ADHD early, we can actually prevent this from happening. So here's cannabis use. This is the Monitoring the Future study. It's a huge study of high school students. And this is the population risk of using cannabis as a high school senior. It's about 30%, 20 to 30%. And this is what happens if you treat children with ADHD. So if you treat children prior to age nine for ADHD with stimulants, you eliminate that risk. These two are not significantly different from each other. So it means we have to catch children earlier, and we have to treat them for ADHD. We have to treat with stimulants, and we have to treat them consistently. I know it's difficult. I know there's like, I know the laws, the regulations with scheduled substances is miserable, but it really is a crisis, and we have to do more for this. And this is data just showing that it's not just cannabis use, that if we treat children early and consistently, we decrease the risk of binge drinking, cigarette smoking, cannabis use, even cocaine use, and any substance use disorder in children if we can do it early enough. And I know it's a challenge, but I'm trying to just get this message out there. And even if we treat adults, we can still get this out to our communities, the importance of this information. So I'm going to go back to my patient, my 25-year-old patient. So as I mentioned, he was treated with methylphenidate. He improved. His grades improved. His ability to complete his schoolwork improved, but he lost access to care because he wasn't abstinent from cannabis. And this is really quite problematic because what's happening commonly is that patients who have ADHD test positive for cannabis, they lose their prescription. What needs to be happening is we need to be addressing, maybe we're not treating well enough. Maybe that ADHD required more medication. Maybe it required behavioral treatment on top of medication. Rather than withholding care, we should be asking, how can we treat better? We don't do this with diabetes. We don't be like, oh, your hemoglobin A1C went up. No more medication for you. We don't do this with other disorders, but this is common in our communities. So what should we be doing instead, instead of withholding care? Well, we can use methylphenidate. Methylphenidate is recommended for ADHD as a first-line treatment in Canada, practice guidelines in Canada. It definitely treats ADHD in adults, but without CUD, but we don't really know what it does with cannabis use disorder. So let me back up a minute. Methylphenidate is first-line treatment for ADHD in the United States. In Canada, there is a push towards using it for ADHD with cannabis use disorder. We're not at that point yet here. However, it should be a consideration. We don't have any research with methylphenidate for treatment of ADHD with cannabis use disorder. There's just a lack of data. We do have a study looking at ADHD with cannabis use disorder on adamoxetine. Adamoxetine was used at flexible dosing up to 100 milligrams a day versus placebo for 12 weeks. The ADHD improved. The cannabis use disorder didn't change. Now I do want to point out, this is a study from 2010, has not yet been replicated, and it needs to be. I suspect that if we went back and looked at this data, we might see some improvement because back when this study was done, we required abstinence as an outcome measure, not just decrease in use. Also this study didn't combine adamoxetine with behavioral treatment or adamoxetine with other medications, for example, guanfacine. So what could we be doing when we have patients who have ADHD and cannabis use disorder? We should consider methylphenidate if it's an option. If there's an opportunity for close observation and hopefully with a family member who can be involved, it should be a consideration. That's not always the case, so we would definitely consider adamoxetine for treating ADHD with cannabis use disorder. Guanfacine may help. Guanfacine is generally used for ADHD in children. However, there's pilot studies showing that it may decrease cannabis use and withdrawal. But we definitely have a lack of data when it comes to how do we manage this patient population. Stay tuned. We are doing clinical trials in this regard. We can start now with trying to treat patients, even if we just start with behavioral interventions. Even if we just start with having people recognize that they have ADHD and that cannabis is being used as a self-medication, it's a place to start. Now I'll switch and talk a little bit about depression and cannabis use. This is data, again, from children showing that children between the ages of 12 to 17, if they have depression, shown here in the blue bars, are much more likely to be using cannabis or other drugs compared to those who don't have depression. Treatment does, like ADHD, does reduce the risk. So if we can do more to treat adolescents and teenagers for depression, we can do more to try and prevent cannabis use and cannabis use disorder down the road. So let's shift gears. Let's talk for a minute. So what's the problem with self-medication? I get asked this question a lot. Like, well, if cannabis makes my symptoms better, if it makes my ADHD better, if it makes my depression better, why can't I use it? And the first problem is that the relief is only temporary. You know, the relief that cannabis provides as self-medication only lasts during the time of intoxication. So if I'm feeling anxious and I use cannabis, I definitely feel less anxious, but I'm also intoxicated. That relief from anxiety doesn't persist beyond the period of time of intoxication. So as the drug use wears off, the anxiety comes right back. It's the same with alcohol. If I use alcohol for social anxiety, I feel more social while I'm intoxicated, even if it's mildly intoxicated. But as soon as that intoxication goes away, the social anxiety comes right back. And then the second reason is that self-medication definitely increases the risk of developing a cannabis use disorder. You know, I say this to teenagers all the time. Psychiatric symptoms happen all the time, right? Day and night, we can't control when they happen. They don't just happen, you know, after work on a Friday. And so if I'm using cannabis to treat a psychiatric disorder I'm gonna be using cannabis day and night. I'm gonna be using it at times that are inappropriate to be using it when I need to be getting things done. And over time, the use of drugs on a regular basis becomes a habit. And once it becomes a habit, it generally lends itself to becoming a substance use disorder. So these are the criteria for a substance use disorder. I won't go over them, you know, just to bin them in groups. It's impaired control over substance use, social impairment, risky use, and pharmacological effects. We divide these into mild, moderate, or severe substance use disorder. A mild substance use disorder is meeting only two to three of these criteria. And it's really important that we do a better job as the medical community of recognizing a mild substance use disorder. I will tell you most of the research, I think almost all of the research is in severe substance use disorders. We have neglected mild for a long time and we need to be doing more about it because just like, you know, just like diabetes or hypertension, it always begins mild. The earlier we intervene, the easier it is to treat. And, you know, so I think we have an obligation to inform our patients of the criteria for substance use disorder because they can really also monitor themselves. And, you know, we often, you know, I use the word now substance use disorder instead of addiction. I don't love the word. It's got too many S's, substance use disorder. But, you know, you can't tell a patient they have a mild addiction. That goes over very badly. But we can talk about a mild substance use disorder. So when I talk to patients or I talk to, you know, high school students about substance use disorder, I don't really use these criteria. They're kind of vague. You know, they're a little too vague. So I try to put this in common, you know, everyday language, you know, drug being used in larger amounts or taken over a long period of time. I ask people, are you spending more money than you intended to? Are you using more than you used to? Are you using more than your peers and friends? And most people know if they're using more than their peers or friends. As humans, we always compare ourselves to each other. You know, is drug use being triggered by stress or being around other people using it? We ask about both. You know, the criteria of the use, the criteria of using that results in a failure to fulfill major obligations, this is a really important criteria when it comes to a substance use disorder. So any intoxication that's during work, school, during childcare, eldercare, that is a red flag for a substance use disorder. And I really focus on this a lot, especially with high school students. I'm very clear with high school students. Any drug use at school that includes vaping in the bathroom is a red flag for a substance use disorder because it's not meeting obligations. Current, you know, cannabis use that occurs during situations that could be dangerous. This is like driving. Everybody thinks of driving and drug use, which is definitely meets this criteria, but other activities as well, like swimming during drug use, hiking, biking, skiing, all these are dangerous and should be considered cannabis use that is physically hazardous. And then we have cannabis use despite having social or interpersonal problems. I always ask about loss of friends. That's a big red flag. If somebody has lost friends because their cannabis use, especially those who weren't using and maybe gained new friends, that's also a risk factor. And then giving up on an occupational recreational activity. I always ask about, you know, did you give up on a passion, you know, with like art, dancing, sports? You know, were you on a team before, even there was a pickup game and now you're not because of cannabis use? That meets the criteria for giving up on activities. And then tolerance and withdrawal. You know, when we think of tolerance and withdrawal, especially the regular, you know, the lay community, people think of, you know, severe tolerance and severe withdrawal, but tolerance and withdrawal can be very subtle. So anyone who's using cannabis on a daily or near daily use likely has tolerance. It's very difficult to use it this common, to use it this frequently and not have tolerance. If somebody has daily or near daily use, I tick them off as meeting criteria for tolerance. I'll ask more questions, but it really is most likely to be there. Additional questions, are you spending more money than you used to? Again, do you use more than friends? And have you ever taken a drug holiday? This is actually common. People who are increasing their spending because of drug use will take a drug holiday to try and decrease their tolerance. Generally when they take a drug holiday though, they don't, they replace the drug. So it's common to use alcohol instead of cannabis when trying to take a drug holiday. Drug holidays are kind of all over the internet. So people know that if they're using more and more, it's time for a drug holiday, but they don't recognize that that's a sign of tolerance. And then withdrawal can be very subtle. Definitely happens with cannabis use. And with cannabis, it can be really protracted. It can go out to 21 days. People often can't tolerate the withdrawal. And so we'll start using cannabis again. Obviously cannabis will alleviate the withdrawal symptoms, but I always ask about withdrawal symptoms like anxiety, irritability, insomnia, fatigue. Stomach aches is actually abdominal symptoms is very common with cannabis withdrawal. People might report anything from just sort of loss of appetite to real frank abdominal pain can happen with or without vomiting. So it's important to ask about these symptoms and to consider these as symptoms of cannabis withdrawal. And let me just add, you're more than welcome to have my slides. If you don't have them yet, I will send them to you. And just to talk a little bit about cannabis hyperemesis syndrome, this is sort of showing up more and more in the literature and more and more in emergency departments. Cannabis hyperemesis syndrome is a cyclical nausea and vomiting that's seen in 100% of the patients. The vomiting is cyclic. It occurs in patterns over months. Hot baths and showering for some reason, it's not known why, alleviates the symptoms. The only resolution is to stop cannabis use altogether. There's no other solution to this problem. And it's predominantly seen in males. Here's the data with cannabis hyperemesis syndrome. It's mostly seen in people who use daily. It's also can be seen in people who use weekly and it can be seen not common, but it can be seen even people who use less than weekly. So it's probably a combination between the frequency of cannabis use and some underlying diathesis towards this disorder, but it's definitely becoming more common. We're also seeing a prodrome syndrome with cannabis hyperemesis syndrome. So there's more and more people who are reporting nausea often in the morning, can occur without emesis, but there's a fear of vomiting, abdominal pain and weight loss. So it's worth asking patients, even if they haven't presented to an emergency department with this, asking them about morning symptoms, abdominal pain, nausea, with or without vomiting, because this can be sort of a prodrome of cannabis hyperemesis syndrome and definitely counts towards the criteria of a cannabis use disorder. When it comes to the treatment of cannabis hyperemesis syndrome, the only treatment is really supportive. If it's severe and they're in an emergency department, there's more that can be done, but it's really intravenous, fluid, supportive care. And as I mentioned, the only treatment is absence from cannabis use altogether. So let's talk about treatments for cannabis use disorder. Let me just say there are none that are currently FDA approved. There are none that are really a slam dunk treatment when it comes to pharmacology for cannabis use disorder. It's not for lack of trying. There are many clinical trials in cannabis use disorder that have been done. They are unfortunately remarkably negative. It's harder to treat cannabis use disorder than it is to treat alcohol use disorder. Some ways we have fewer treatments than it comes to opioid use disorder, right? At least opioid use disorder, we have treatments. We have buprenorphine, methadone, naltrexone. Cannabis, we have very little. And so I really think it's important to prevent people from getting to the severe state with cannabis use disorder. And even if we can prevent it as much as possible, as I mentioned, by recognizing psychiatric disorders and self-medication, because once we get to a cannabis use disorder, it's tough to treat. So there are some hints that some medications might help when it comes to abstinence. So the FDA, when it comes to clinical trials, has previously required abstinence as an outcome measure when it comes to finding medications for substance use disorders. That's a remarkably high bar. It's hard to meet. We don't require that for other disorders. We don't require complete remission for diabetes or hypertension, but that's what we have been traditionally required for clinical trials with respect to substance use disorder. That really changed when it came to naltrexone for alcohol. The FDA accepted a decrease in drinking as a valid outcome measure for alcohol use disorder, and hence naltrexone was approved. Trying to accomplish the same thing with cannabis use disorder, there's a bit more pushback, but we have to be willing to accept a decrease in use as being a viable outcome measure. So if we're talking about a decrease in cannabis use rather than abstinence, there is some hope. This is data from a secondary analysis, and what it showed is that catiopine, 300 milligrams PO at night, was actually helpful at reducing cannabis use. It was most helpful in taking heavy users and having them become moderate users. So it wasn't really effective at decreasing moderate use, so it was heavy to moderate, which is still promising. Again, we'd like to go to light use, but it is at least a promising direction. There's also data that dronabinol, so this is synthetic THC given BID, can treat cannabis use disorder. Of course, dronabinol is a controlled substance, so that leads to those issues. And then a combination of lofexidine and dronabinol also decreased heavy use. So this was heavy users went to moderate use. So stay tuned for more clinical trials, but this is at least a promising direction. There was some really interesting results when it came to inositolcysteine. Inositolcysteine, which is FDA approved for acetaminophen overdose, it's also available as a supplement. Sometimes people take it from health food stores. There was a trial that was done a little while ago that looked at adolescents with cannabis use disorder between the ages of 15 to 21, and it showed an increase in abstinence. So it was very promising. This was done by Kevin Gray in 2012. However, a follow-up study that was done in adults between the ages of 18 to 15 showed no difference between inositolcysteine and placebo. So that was not promising. But again, stay tuned for more clinical trials. This is a recent study that came out. I won't spend a lot of time on this, but it's kind of exciting. This just came out recently. It's with a medication called AEF-0117. It's a pharmaceutical company called A-List, and it did show that this medication decreased cannabis use. It's an allostilic modulator of the CB1 receptor, so it modulates downstream signaling. So it's very interesting, and we're actually in the middle of a clinical trial. This was a lab study that we did. It was a clinical trial that's ongoing now to see if this medication can treat cannabis use disorder. Behavioral treatments have been tried and should always be tried. These include cognitive behavioral therapy, contingency management, and motivational enhancement therapy. I won't spend a lot of time on these, but I will say that if you're interested in learning more about these behavioral treatments, you can go to PCSS. There are many online trainings and discussions for these behavioral treatments. And I'll just refer you there if you're interested in behavioral treatments for cannabis use disorder. So now I'm gonna switch gears, and I'm gonna talk a little bit, how much time do we have, about the impact of cannabis on the development of psychiatric disorders, because this comes up a lot. And I'll just say, you know, the research is mixed. You know, certainly when it comes to the development of a psychiatric disorder, this often happens in adolescence. We know that most psychiatric disorders began before the age of 24, so adolescence and early adulthood. So it's hard, it's very hard to tease apart which is starting first, the psychiatric disorder, or the cannabis use disorder, or cannabis use. So the evidence is mixed, but there is some evidence that cannabis use is developed, sorry, is associated with an increase in the development of depression, anxiety disorders, and bipolar disorders. This is mostly the case in adolescence. But as I mentioned, it's possible that people who are developing a psychiatric disorder are turning to cannabis use, and the two are mixed together. I'm often asked about the question of cannabis use and the development of schizophrenia or psychosis. There's a lot of data and a lot of information out there. What I'll say is that, you know, that the data suggests that high potency cannabis, it's used frequently, increases the chances of developing psychosis. However, I think this has to be qualified. Most people using cannabis do not develop schizophrenia. And so what we can say is that patients with a preexisting vulnerability to psychosis who use high potency cannabis on a regular basis are more likely to develop a psychotic disorder of greater severity. So I don't think at this point we have the data that can say cannabis causes schizophrenia. We don't have the data that can say cannabis causes depression or cannabis causes anxiety. We do know that cannabis causes a cannabis use disorder. That's the one thing we can say definitively. It causes an effect when it comes to cannabis use and developing a psychiatric disorder. There is an association between cannabis use and suicide. This is data looking at drug use, but it's not just related to cannabis use. All drug use increases the risk of suicide. This is data looking at drug use combined with different psychiatric disorders. So here we see the combination of cannabis use and major depression significantly increases suicidal ideation. Cannabis use disorder alone does as well. So when it comes to comorbidity, cannabis use disorder plus psychiatric comorbidity, this is just a data with depression, but we could apply it to different disorders as well. There is an increased risk of suicide and we need to be very sort of mindful of that when it comes to our patients. Again, it's not just limited to the cannabis. Any drug use is associated with an increased risk of suicide. So this is data with suicidal ideation. This is data with suicide completion. This is from the CDC, and what it shows is at the time of death, about 25%, 22% of those who died by suicide had alcohol on board, 20% had opioids on board, 10% cannabis, and about 8% stimulants. So certainly, not only does a cannabis use disorder increase the risk of suicide, but current use increases that risk as well. You can imagine somebody who has something like a depression, where ADHD also has an increased risk of suicide completion, and drug use on top of that not only worsens the likelihood of a use disorder and risk of suicide, but also just drug use in itself makes people more impulsive. So if somebody's feeling suicidal and drug use is added to that, they tend to be more impulsive and more likely to act on those thoughts. So unless y'all have questions, I'll move into the next topic, which is a little lengthy. And the question here is, does cannabis really have medical effects, medical benefit? Does THC serve as a medication? Does CBD serve as a medication? Certainly what I can tell you is that across states, when it comes to medical marijuana, many disorders have been approved for medical marijuana. Here's a list of them, include autism, glaucoma, as a note and aside, there is no data that shows that cannabis actually treats glaucoma, Alzheimer's, hepatitis C. Most of these are not supported by data. We simply mostly don't have the data. So despite the fact that medical marijuana might be approved for these indications, doesn't mean that there's actually evidence behind it. We do know that in the US, dronabinol, which is synthetic THC, and nabalone, which is related to it, are FDA approved for chemotherapy-induced nausea and vomiting, appetite stimulation, and AIDS. So we do have data supporting those. In the EU, the UK, nabixamols, THC, and CBDs, this is a spray that I mentioned, is approved for spasticity and neuropathic pain in multiple sclerosis. So that's all we have when it comes to sort of definitive data. There is a lot of data showing that THC can be helpful for pain. This is a lot of different types of THC, whether it's cannabis or dronabinol or nabixamols or nabalone, there's data showing that it can be helpful with pain when it comes to multiple sclerosis, inflammatory bowel disease, and in palliative care. But it does come with side effects. It comes with somnolence, disorientation, dizziness. It's the same thing, like the effect on pain mostly lasts during the intoxicating effect. So if we're talking about treating somebody with refractory cancer pain, then there's absolutely a reason to be using THC if nothing else works and or if they can't tolerate opioids. But if we're talking about, you know, pain in adolescent or short-term pain in an adult, I would not recommend cannabis for that use or THC for that use. When it comes to THC with other psychiatric symptoms, there is evidence, moderate evidence, that it can help for sleep in the short term. All of this research is done in patients who have other medical conditions, such as fibromyalgia cancer, chronic pain, and multiple sclerosis, also sleep apnea, although definitely could not recommend THC for sleep apnea. But you know, if we have a patient with cancer pain and they need THC for sleep, that's a different category. There is evidence that THC can help with anxiety in medically ill patients. There's a lack of placebo control. So this is, for example, THC is effective at reducing anxiety, for example, in patients with multiple sclerosis. We don't have data in anxiety disorders and can't use it for anxiety disorders. There's actually a lack of an effect when it comes to depressed moods. So these are studies, for example, multiple sclerosis, looking at the impact on mood, and there's no difference with placebo. When it comes to PTSD, there are small studies showing that dronabinol or nabalone might help versus placebo, but a recent double-blind study showed no effect. And when it comes to anorexia, there's some small studies looking at THC for anorexia, increase in body weight. But again, we really need more data before we could recommend it for this indication. When it comes to CBD, there's some evidence that CBD might serve as a medication. This is for childhood epilepsy. This is the most definitive data. This is now FDA-approved. CBD can be used for childhood epilepsy. There has been studies looking at CBD for psychotic disorders, schizophrenia. They're sort of very mixed when it comes to schizophrenia, and this was in patients who were being treated with traditional medications for schizophrenia, CBD was added because of ongoing symptoms. There's a couple of studies looking at CBD for anxiety disorders, but they're very mixed and very preliminary at this point. And there's one study looking at cannabidiol as a treatment for cannabis use disorder. And it did show an effect, but it was a small effect. The decrease was small. So when patients with cannabis use disorder were treated with cannabidiol, they decreased their cannabis use by 0.7 days per week. So it was a small effect, it was there, but I wouldn't say that we can use CBD at this point to treat cannabis use disorder. At this point, there are no randomized controlled trials with CBD, with PTSD, autism, depression, bipolar disorder, generalized anxiety disorder. There are studies being done with CBD for these disorders, but there's no data yet. I'm not sure how much time I have, I don't know if you want me to leave time for questions or go through some more slides. I think you can go another five, 10 minutes, and then we can stop for questions if you want. Great. So now I'm going to talk about what are the risks of THC, what are the risks of our patients who are using medical marijuana for these different educations? Well, the first risk is that of accidents. Patients need to realize that when they're using medical marijuana, it's still marijuana, still cannabis, still THC. So it impairs decision-making, physical coordination, there's a risk of accidents, this includes motor vehicle accidents, and a big risk of falls, especially in medically ill patients. There's a risk of overdose as well. Overdose with cannabis is not lethal, but it can be really quite miserable. Cannabis used with other drugs does increase the risk of overdose with other drugs, so if we're talking about cannabis with opioids or cannabis with alcohol, there is an increased risk of overdose when we mix drugs together, but not on its own. Cannabis can cause over-intoxication, and this happens a lot in medically ill patients, especially if they're taking it orally because it doesn't have an effect for a while, so people take more and more and more, and then they become over-intoxicated. It's quite miserable, symptoms of anxiety, depression, anxiety paranoia. They can also cause hypotension, ataxia, and vomiting, so people can get really quite miserable on it. And there is a risk of cannabis with heart attacks, so this is mostly being seen so far in smokers. The risk is about 1.5% of patients, so it's not a big risk, but it is definitely there. It's a bigger risk in medically ill patients. It's generally seen within 60 minutes of smoking cannabis. It's higher in patients who have a history of heart disease, but other patients we do see reports of young, healthy individuals having cardiac symptoms with smoked cannabis use. So when it comes to cannabis use in all patients, but including those who are using it medically, need to remind patients that any symptoms of chest pain, chest pressure need to be taken very seriously, and they need to get to an emergency department. So what are the risks of taking CBD medically or for medical indications? There is a potential for liver injury, elevated LFTs. This was seen in the studies that were done with epilepsy, so these were very high doses of 20 milligrams per kilogram. Doses that were lower than this, such as the studies with schizophrenia, a change in LFTs was not seen. So this is the biggest risk when people are taking really big doses of CBD. It's not common that patients are taking huge doses of CBD if they're buying it from a dispensary or if they're buying it from a store because it's quite expensive, so you'd have to spend a whole lot of money. But it's still something to be mindful of, especially in patients who have liver disease. One thing that is happening a lot lately though is when people buy CBD, especially if it's online or from a recreational source, there's often Delta-8 THC involved. So more and more we're seeing Delta-8 THC being included in CBD products. It's not Delta-9, so in some ways people think that they're skirting the law when it comes to the THC component of CBD. The FDA will tell you that they're definitely not. THC can be synthesized from CBD, so it's actually quite an easy synthesis. It's one of the reasons why it's being seen in a lot of CBD products. But the bottle won't necessarily specify that it has Delta-8 THC in it, so people end up sort of unexpectedly intoxicated. They might take too much, and they can have a lot of the symptoms that I mentioned that can happen with THC. They can have chest pressure symptoms or over-intoxication. So any patient who's taking CBD from a source that's recreational in nature or from online should be warned about the potential presence of Delta-8 THC and the potential for feeling intoxicated and feeling some effects. Because people sometimes take it in the morning, they think it's just CBD, it's not going to do anything, and then they can be someplace that's unsafe. So in summary, what can I say about cannabis, THC, and CBD is treatments for medical conditions Again, THC can be used as a treatment for nausea, vomiting, appetite stimulation, and AIDS and pain when it comes to these medical conditions. There's no clear evidence yet when it comes to psychiatric disorders and psychiatric symptoms. Many patients using THC and cannabis are using it for self-medication. We have to be mindful of the fact that this isn't really a treatment, it's just a stop gap. As we're all aware, it's much easier to get access to cannabis than it is to get access to medical care for psychiatric disorders, but we have to be aware of this and be mindful of it. When you're seeing a patient for ADHD or depression, please ask about cannabis use. We need to have discussions with our patients that are sort of judgment-free, which I know all of you are doing, which is why you're asking for this kind of training, which I greatly appreciate. With that, I will finish. This is my slide. This is the feedback that the ORN asks me to ask you to do, and I think that is my last slide. I'll stop here. I'll leave this up. I think it's up, and I'd be happy to take any questions. Thank you so much. That was really informative. This actually ties really nicely to, we're in the middle of our child and adolescent psychiatry block, and I think literally just last week, we were doing the ADHD talk and talking about the importance of treatment and the risk, if you don't, as it relates to substance use. We talked about treating earlier is better than treating later. This really ties together, I think, very nicely for us. The one question I have, and then I'm going to turn it over to the trainees to ask whatever they want. I'm a child and adolescent psychiatrist, so I'm curious, when you have patients who come to you, especially in this age of marijuana being legalized and CBD being very readily accessible, and they say, well, medications never worked for my kid, or a patient says it never worked for me, can't tolerate it, but I'm trying these CBD or gummies or whatever it might be. I'm just curious what your response is to that and how you might give advice to the trainees on some of those conversations. Sure. A lot of this started because I started giving talks to high school, starting with my own son's high school. He's now 21. What's interesting, and I really do focus on ADHD because that's what I see. Sorry. That's what I see. I wish I could be a time traveler because I'm seeing people in their 20s, 30s. If I could just go back in time, I could do more, and I'm very definitive. The data with stimulants is extremely strong. I don't think there's a bigger effect size in all of psychiatry. I don't think there's a bigger effect size in all of medicine, with the possible exception of chemotherapy and cancer. We don't have a more definitively effective treatment than stimulants for ADHD. It's incredibly well-studied because everyone's terrified of giving stimulants to children, but what we've seen is we not only decrease the risk of drug use in teenagers, we decrease the risk of substance use disorder. There's also a decreased risk of suicide when we treat ADHD with stimulants. There's a decreased risk of obesity. There's improved social functioning, and there's a decreased risk of dying in a motor vehicle accident or having a sexually transmitted infection or unplanned pregnancy. The data just doesn't stop. I understand, as I mentioned, a lot of kids with ADHD, they have this underlying anxiety and agitation. I don't think stimulants help that, which makes sense, but what we do have is we have a wide range of stimulants. We have so many different preparations. Medication shortage aside, there's now methylphenidate patch, and I understand some of these are covered by insurance or non-insurance, there's a mess, but we do have a lot of ways. There's long-acting, there's different ways to address this problem. There are definitely side effects, but we have a lot of preparations that can be used to try and address this. Honestly, I think guanfacine, in some ways, is underutilized. The data with guanfacine in children and adolescents is very good. It helps with sleep, and it helps with ADHD. Another way to address some of these side effects is perhaps lower the stimulant dose and increase the guanfacine. It's a lot of trial and error. We have to have parents who are dedicated to this. When I give talks to schools, the students are all on board, the educators are all on board, and when I talk to parents, that's really been my main stopgap. I'm sure you know as a child and adolescent psychiatrist, it's like getting the message across to parents is really very hard. Now, when I talk to high school students, I talk about the data. I don't often say like, well, if you weren't treated by age nine, it's all over for you. The data is definitely stronger with age nine, but that doesn't mean that treating later doesn't have a benefit to it. I do think we need better medications for ADHD. I think as a field, we tend to think like, oh, it's been solved, stimulants work, but stimulants do have, you know, they have their downside, a lot of downsides. So it would be nice to have additional medications. There are some clinical trials coming out looking at other things. I don't think there's enough, but, you know, we do have some tools to try and address this. And I'm really quite grateful that you're paying attention to this because what I need in my life is fewer patients. Thank you. I had a question. This goes back to like the chicken and egg thing, but how do you differentiate between primary diagnosis of ADHD, anxiety and depression versus substance induced? I know that one of your slides mentioned that the patient doesn't necessarily need to come off of cannabis for you to treat ADHD, but do you look at it as the patient clearly has signs of ADHD or severe anxiety or depression, you can just treat it and then help counsel them for ways to decrease the substance use? Or do you just say that we need to just come off of substance and see you at your baseline beyond 21 days to see if those symptoms still persist? So we definitely, you know, when it comes to DSM, we have all these criteria, which came first, the substance use of the disorder. Real life isn't really quite like that, right? It turns into a big ball. And if you try and tease them apart, you'll get a lot of valid information about your patient, but you probably won't have the answer to that question, I think is generally unanswerable. So really what we have to do is, you know, as we move forward. So as I mentioned, like, I think it's unfair to punish patients who keep using THC when they're being treated for ADHD and withdraw medication. At the same time, we can't say, oh, go ahead, you know, use your cannabis. We really have to sort of like, we have to enable patients or help them take ownership of their own health. Part of that is certainly, you know, decreasing their cannabis use over time as best they can and controlling their ADHD through not only medication, but through, you know, other treatments as well. A lot of these are behavioral treatments, but there's also a lot of resources that patients can use to try and like, you know, address their cannabis use through therapy or through interventions with you all. So certainly what we need to be doing is treating the two disorders at the time, cannabis use and let's say anxiety. We have to tackle them both at the same time. We used to back in the day say, oh, you have to do the substance use disorder first. They have to start using substances. That doesn't work. So now we're like, okay, we have to address both of these at the same time and let our patients know that they feed into each other. If you're using cannabis to treat anxiety, yes, it's working temporarily, but it's not working in the longterm. And the longterm is increasing your risk of having a cannabis problem. And this increases your risk of having a mild substance use disorder turn into a severe one. So we can ask patients to take some ownership and to work on that with us. So there's just been like a headliner that potentially like the Justice Department is rescheduling marijuana from Schedule 1 to Schedule 3. I'm curious how you think that's going to impact us as psychiatrists. Oh yeah, we're going to have a wave of cannabis problems and it's started and it's just going to get worse. I'm not saying that it should be illegal. I'm not saying it should be Schedule 1. I don't think that worked either. We all know that restricting access doesn't decrease use and doesn't prevent a cannabis use disorder. Interestingly, there is data looking at states that have recreational and medical marijuana legalization and looking at the impact on children and adolescents and adults. What that data showed, and it needs to be replicated as time goes on, but what it showed is that as laws changed and we allowed medical and recreational cannabis use, people over the age of 26 were using more and were more likely to develop a cannabis use disorder. Those were the people who were less likely to use an illegal substance. When it came to teenagers and young people, the use didn't really change that much. Cannabis use disorder changed a little bit. What that says to me is that young people already had access to it and were already using it. So legalization didn't change that a whole lot because the legal stuff is generally more expensive. That said, what will be changing is the perception of safety, and that's something that we have to counteract. Alcohol is legal, and we've managed to get a pretty good message across to people that alcohol use is problematic. Tobacco is legal, and we've gotten the message across to people that tobacco use has its downsides, and we have to do the same now with cannabis. Making it illegal doesn't solve the problem, but as legalization moves forward, we have to get the message out that it's not without its risks and it's not without its harms. The solution is to be mindful of those risks and harms and to mitigate those as best we can. Thank you. I have a question regarding the general guidelines by APA or another body for psychiatric treatment for ADHD. You were talking earlier in your slides about how a positive THC on urine drug screen may be precluded further treatment of ADHD with stimulants. Is that just based off the discretion of the psychiatrist, or is there a general stance for psychiatrists to follow regarding that? Would it preclude ongoing treatment with stimulant if somebody persistently is testing positive for THC? To my knowledge, there is no specific guideline. I can definitely try and send you some papers on this. I do know that Kaiser Permanente in California has a guideline that if someone tests positive, they're not supposed to get their medication. There is a guideline for the opposite, which is not database, it's not science-based, and to me is punitive. Certainly, as psychiatrists, we have the ability to look at this information more carefully and make decisions. I think as psychiatrists, we often use treatments that require close observation and close consultation with our patients and, if possible, family members, especially in children. I think as a field, we need to do a better job of this. I don't know of any guidelines per se at this point. I will look for you, and I'll send an email. I'll send a paper if I can find one. I work with colleagues here where this is sort of their specialty is ADHD, so I'll ask them. Thanks, that's really helpful. It made me really think about how it's a personalized for each patient, knowing that it could be helpful for them if they're using it in a way that's synergistically effective for their mental health. You don't want to just necessarily cut it off. If you can gauge whether or not their use is not helpful to their life or they're having troubles. Right, right. I mean, one of the problems with ADHD is that people make decisions that aren't beneficial to them down the road. So if their cannabis use is a manifestation of that, then we need to treat the underlying disorder better. Hi, thank you so much for such a great presentation. I just couldn't help but think about a couple patients that I have who they always say, oh, I want to stop using marijuana, but I can't sleep. Or I start getting nauseous the next day and I can't go to work. Like, I just can't stop. I guess, how would you go about that? Because I do offer Zofran. I do offer something to help them sleep. And they're like, no, marijuana is the only thing that works for me. You know what I do? I do this. As I mentioned, I give a lot of talks to teenagers, starting with my own. And what I hear constantly is, oh, cannabis is safer than alcohol. I'm like, well, it's really not, if we look at the data. Sure, alcohol causes liver disease down the road and cognitive problems. But if we're just talking about a substance use disorder, a substance use disorder is a substance use disorder. So what you're seeing is the symptoms of a substance use disorder. So often when I'm trying to get the message across, I compare alcohol and cannabis, which really aren't that different. If they were drinking alcohol and couldn't sleep without alcohol, they would recognize it as being more of a problem that needs to be dealt with. So that's one way of getting the message across, is that people will kind of have in their heads the risks of alcohol. Sometimes I compare the risk to tobacco. Like, yes, tobacco 30 years from now has a risk of cancer or 20 years. But right here and now, what are the problems? And people are kind of more mindful of the problems with tobacco or alcohol. And we put cannabis in a different bucket. So it really takes a lot of education to change that as best we can and to make it clear that that is a symptom of having a cannabis use disorder. They may have a mild disorder now, but the last thing you want is moderate or severe because it's really hard to treat. So part of it, you know, I applaud you for giving medications. I certainly think that helping with withdrawal symptoms, with the sleeplessness and the abdominal pain and the nausea is, you know, very important to help people get over that hump of withdrawal. But they also have to understand that this is a symptom of developing a disorder. And if we were talking about alcohol withdrawal symptoms, they'd be scared out of their minds. From my perspective, you know, I get asked this question a lot by my kids. Like, from my perspective, I study all medications, cannabis, tobacco. You know, in my division, we have people who just focus on cannabis. As a physician, I'm one of the people who has to go between everything to try and figure out which moves to the clinic. So in my mind, most drugs are the same, right? Like, I don't see a huge difference between different drugs. And I know that's not really the population at large. But what I can say is when it comes to developing a substance use disorder, cannabis is the hardest for me to treat. It's harder for me to treat this than if you had an alcohol use disorder. If you had an alcohol use disorder, I have more tools. So I make that clear to my kids. This was really helpful. I really appreciate it. I want to be mindful of your time.
Video Summary
In the video transcript, Dr. Martinez discusses the importance of addressing substance use disorders, specifically focusing on cannabis use in individuals with psychiatric disorders, such as ADHD, depression, and anxiety. She emphasizes the need for early intervention and treatment of ADHD to prevent the development of a cannabis use disorder. Dr. Martinez also highlights the challenges in treating cannabis use disorder and the lack of FDA-approved medications. She provides insights on the potential benefits and risks of using THC and CBD for medical purposes, particularly for conditions like epilepsy and pain management.<br /><br />Regarding the impact of rescheduling marijuana from Schedule 1 to Schedule 3, Dr. Martinez anticipates an increase in cannabis use problems due to changing perceptions of safety. She addresses the importance of educating individuals on the risks associated with cannabis use and the potential consequences of developing a substance use disorder. Dr. Martinez emphasizes personalized treatment approaches for patients struggling with co-occurring mental health issues and cannabis use, encouraging clinicians to address both disorders simultaneously, along with promoting patient education and self-awareness.
Keywords
substance use disorders
cannabis use
psychiatric disorders
ADHD
depression
anxiety
early intervention
FDA-approved medications
THC
CBD
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