Approved Nursing Diagnosis

these are in listen-only mode. welcome everyone, thank you for joining our webinar with andrew penn, rn, ms, np, aprn-bc. andrew was trained as an adult nurse practitioner and psychiatric clinical nurse specialist at the university of california san francisco. mr. penn currently serves as an assistant clinical professor at the uc san francisco school of nursing. also he is a psychiatric nurse practitioner with kaiser permanente in california, where he provides psychopharmacological treatment for adult patients and specializes in the treatment of affective disorders and trauma. he has interest in promoting psychiatric wellness through exercise, meditation, and meaningful social relationships. he is also interested in emerging novel treatments for psychiatric disorders, is presented nationally, and is a passport member of the california chapter of american psychiatric nurses association.

today mr. penn will explore the controversy of using cannabis therapeutically for mood stabilization, anxiety reduction, and the promotion of sleep. he will explain how cannabis works in the brain, what we know about the risk of exacerbating mental illness, how to reduce these risks, and what we still need to learn before we know if cannabis can be therapeutic for bipolar patients. welcome andrew, we're so happy to have you with us today. thanks for that introduction debbie and thank you to you and melissa for inviting me, and the international bipolar foundation for your interest in this topic, and thank all of you who are out there on your computers for taking some time out of your day to learn about this. so i'm coming to you from redwood city, california, which is close to san francisco, and i think it's always appropriate and professional to disclose one's biases before starting a program such as this,

and one the things that i run into when people hear that i'm from san francisco, when i present nationally on this topic, is they say, "oh, we know what you're going to talk about," because my town is the place where an enterprising girl scout once set up a stand for her cookies outside of a medical cannabis dispensary and managed to sell a hundred and seventeen boxes in just two hours. but i want to be clear that i have no financial interest in the cannabis industry i'm not promoting the use of cannabis per se. i want to try and present some scientific evidence of what we have, what scientific evidence we have around cannabis specifically as it relates to bipolar disorder, and i also want to underscore that at my heart i am a clinician and not a researcher, so i'm leveraging the research that has been done by other people to try and sort of consolidate that information into something that's useful. but i am not a clinical researcher per se. i spend most of my day treating patients within the kaiser permanente system

and teach on the side at ucsf and in the continuing education conferences. so i have no financial dog in this fight. so it's worth just doing a little review of the history of cannabis, if nothing else, because it's a fascinating history. cannabis has been part of human culture and human medicine for 5,000 years now. there's history going back to china, to 2900 bc, that cannabis was used as fiber, as medicine. and it became more commonly known as a medicinal substance in the united states in the 19th century, when it was often used in these sort of combination patent medicines, like this wild cough syrup here that contained alcohol, cannabis, chloroform, and morphine. i'm sure that probably did it ensure a very good night's sleep. (excuse me) and interestingly cannabis became... yes? can you hear me?

(i'm sorry, but we are unable to see your slides, can you please try and click on the screen sharing button once again?) oh sure, let's try that again. hold on one second, thanks for your patience. has that changed anything for you? (no, not yet) can you see anything now? (there we go, there we go) (absolutely) they're working? okay. (there were go. thank you very much) there we go. there's that girl scout i spoke about. (there we go, excellent) can you see the girl scout?

(yes, thank you very much) okay, so as i was saying, cannabis came into some popularity in the 19th century in the united states as a means to actually help people get off of opiates, which were very commonly used at that time and were creating a lot of problems. in the 20th century, cannabis became vilified through such sort of propaganda films as reefer madness, and that's actually where the term "marijuana" started to be commonly used instead of the botanical term "cannabis." "marijuana" was was used as a sort of a racist strategy to associate the cannabis plant with mexican immigrants, who were commonly being vilified, unfortunately, during the racially-charged politics at that time. of course we all know about cannabis's prominence in the 1960s subcultures, including some former presidential...

former presidents that we've had. we went through the 1980s with this sort of backlash to the culture of the 1970s, with "just say no" from nancy reagan and vilification and prohibition of the drug. i would call this sort of the demonization of cannabis. and then since, really since probably the early 1990s, california had the first medical cannabis law in 1996 with prop 215. we've kind of gone into this gray area of medical use and increasingly, which i sometimes call the "cannibization" of cannabis," and then we've gone into this sort of de facto or outright legalization as we've had in several states, such as colorado and washington, and really the culture has changed to the point where even our current president has admitted that he has used cannabis in the past. we have now 24 states with some degree of legalization or medicalization of cannabis, and there are five ballot propositions on the november election, including one in my own state of california, for some variation of either legalization or medicalization

so it's very clear that the times have changed, that cannabis is increasingly being seen as being less risky and is being used somewhat more as a result, and we can kind of see where these cultural shifts happen as the lines cross over each other, in the mid-1980s with the "just say no" campaign, and then the shift again with bill clinton being the first president to admit to having used cannabis, albeit not in healing, in the early 1990s. and what i'm finding with my patients is that this sort of idea of just saying "no" to something is really, it's really inadequate, and what my patients want to know - they want to know about the drugs they're using, and i want them to know about the drugs they're using. because i'm a big believer in harm reduction. the idea of harm reduction is that the total abstinence is not always the goal.

it's not always the patients' goal and it may not be the goal of treatment, but that any movement towards using less substance, using it later in life, and using it through safer routes is a step in the right direction. i think if harm reduction had a bumper sticker slogan, it would be "don't let the perfect be the enemy of the good." so any reduction in use or in the change in the pattern of use is a step in the right direction. so i'm going to refer back to harm reduction several times in the course of this talk, because it's really a guiding philosophy that i use in my daily practice with patients. so before it's about cannabis as a plant, cannabis is... there are two primary species of cannabis, so the word "cannabis" is the genus in the scientific taxonomy,

and the species, the two most common species are sativa and indica. in more sophisticated hybridization growing methods a lot of times the material from these two plants are hybridized to create kind of a combination plant. in general, sativas are considered to be more stimulating and have a more cerebral mental kind of intoxication effect. for some people they do cause more anxiety, and sometimes they are higher in thc and lower in a compound call cannabidiol, which i'll talk about more in a moment. indica is the species which is generally considered more sedating, has more of a sort of physical intoxicating effect, often is more anxiolytic, or reducing in anxiety, and can be lowering thc and raising cbd. now, most people are familiar with smoking cannabis in the form of a cigarette or a pipe, and the part of the plant which is typically smoked is the unfertilized flower or bud of the plant, which is where there is a structure called "trichome" which is where these cannabinoids, the active ingredients in cannabis, are concentrated.

there is some in the leaf of the plant, but most of those cannabinoids are concentrated in the bud, particularly thc. increasingly in more recent years, there's long been hashish, which is a dry concentration of these cannabinoids, but with more sophisticated production methods there have been ways of extracting these cannabinoids from the bud with things like butane and other solvents to create such things known as hash oil, shatter, wax.. these are all terms that can be used interchangeably. and these are very concentrated forms of cannabinoids. just to give a little bit of a orientation to measure, a very common measurement, the unit of measurement in cannabis is the eighth of an ounce, so these are sort of relative sizes of, obviously this would vary in the density of the plant,

but to give some idea of when we're talking about measurements, and when i'm talking with patients i will often ask them how long it takes them to go through an eighth of an ounce, because that gives me sort of a ballpark idea of how much cannabis somebody is using. cannabis can also be ingested orally, and this is increasing this is increasingly, particularly in states that have legalized or states that have medicalized cannabis, there are edible versions of this drug that can be ingested orally and there are even topical salves that can be a relief. one of the challenges that i'll talk about a little more in a few minutes, with ingested cannabis there's an issue of unclear labeling, which can lead to somebody taking more than they are thinking, taking more than they should, but then there's also the delayed onset with smoking or inhaling cannabis,

the onset is usually fairly rapid and the person will usually somewhat self-limit how much they're taking, depending on the subject i can take down up to an hour or more before the intoxication effect occurs and that can sometimes lead to people getting impatient and taking a second dose right about the time that the first dose is starting to come on, and then being surprised by the intensity of the intoxication. so when we talk about cannabis, it's important to be clear that the plant is a carrier for a very complex amalgam of different chemicals. there's over 450 compounds in cannabis and what most people are familiar with are what are known are fibocannabinoids - so, cannabinoids made by the plant the cannabinoid that most people are familiar with is tetrahydrocannabinol, which is thc, and this is the psychoactive part of the drug. there are about 65 other cannabinoids besides thc.

one that is getting increasingly more press is cannabidiol, or cbd. this is a non-psychoactive part of the plant, so by non-psychoactive i mean it doesn't make you intoxicated, doesn't create.. doesn't make you high. and there are others that are less well-studied, but there's increasing interest in looking at these for their own therapeutic potential as well. so one of the things that's interesting about cannabis is that one brains, our central nervous system, our bodies, actually have a relationship with this drug, and the parallel that many of you may be familiar with is the opioid system. so as you probably know, we have receptors for opioids in our body, and when they're made by our own body we call them endorphins. and this poses the question of, well if we have a receptor for cannabis, why is that? our bodies... have they been created to use cannabis? and the answer to that is "no," but what it turns out is that what's called the endocannabinoid system,

the body's own cannabinoid receptors, and the cannabinoids that plug into those receptors play an important role in regulating neural activity within the central nervous system. so this is kind of a crude diagram. to the left is two neurons connecting to each other, and as you may know they don't connect, they don't actually touch each other. there is a gap between them known as a synapse, and that gap is bridged by a release of these neurotransmitters. so to the right is a bit crude schematic of a neuron talking to another neuron, and we call this, a neuron that's releasing the signal is called the presynaptic neuron, and the neuron that is receiving is called the postsynaptic neuron. so usually a signal comes down the line and it's passed on down by these little neurotransmitters, which have made it, symbolized by these green triangles,

and this could be things like serotonin or dopamine or norepinephrine among others. they plug into receptors on the postsynaptic side, which then sends that - if enough receptors get occupied, that signal then gets passed down the line. so enter in the endocannabinoid system. so you might think of this as an excitatory process. the presynaptic neuron is telling the next neuron down the line "go, pass this message down the line." you could think of it as sort of like an old-fashioned game of telephone where one person passes a message for the other person, who passes it to another person. with the endocannabinoid system, the receptors are actually on the presynaptic side, so they're on the side that is usually releasing information to the next neuron to pass it down the chain.

and the neurotransmitters are actually released from the other side, so this is called retrograde signaling. so these endocannabinoids, the most well-known is something called anandamide, are released by the postsynaptic side, the receiving, typically the receiving side of the neuron, and their job is to go up to the neuron that's releasing the neurotransmitters and say "whoa, hold up, hold up." it's kind of like if you've ever helped somebody move and there's a bunch of you, and you're all passing boxes down the line and then stacking them in a storage room or something like that, and the person who's doing the stacking city is getting a little overwhelmed by how fast the boxes are coming, and that person's holding up the chain. this is kind of how endocannabinoids work. so these endocannabinoids send a signal back upstream and say, "wait, hold up!"

and this is exactly also where exogenously, or outside the body, cannabinoids such as thc have a mechanism. so why do we even have this system in our brain? the person who discovered thc, an israeli scientist named raphael mechoulam, discovered thc in 1964. he isolated that from the plant and he said, "you know, it's unlikely that nature would create a compound so a kid in san francisco can get high." and so when we find these things in the brain, we have to ask ourselves "what's the purpose of it?" and what it appears that some of the functions of the endocannabinoid systems are to regulate things such a relaxation and sleep, appetite regulation and memory and forgetting, which is - memory and forgetting is an interesting subject, because when you think about it, most of what we encounter in the course of a day, we actually don't need to help onto.

so for example i can tell you what i had for dinner last night, but if you ask me in 10 days what i had for dinner last night, i won't remember because frankly it doesn't really matter. so a lot of what goes into our minds and brains we don't need to hold onto. but the brain has to figure out, what does it hold onto, what does it let go of? and it may be that endocannbinoids play a role in that. now if you look at this triad of functions you can also see that these are exactly some of the same things that people are using cannabis for, possibly therapeutically and also may point to some of the side effects, which are very common with cannabis, such as cognitive problems, which we'll talk about in a few minutes. if you really want to take a deeper dive on this, i really love this website,

it's designed for people without a neuroscience background, has some kind of fun and playful animations that illustrate the mechanism of action of a number of different substances. so if you want to check this out the web address is on the bottom, if you just google "mouse party" you'll probably find it pretty easily. so it's important to make the point that cannabis use exists on a continuum. don't get too hypnotized by the spinning cannabis leaf there, ranging everywhere from no use to a very chaotic dependent relationship with cannabis. and there are plenty of people who exist somewhere along this continuum who may use only occasionally, who may use a few times a week, who may use daily, who may use all day long. and it's it's important for us to think about cannabis use along this continuum rather than thinking of it categorically as something that is either "yes" or "no."

we do know that we have a huge problem with overdoses in this country right now. we're facing an epidemic of drug of overdoses and one thing, one good news that i can report is that they are not coming from cannabis, they are largely coming from pharmaceutical opiates, and sadly as we've begun to all put limits on and come to our senses about the prescription of opiates in the medical field, we've seen people switching to heroin and to illicitly acquired pharmaceutical opiates and we've seen an uptick in overdose deaths over the last dozen or so years. alcohol also accounts for a number of these overdose deaths cannabis, fortunately because there are no receptors for cannabis in the areas of the brain which control breathing,

unlike opiates, an overdose of cannabis might make somebody very intoxicated, but it's not necessarily going to result in them dying. now... let's start talking about some of the risks of cannabis. we definitely know that the earlier somebody starts using cannabis, the more likely they are to develop what we call a cannabis use disorder, which, in lay language, might be considered a cannabis dependency. so as you can see from the downward trend in this chart, if somebody starts in early adolescence, they are much higher risk of developing they are much higher risk of developing ongoing cannabis use.

so one of my recurrent messages in this is, the longer somebody can wait to use cannabis, the better. cannabis dependency is more likely to happen, as mentioned, in the younger people, and it's about half the rate for people who start as adults. it's about the same use that people who begin as adults will begin to develop a dependency upon the drug. so about one in ten - that is a similar rate to those who begin to use alcohol, so people who use alcohol, about one in ten people will develop a problem with that particular drug. so again waiting to use this drug is related in everyone's best interest. another area of concern is is there a cognitive risk in using cannabis, and there are some larger called "cohort studies" where a big chunk of people are followed from early in life until later in life,

and they're measured a long way on different measures of things like intelligence and mental illness markers and substance use. there's a group out of new zealand, in the town of dunedin, new zealand, it's been followed for i believe over 40 years now, and there's been an association found that the young people who began using cannabis heavily in adolescence were found to have a loss of iq of about six points when they're retested against at 38. there was some drop in intelligence quotient scores in people who began using cannabis as adults, but it was not as significant as those who began using in childhood or adolescence and began using heavily. so again i think this really underscores the point that waiting... the longer somebody waits to begin using cannabis, the less likely it is to be impactful for them. now speaking about bipolar specifically, because i'm sure many of you in the audience...

pardon me. i'm sure many of you in the audience are interested in it specifically as it relates to bipolar. it's very well established that there is a strong comorbidity is the term we use and my line of work between or correlation if you will between substance use and bipolar disorder about forty percent of people with bipolar disorder will have a problem with

substances at some point in their life and about twenty percent will develop a cannabis use disorder so cannabis is is the second really only to alcohol and aed is alcohol use disorder on this on this graph here second only to alcohol as most commonly problematically used substance and bipolar populations and there's also

data that indicates that people who develop bipolar disorder will develop it an earlier age about three years earlier with ongoing substance abuse and this was looking at different not only cannabis but other substances such as alcohol so particularly in somebody my advice to somebody who is more vulnerable for developing bipolar

disorder say somebody has a parent are more than one parent who has bipolar disorder somebody the real strong family history or sibling with bipolar disorder i would definitely caution them to stay away from cannabis because of the risk of developing bipolar disorder at an earlier age now if somebody already has bipolar disorder and is using there is

data is to suggest that up people who continue to use cannabis with the bipolar disorder tend to stay manic and or depressed longer than those who don't use cannabis is also worth pointing out here that tobacco is also a risk for longer durations of depression and mania so that middle middle store or into their the middle graph there is a

depression scale and the one on the right is a mania scale so we see these increased risk in people who the is less less likely to to go into remission from depression and mania if one is using if one is using tobacco and canvas together and tobacco also creates a risk for longer duration of illness episodes wheel with a related illness of course

there's this sort of fuzzy territory the twins is for any and bipolar disorder sometimes we call that schizoaffective disorder when working at schizophrenia populations that schizophrenia generally begins about three years earlier the people that are heavily exposed to cannabis which is which distance thing but it again practice for people that

having genetic loading for cannabis check for schizophrenia to definitely avoid the use of cannabis in the in study again one of these cohort studies following a group of young men from recruiting or between first and seventh grade before they began using cannabis up until the age of 18 that each year of regular cannabis used to

increase the level of what we call subclinical so they don't actually meet the diagnostic criteria for disease such as schizophrenia that they were developed they were showing these these symptoms related to those illnesses such as paranoia and auditory hallucinations so for each year of regular cannabis use the risk of developing those kind of

symptoms increased by about twenty percent and some of it for some of these subjects that these symptoms persisted even after they stopped using now one thing that's unclear about this is is it that the young man in this study who gravitated towards using canvas might they had already been showing symptoms of a psychotic illness such as

schizophrenia and then were drawn to cannabis as a result of that or to the cannabis cause the symptoms that we're seeing its it's difficult to to make that clarification sometimes that direction of causation are directional correlation is difficult to establish i often get asked him if there are genetic markers that might predispose somebody

too great a risk of developing a psychotic illness if exposed to cannabis there are a couple of targets that you know targets the one called cmt and this is for this codes for an enzyme that breaks down and things like dopamine and if you're a carrier of one particular variation of this gene there's a correlation between developing psychotic

symptoms at a younger age if exposed to campus over a different gene one called akt1 this is a gene which if present in a certain way so it won't what's called an allele tends to predict or somebody developing paranoid symptoms when using canvas now for some people paranoid symptoms create a kind of a self-limitation with cannabis use so if

you become paranoid a lot of times people don't want to continue using the next that's probably a good thing because if you are a carrier of this gene and use cannabis daily heavily and daily there was as a seven times higher risk of developing a psychotic disorder with that kind of use pattern so my take-home message and this is if you get

paranoid when you use cannabis don't use it it's probably not a good thing for you i'm now this question of does cannabis make you easy does it make you what we call a volitional this is a an area of research that's really kind of lively right now there are some people that say a lot of people who gravitate towards using cannabis are depressed and

people with depression are often lacking in motivation just as a feature of the depression and so then it may be that particularly in adults that cannabis use is more than 30 let me rephrase that that the adults the lack of motivation that we see in people with cannabis use maybe better accounted for by depression as some newer research looking at an

area of the brain known as the nucleus accumbens which is the area that lights up when we get rewarded this is an area you know when you're thirsty and you take a tall drink of water if we could look at your new police accumbens we would see it light up because it's it's being rewarded its own please

one of the things that happens with repeated use of drugs that are intoxicating is that the response this area of the brain has to the drug becomes less and less and this is also the area of the brain which we need in order to motivate it towards a reward and that reward might be being told that you got the job or being told that you

got into the school you wanted two were being told it yes that person will go out on a date if that area of the brain becomes kind of blunted then we would stand to reason that there might be a decrease in motivation towards these kind of the sort of daily life rewards so this is really my take-home message for young

people is the longer you can wait sana are good the it was referring to psychosis and it's smoking the pot you want but wait until you're 30 and i recognize this is difficult because the average age of spreading canvas use in the united states is about 17 so we really could do a better job with educating our young people to hold off

and tell their at least into their mid-twenties now i know a lot of people a lot of my patients use canvas for treatment of anxiety and this is the association orange lines being bipolar populations anxiety as many of you in my audience know is a very common code traveler with bipolar disorder and it's it makes people might use cannabis to

try and palliate that it's it's interesting to look at this in young people because so this is an interesting piece of dna about thirty percent of people who qualified for a cannabis use disorder which means that they use it regularly also had social anxiety disorder but interestingly have four over four fifths of those people

reported that they had the social anxiety disorder before they started to use cannabis and i think this is really important to to look at this so that the cannabis did not the cannabis the the social anxiety predated the cannabis use so what this tells me is if you're a socially anxious young person and many and frankly you know many of us were

when we were young that cannabis might be a very attractive way of dealing with that anxiety but the problem with social anxiety and avoiding the things that make us anxious is that we never develop mastery over them so it's normal to be anxious when we're young there's many things that we haven't done we've never gotten a job we've never ask

somebody out for a date etc and if we every time we feel beings 90 of a threat the anxiety generated by happens to do one of those those things we use canvas to deal with anxiety and then we don't go and do the thing that we're making this making shank making is anxious we never get the opportunity to really master that skill and i think this is

sometimes where some people refer to serve an emotional stud- i find that somewhat of a pejorative term but this version to taking risks socially they sometimes see in my young adult canvas using patients now cannabis as medicine is a very thorny subject and i'll tell you right now this is the sort of how this is set up we have way we are way

behind as a scientific community in understanding the benefits of cannabis and what that means is we have a lot of user reports a lot of anecdotal data which is usually considered a fairly low quality because it's not controlled for things like bias there's a lot of people who have found benefit and cannabis and are convinced that it's working for them

and they may well be right but the primary now is as as clinicians we don't have a lot of scientific data to guide us and this is in part because we have this very convoluted system as to how canvas gets approved for clinical studies in the united states and i'm not going to belabor this too much but i the there are a lot of barriers that exist

to doing my research around cannabis as a therapeutic drug that don't exist for other pharmaceutical drugs and this is some of these restrictions have been lifted in recent months by the obama administration but the biggest restriction is that canvas remains a schedule 1 the dea drug enforcement administration considers a schedule 1

drug which by definition isn't drug that has a high potential for abuse and at low and and no therapeutic benefits so it begins challenging to try and study it as a therapeutic drug because by definition it doesn't have any therapeutic basis as far as the federal government is concerned and that's a real problem for

getting good data so what as schematically this is that we have a lot of states that have medical cannabis laws this is any an ad from one in my state and as you can see it's sort of listed as a sort of panacea for all sorts of conditions and very few of these conditions we actually have data for

that it helps now you'll have lots of anecdotal data and somebody again maybe absolutely true we don't have good scientific community guy this where we do have some data for thc is in these conditions so nausea and vomiting multiple sclerosis neuropathic pain and anorexia loss of appetite and weight loss and conditions like cancer and aids

from the psychiatric standpoint the the compound that i'm most interested in is have a da e there is some preliminary data that shows that this is helpful in things like anxiety and may actually even be an intern psychotic this was a comparison to a drug called camisole pride which is that in a psychotic that is generally that it's not a print in

the united states butts and used widely in other parts of the world comparing a high dose of cannabidiol much more than you could really get for me any kind of smoked plant matters is really purified can have a dial comparing it to the school pride and finding it equally effective as an anti-psychotic because a very

tantalizing result on a lot of my patients use cannabis for sleep and particularly cannabis indica we do it again we don't have great data on this i have plenty of anecdotal the data that anecdotal evidence that would say that it's helpful one of one finding that is certainly makes sense to me is if somebody has

chronic pain and their pain is reduced by the cannabis use in their sleep quality is generally better but we don't have a lot of good data that cannabis actually help sleep but i certainly have a lot of anecdotal data from my patients that there are some studies looking at various psychiatric conditions and

cannabis again they're difficult to do because of all the federal restrictions this is one that if you're interested in looking at you can go to clinical trials that god's this is regarding ptsd and held cannabis clinical trials.gov is a clearinghouse for ongoing clinical trials all should know about it it's a great website for searchable you can use

a google style text box and where you can take in something like bipolar and and cannabis and your geographic location and see what comes up so for people who are already using kind of getting in the home stretch here i want to leave some time for questions these are the kind of places where i look to reduce harm let me go through

some of these briefly if you are already using one of things that i'm interested in with my patients as i want to understand the pattern of how somebody uses and so i might ask them to keep a checklist like this and just put a check in the box when you use and we'll see if there's any kind of pattern in this particular example made here this is

clearly somebody who's using a lot in the evening and uses doesn't use very much during the day except on weekends so with somebody like this i might say hey can we figure out a way to help you with your sleep if the campus is creating side effects that they're they're not pleased with and there are also some apps such as this one i called

joint effort that comes out of australia to help people track their cannabis use i also asked the people be unconscious how much they're using to actually get a scale and weigh out how much they're actually using to get a real measured sense and to also begin to read labels we're all familiar with the labels on food in states that have medical or

recreational cannabis there are often labels that break down the amount of different compounds such as thc there is some question as to how trustworthy these labels are there's not a lot of standardization in this industry and plants by definition can be somewhat inconsistent so if the blood is on the top of the

plant that may have more thc than a bud it's on the bottom of the plant and there's some data that's that's found that these labels may actually be over reporting that the amount of thc and the product i i caution my patients to be very careful with highly concentrated cannabinoids these hash oils or shatter wax the higher the thc content more

likely they are to cause psychotic like symptoms and also i i really advise people to stay away from synthetic cannabinoids which are known as spice or k2 because these while they mimic thc they often bind to that cannabinoid receptor much more tightly than thc and can cause a lot of psychotic like symptoms if somebody is eating to be

careful with how much they eat and to go slowly and have a sense of that dose can labeling is helpful and if they're smoking to to try and use a vaporized method instead of actually smoking which spares the lungs the hot papers answer had combustion products that come from smoking cannabis with patients who are using i try and find ways that they can

reduce their use for example using canvas only after the kids have gone to bed or after work so that they're not played the side effects of things that cognitive problems if they are in a state that does have some automatic was a issue legalization of cannabis to get legitimate sources so that they're not exposing themselves to the potential

harm of legal action and to use products with lower thc and higher cbd and of course not to drive and especially not combined with alcohol because that does present some risks and i'm really not here to say whether somebody's canvas use appropriate or not i think that really depends on each individual person i really would caution young people

under the age of 25 to try and stay away from it for as long as possible so really this is a conversation to have with individual clinicians and with the people around you to take a look and see what kind of sign of x and benefits they may see from some of these candidates use and then to really have any a thoughtful conversation with

your providers with the people aren't with that with your loved ones about cannabis use so with that i'm going to go ahead and open up to questions thanks for letting me go a little bit over here and we started a few minutes late but i cannot think he's going to moderate questions and i'll be i'll do my best to answer them

great thank you very much for your presentation that we do have a few questions coming and and the first simple question is what does couch look for excusing couch lock mean couch lock is that the term that that i got your workout then let everyone from one of my patients where you just youyou don't want to get up you want to just lie on

the couch and watch tv or play video games and and really not do anything it's sort of a slang term for sedation great thank you and the next question is the harmful effect data for daily use and/or for occasional use as well so the the harm the harmful effects particularly the studies around psychosis

there's a clear uptick in people in the harm the risk of harm for people who use it daily and use it heavily daily different studies of defining the term heavily but really another opportunity for harm reduction is to move from daily used to what's more will be considered more occasional use so once or twice a week for example really it seems like

daily at perturbing the endocannabinoid system on a daily basis particularly during that window of development of the adolescent and young adult brain is probably not good for the brain particular somebody who is predisposed to mental illness genetically sun thank you the next question i'm curious as to what the relationship is

between adverse childhood experiences or trauma and cannabis use mental health diagnosis well that's a great question it sounds like the writers is referring to the adverse childhood experiences study which is a landmark study that came out of kaiser number of years ago looking at that kind of load of how adverse

childhood experiences such as being sexually or physically abused not having a parent present etc and that the higher the number of those kind of adverse experiences somebody had the more likely they were to go on to develop not only mental health problems but physical health problems such as heart disease i'm not well-versed in the correlation

between address travel experiences in cannabis use i would not be surprised if there is a positive correlation between the two but i don't have that data at my fingertips that's a great question i'll have to check it out we thank you and the next question is if someone doesn't have a doctor to ask because

they can't afford etc and advice do you have any recommendations or you can refer back to finding impersonal condition if somebody doesn't have a clinician to work with is that the question right yeah i mean you know it's sort of a two-part problem because we have a shortage of psychiatric providers in

this country and i would say we have a shortage of psychiatric providers for sophisticated in this subject unfortunately there's still a residual of a lot of anti-drug propaganda that really lacked a lot of nuance and sophistication and so there are a lot of providers who have a very kind of all or nothing approach to use the canvas which

is unfortunate because i think what that tends to do is to make people be secretive about their cannabis use them feel ashamed of it and it and it doesn't allow for the the patient if you want me to use that term to really have a full rotation with that clinicians and so it's sort of a two-part problem was finding a

condition that you can work with afford and the other is finding a condition that you feel comfortable talking about your cannabis use with and you know i think it's okay to ask straight up a clinician tell me you're at your feelings about about cannabis i want to understand i'd like to know that about you i think that's a fair question asked

when you're interviewing a provider i want to go back and add a second answer to the question about adverse childhood experiences one thing that i have seen clinically is that sometimes some of my patients who are using a lot of cannabis more than you might consider to be recreational and by that i would mean they're using cannabis from the start of

the day to the end of the day i mean that to me is a red flag that somebody is trying to treat something that can be as most people don't need to be intoxicated all day long if somebody needs to be under the influence of cannabis all day long they start to wonder what are they actually trying to treat with that and it's not uncommon

that what i find is that somebody is doing a lot of trauma and that they're trying to manage their fluctuating anxiety and hyper vigilance and a related distress to that trauma by using cannabis so that's that means sometimes a red flag that there may be some drama going on and i often sometimes find before people are diagnosed with bipolar

disorder that people are using large amounts of cannabis are sometimes trying to manage some of the energy and mood fluctuations that are that accompany a bipolar disorder great thank you for that answer and the next question is any suggestions as to how to quit using cannabis yeah so you know we're not very good as clinicians

at helping people get off of cannabis because for a long time it was thought about to be physiologically addicted to a big fan of the word addiction but it doesn't fit in creative physiologic dependency and the reality is is that it does now the withdrawal is not as dramatic as it is from some other substances say alcohol or opiates but a

lot of people when they go to stop using cannabis will experience things such as insomnia i'm at a loss of appetite agitation irritability i'm so one way of approaching this is to to try and taper to use increasingly lower thc containing compounds there has been a little bit of study looking at any over-the-counter supplement called n-acetylcysteine often

abbreviated and neck or any seat well this is a amino acid that can be bought over the counter that in a couple of studies has been found to help this is in younger people in teenagers going through a substance abuse treatment program were able to go longer without using cannabis when taking 1,200 milligrams twice a day of nac which is

generally pretty well tolerated and i'll use this strategy with my patients sometimes i'm there's been a few small trials looking at gabapentin and two pyruvate tokamaks as ways of helping people reduce cannabis use kind of mixed data as to how helpful it is in the future there may be a product available that's actually normal spring it's a

combination of cannabidiol one part cannabidiol and one part thc it's goes by the brimming with sativex it's not approved in the united states yet but is used in europe and in canada to to help with the pain and spasticity people get with multiple sclerosis and i think it might be a useful tool to use will call off label to help people reduce cannabis

and has been ordered to taper off of cannabis in much the same way we might use a drug like librium to help somebody detox from regular alcohol use i think there's some interesting things on the horizon that are not available yet in the united states that might be in the not-too-distant future great thank you also what would you do

what type of approach would you use to encourage young people to get off of the cannabis or reduce their intake well you know yeah especially living in california which the states had medical marijuana years now this idea of cannabis as medicine is a very common one and so i sit so somebody comes to me and says you know i use cannabis

additionally the first thing i want to do as well what are you treating with it and i not explore that with them don't make any judgment on whether or not that's a good or a bad idea what i really want to do is i want to understand it and so i'll start by asking questions like will tell me about how it helps you and then later in

conversation might have a conversation about how what are the side effects that you notice because you know we're talking about this is medicine all medicines have side effects there's no minutes in the world that doesn't have side effects and talk about cannabis as medicine that includes cannabis and it you know if we're having

that kind of candid conversation sometimes people will say you know i noticed that i'm not a sharp in school or not forgetting things and then that gives me opportunities to start talking about where might you start reducing your use and other places where you could perhaps use less or if somebody really is a sophisticated consumer of

cannabis and is using a dispensary and has access to lower thc products could you use our tht product in these situations where your cognition is is needs to be preserved to really try and start reducing it i'm if somebody's really ready to to sort of on the cusp about maybe stopping i might suggest a whether you do it sober month or two

just take a take a couple months off from the drug and let's let's take that information that you gain from that and compared to how you're doing now and see if there's any benefit and see what you see if also any kind of symptoms emerged that were have quieted down by cannabis and maybe that gives us targets for treating them differently

there may be other might be medications that are far more useful for more effective for treating that symptom that perhaps don't have the same side effect burden and ultimately the reason i use that scale graphic in that my last slide is because ultimately everyone needs to make a decision for themselves and how much benefit of the gang from whatever

substance is whether it's cannabis or lithium or depakote it doesn't matter the benefit has to outweigh the costs and the costs are side effects and the stigma of taking the drug and having to the lab and having the pharmacy that's all of the cost side so as a clinician it's really on me to find something that that works that has more benefits and

costs and that's the that's always a conversation to have with patients and and i really believe in a very conversational approach to providing mental health care do you have any information around using sleep aids with cannabis or to help us sleep issues it's so i'm assuming my sleep aids are talking about

prescription medications and i'm sorry for people yes you and prescription or over-the-counter sleep aids yeah you know there isn't any any good studies about this and i'm aware of anecdotally i certainly didn't just think of a patient i was talking to yesterday who said he takes clonazepam

and had some cannabis he sleeps very soundly so i would suspect particularly the more sedating strains of cannabis the indica strains are which and more that sedating effect are going to an additive effect within any prescription medications uniting them you start coming finding drugs there you can get into sort of

unpredictable effects so i think caution is definitely warranted and i would i would say the same thing about legal substances such as alcohol i mean honestly i'd be far more concerned about somebody coming in and saying that they were taking ambien with a with a big glass of wine that would that would actually worried me a lot more because

those two together are much more likely to be really dangerous but that said i don't wanna i'm not i'm not endorsing the use of sleeping with cannabis because it's we just don't really know about the safety of it great thank you on the next question my son had a complete psychotic episode while wait school at 19 years old

using involuntarily admitted to the hospital and had nothing other than marijuana in the system he spent three days in a psych ward was diagnosed with bipolar he's currently on meds and see psychiatrists regularly my question is could this marijuana have caused him to become bipolar or be diagnosed or was it just the perfect storm

i'm really sorry to hear about your son you know it will never know obviously i'm and i'm not and i'm not really sure how much benefit anybody gets from and doing at packing moving on sentimentalist you know it's that is exactly the age at which most people develop either bipolar or schizophrenic schizophrenia and so we'll never know

because there isn't a it's not like a clinical trial where there's a control group where there's an exact replica of your son who didn't have the same cannabis exposure i think really at this point what's probably more important is just moving forward and getting your son good care and at this point if he were my patient i would strongly advise them

to stay away from candidates because of this is already had this experience of having a psychiatric episode after using cannabis so and from a standpoint of safety and cost and i would definitely advise him to steer clear of it i still there yes can you hear me now hope

ok walking him ok next question is have you personally seen any clinical improvement of a psychiatric condition and a patient from cannabis use i've seen improvement of symptoms i think and limited symptoms i would say that the probably most symptoms up i've probably seen with the most improvement or sleep with cannabis use occasionally with

patients that are having real problems of with weight loss i've seen some improvement and and being able to maintain weight with canvas with regards to what sort of other common psychiatric symptoms such as as depression and anxiety and mood instability we honestly with with my bipolar patients who are having a lot of problems with with mood

and energy and stability it would be one of the areas that i would say you know this is something we can we can look at this is this is a modifiable part of your condition i mean we can't control for your genetics we can control for your biology but your canvas using something you can modify and so you know again i'm i'm interested in information

of interest in india so somebody is willing to say you know what i'll take six months off and let's see how it goes and we'll keep everything else the same weekend medications the same and they come in they say you know i feel a lot worse since i stopped using cannabis and i first of all would wonder what do they mean by worse you know that by that

might be there more anxious and we might have more insomnia and those are targetable areas of treatment and i say you know let's let's do a better job of treating insomnia let's do a better job treating your anxiety but it's it's a difficult question answer so i i think i have seen some sort of palliative benefits of

cannabis use in some of my patients but certainly not enough that i can enthusiastically recommend it for anybody because i think for a lot of people the side effect burden is a lot higher than the benefit and frankly i would say the same thing about a lot of our pharmaceutical drugs so again i might my

bias that i disclosed to the beginning of it is that i don't have any interest in another financial interests in the cannabis industry i also don't have a financial interest in the pharmaceutical industry so i have some nights i also have some skepticism about the drugs that we prescribe conventions for bipolar disorder of some are great like

with them think what they very drunk i think we'll know dreams really great drug summer not state and as training videos in this audiences taking someone's probably has a list of both good and bad drugs for them and and their good and bad drugs might not be the same as as the person sitting next to them so again individualized medicine

i think what we really need to do is as conditions is work with work with patients to find what works for them and in order to have that conversation we need to create an environment where our patients feel comfortable being totally forthright about their substances great thank you on the next question for young or occasion for young regular or

occasional users under 30 if they quit now are there benefits for quitting now and that gap time or has the damage already been done mmm that's good question i don't really know if it's been studied you know if you look in those in this cohort studies like that the one out of new zealand the way that they measure that is that they

would check in with these folks every three years or so and one of the measures were is a mess pero use and so for people that have fewer instances of so they're actually diagnosing for what musical cannabis dependency is now called cannabis use disorder dsm-5 but people that had repeated diagnosis of cannabis

dependence or more likely to show those declines in iq score compared to those who had fewer episode fewer points in time where they met criteria for that diagnosis so i think i i wouldn't say that the damage has been done i think one of the very one of the central tenants of harm reduction is it's never too late to quit so if

somebody wants to stop using even if they've used for a while i would be all for and i don't ever say well entertainment system done so you might want to keep using i think anytime somebody wants to reduce the user stop i'm all in favor of that great thank you the next question is there an alternative for dealing with social

anxiety other than cannabis sure i think the the best and long most long-lasting treatment is to gradually do the thing that's frightening and i know most patients with anxiety disorders when i brings up they look at me kind of sideways and you've got to be kidding and i'm not talking about somebody socially anxious should suddenly oh i

don't know get on our webinar with a few hundred people and all i have to say this is a lot easier to be sitting staring out my window of my office and talking to my computer than it is talking to 500 people in the conference call it makes my social anxiety a lot easier but to gradually do the things that we can make me anxious

i really think is the best treatment in and you're working with a good therapist who is familiar with this idea of exposure therapy to create a hierarchy of fears and start with the easy stuff first and get some mastery over little things like it might be something as simple as being okay with raising your hand in class and you you start by doing

that in the class that has the nicest people with the nicest teacher or your your most comfortable and then you move up to the class that maybe isn't quite so friendly and and so on and so on but just gradually gaining that sense of mastery of like yeah i'm scared but i can do this that's really the core thing that we

need and that we all need to get as we grow and develop and adolescence that's sort of the central task of being a young person is getting a sense that yeah this is scary this adult stuff but i can do it i've done it before and i can do it again and there are medications that helps them up with social anxiety and some of the

serotonin reuptake inhibitors have some benefit in and social anxiety but really there's no substitute for actually going out doing the thing that's right michelle says you know we all have anxiety it's just part of being human but how we want to handle it is is is important great thank you the next question i use

cannabis to counteract mania feelings does this increased depression um you know it's hard for me to know without knowing the person more closely i would ask them to i think for a lot of people making a particularly early mania takes the form of anxiety those kind of raising the odds and inability to sleep can feel very much that right not just

like anxiety they are anxiety i'm you know and if we think about me as an increased state of energy increase thinking in and worry is a is a form of it is a form of that energy increases between me and so i think for some people they definitely find some subjective benefit in using cannabis to go to curtail their be exciting that

they feel in that state i think what i would ask this person oppose working with them clinically would be what else do you find when you do that you know somebody might tell me where i can then then i can sleep if i can start sleeping it kind of dampens down the mania whereas if i don't sleep i'm gonna start running out and getting more manic you

know then it might be beneficial in that particular case can't speak to that broadly and have to really understand the details of the individual in front of me if somebody said yeah i use it but then i start getting paranoid it's saying is that really the way you want to be treating your meeting with something that makes

you paranoid might we find him there's something that's not going to make yours so that's a long answer your question but i hope it helps create thank you so many questions and do you have time for some additional questions and you or i can do about to walk again yeah i can do about 10 more minutes of questions and then i've gotta scoot to

in my clinic so i association patients actually actually absolutely thank you so much for extending that your time with us next question is can you comment happy little girls yes very much so and can be comment on mixing cannabis with seroquel are all marked typically questions just rhian and you need to answer based on a print

on a personal basis and so these we should leave out okay i mean in yeah i mean i don't be able to comment on specific drugs with cannabis may i think it's it's so the conventional wisdom is that that psychiatric medications are less effective with when combined with cannabis now you know what honestly we really need data to support that i don't

know if that's true or not my clinical experience would say that that is the case because you're particularly with things like psychotic disorders if somebody is is is taking it now don't know why the person taking seroquel of course we use that in many different conditions bipolar psychosis sometimes use even small quantities just for

sleeping medication use it off label for anxiety so without knowing again more about the person but if if somebody's taking it for a psychotic condition and then they're adding a drug which potentially can increase psychotic symptoms your kind of working at cross-purposes and so i think it would depend on why

the person is taking seroquel and again i would want to individually explore that person's experience with the combination of these two drugs like i i wouldn't be able to say no i wouldn't be able to say that just in general that that there's a strong with that other there maybe with that particular person but in general i think in a lot of times

when people are combined in canvas with psychiatric man's there are times when it it makes her condition worse there may be times anecdotally want to make some better i would really love to have some good studies on this to guide me so i anymore but it's those kinds of studies are really pretty difficult to do

great thank you for the response to that question and the balance of our questions are related to personal situations with medication and cannabis so i think we're going to wrap it up here i just want to say thank you for this very engaging and insightful discussion i'm very happy to have this webinar uh take place today and also be

recorded and archived on our website for future viewing or sharing with others and so thank you everyone for joining us and thank you mr. pen for joining us as well and have a great day well thank you for taking time out today and i appreciate everyone's interested i hope it's been helpful thank you all right take care