hello, i'm norman swan. welcome to this program - mulling it over: cannabis interventionin primary health care. cannabis is the least disapproved of,easiest to obtain and most widely used illicit drugin australia. it used to, in the old days,be thought safe, and probably is less toxic than, say,alcohol, but is associated with psychosis,depression, anxiety, respiratory and other disorders,including dependence.
this program is about equippingourselves in rural clinical practice to recognise cannabis-related problemsand deal with them to minimise harm. we'll examine the latest researchand best practice. we'll also look at cannabis use andinterventions in indigenous communities. there are a number of useful resourcesavailable on the rural health educationfoundation's website: before you go there,you've got to meet our panel. alan clough is associate professorin the school of public health, tropical medicineand rehabilitation science
and the schoolof indigenous australian studies at james cook university in queensland. - welcome, alan.- thanks, norman. alan is principally recognisedin australia for his significant contributionto research and practice in the field of substance-use problemsin indigenous communities. professor jan copeland is directorof the national cannabis prevention and information centre. - welcome, jan.- evening, norman.
jan is a psychologist and has a phdin community medicine and public health, and has made major contributionsto the field of cannabis research, before taking on the directorshipof the new centre. fares samara is a general practitionerin kempsey, in nsw, and is a staff specialistin the drug and alcohol service in the north coast area health servicein nsw. - welcome, fares.- hi, norman. fares is a memberof the chapter of addiction medicine and has been so for five years,
and has a special interest alsoin indigenous alcohol and drug issues. last but not least, tess finch, managerof the sutherland cannabis clinic, in the south east sydney illawarra areahealth service. - welcome, tess.- thank you, norman. tess has a diploma of drug and alcohol, and has worked as a drug counsellorfor six years. so welcome to you all. what we thought we'd do tonightis run case studies and talk about the issues
as we go through what we thinkmight be typical case studies. if they're not meeting your needsand there are things you want to know that we're not meetingin the case studies, give us a call or fax us,and we'll address that. if you give us a call,we'll bring you into the discussion and you can join in with us. so let's start with ben. ben is a 20-year-old man, who, in the course of a visit to his gp,
that's fares, with a cough and a cold, states that he's about to join the australian defence force, and needs to take a routine medical examination. but he fesses up that he's scared of the drug testing, part of that job assessment, because it might show positive for cannabis.
he says he only smokes cannabis occasionally, once or twice a month. the last time was about two weeks ago. your patient, dr samara. ben is obviously worried,with good reason, because he might not get the job.it's his whole future. he's smoking, once or twice a month,doesn't seem to be excessive. last time he smoked was two weeks ago. so very likely, he will get a negativeurine drug screen if we did one.
i would perform one for him. to start with, probably i'll do itin a confidential way, just between him and i. but i will use this occasionto opportunistically have a talk to him about cannabis and its effectsand the possible problems it comes with. tess, a bit harmless, isn't it,a couple of times a month? the issue is that ben has startedsmoking a couple of times a month. as fares said, he does need someinformation on cannabis and the dangers. he needs to monitor his useand to know how to monitor his use,
so that if it becomes problematic,he will recognise it. norman: what are the risksat that level of consumption? the risks are that he might start toenjoy that feeling more and associate with people who aresmoking cannabis more regularly, so it could increase his cannabis use.also that he might.. norman:he might start keeping bad company? yes. he might also start to reach out forcannabis when he feels life is difficult and use itinstead of facing his problems.
his problem-solving skillswill actually decrease. did we pluck this out of thin air, jan,or is this a typical story? no, ben is a quintessential,typical australian cannabis user. i have a graphic that shows the findings of the most recentnational household survey. we see that now, as the '60s and '70s happy cannabis users are ageing, the peak rates of overuse are now 30 to 39.
norman: kids aren't taking it up? no, and our next slide will showthat the good-news story, in terms of the very significantreductions in cannabis use that we're seeing in 14- to 19-year-oldsand the older age group up to 29. so this is terrific. however, we're seeing thatthose stuck in cannabis use are showing more problems. there's higher rates of daily use and higher rates of people expressingdifficulty in controlling their use.
it's a different patternin aboriginal communities? it is. that shift in the agedistribution hasn't really happened in the remote indigenous communitieswhere i've done surveys. still get plenty of young usersin the 16 to 19 years bracket and in the 20 to 29. - it hasn't declined?- it hasn't, really. in fact, it's gone up, jan? yes. we don't have great national data,but what we do have indicates that while we've got a 13% reductionoverall in the general community
since the mid- to late '90s, we've got at least a 5% increasein indigenous communities. i know in the communitiesthat alan has been researching in, extremely high rates of daily useamongst this younger age group, which is concerning,given what we know about the risks. and, alan, the earlier you use,the worse the outcome? that's right, yeah. 12, 13, 14 is what sometimes you see? yes, particularlyin indigenous communities,
less so in the general community. we're learning more about braindevelopment from epidemiological studies that use before the age of 16is the red flag for later problems in terms of mental healthand dependence. and other uses. the youngest age of first use i've seenin indigenous communities is ten. norman: and you've seen even younger. a couple of times, younger than that,in the town i live in. norman: so, why the change, jan?
what's gone onin non-indigenous communities? is it just not cool to smoke cannabis? well, that's what we think. we've, just in the last five years, had good public-health campaignsaround cannabis. we've had better and longer campaignsaround tobacco. we think that part of the smoking isuncool and dirty and messy message is rubbing off to those users who werepossibly never going to experience significant problems with cannabis.
they were recreationaland experimental users. norman:so they switched to other drugs, kids? i think so, at least in rural areas. it might be different in big cities. we have a fair bit of peoplewho use speed. i've got more and more people presentingwith amphetamine use, and alcohol of course stays the same. the problem in country areasis the mixing of these drugs. norman:what does the household survey show?
the household survey showsthat alcohol and amphetamine use has dropped overall. but i'm sure in some rural communitieswhere there's issues of availability... so despite the moral panicabout alcohol, it's dropped too? a similar picture? yeah. and we're seeing the same thing with males dropping offat a more rapid rate than females. we're seeing a convergencein the rates of use, particularly in those young age groups.
what we are seeing an increase inis ecstasy. and you don't know why? no, except it has a reputationof being a cleaner drug. it's more a fun drug. the reputation of cannabis is thatit's a stupid drug, a dopey drug, it makes you tired and not with it. young people want to go outand dance and rage all night and be able keep doing that,and they enjoy it more. jan: but coming down,they use cannabis for that.
of course. how does cannabis rate with other drugs,tess? cannabis has been thought ofas a soft drug, but working in a cannabis clinic, wherepeople are accessing treatment for it, we find that people have a lotof problems from regular cannabis use. 75% of the people who attend atour clinic in particular use every day, and it is impacting onmost areas of their life - their social functioning,their workplace, their relationship in the familyand financially.
so it's not the soft drugthat it was once thought of. let's go back to ben. what are you actually going to recommendfor him? i'd recommend for him to give it up, especially if he wantsto join the defence force. he just can't do it at all,even twice a month. other than that, just tell him to watchmixing it with alcohol, driving, the legal implications of it. again, apart from these things,if he smokes twice a month
and he's not at the defence force and he's careful not to be caughtby the police, i don't believe there isa direct health implication for him. he would join the majority of smokerswho smoke occasionally. as you say, alan, we're looking ata very different pattern of use in indigenous communities. it's quite different. we have high ratesof very regular use there, with up to 60%of the 13 to 36 years age group
in some communities i've done surveysusing on at least a weekly basis. jan, what do we knoware the predictors of cannabis use? we've talked about the obvious ones ofbeing a male in the 20 to 29 age group. in terms of of occupational categories,we know that people in trades who work outdoorsare more likely to be cannabis users. norman: really?- yes. more opportunity to usein less supervised and perhaps fairly routine and mundanework for some people in trades. the group that we're most concernedabout, apart from indigenous people,
is those with mental-health problems. they have higher levels of cannabisand tobacco use. which way does it go? some research suggests that if you havedepression and anxiety as a teenager, that predicts drug use. then some people say the drug usecauses mental-health problems. i think some of it is an association. we're not that clear about causality, although now we have goodlongitudinal studies
that have followed people from birth. typically, they start using cannabis before they start reportingsignificant mental-health problems. norman: drug use may come firstin some instances? more typically. let's go to our next case study, owen. he's a 23-year-old indigenous man with a wife, two kids, living in a remote community.
he's got a chance of getting a job with a mining company doing land rehabilitation. when he's gone for a job, he's tested positive several times in a saliva test. he really finds it a struggle to give up, and give up smoking. he and his family share a single room
in a crowded house. most of the people around him smoke cannabis frequently. he's finding it tough to give up, but he's desperate for this job. is this a real story? it's a real story, norman. it's got a positive outcome, though. the guy got the job after awhile.he succeeded in the end.
obviously a tolerant company,willing to give him a second go. a very supportive company that wereprepared to give him many chances to pass the drug-testing regimes. i interviewed this man back in 2001when he was a cannabis user. i believe he'd started usingat about the age of 14. he'd been abstinent, he told me,for about 12 months prior to applying for the position,but living in such circumstances, where he has little controlover many aspects of his life, he's probably suffering the peerpressure to join in with his family
and consume, perhaps on weekends, then failing the test on mondaywhen he turns up for work. a common story, from your point of viewin a country town? very similar. aboriginal people have a higher rateof unemployment, lower socio-economic conditions,crowded housing. very high rates of cannabis use,and in a binging fashion too. it seems to have taken over from alcoholin previous generations. a very early initiationinto cannabis use
and very common,often in primary-school age. but, yes, a similar situation we have. it's quite common, really a problem,especially the early use because we're worried about braindevelopment, frontal-lobe development, which doesn't mature until the 20s. what help did this man get? got a lot of helpfrom the mining company. also, he had the support of his family. his own determination saw him throughin the end.
like most drug use -most people just give up? he gave up.he wanted to change his lifestyle, he saw the benefits of doing that. not only did the jobget him the position and the money, it got him alternative accommodation so he could maintainthat change in lifestyle. is that reflected across the board, jan, that most people who want to give upjust do it? yes. that's the most common storyof what we call self-managed change
in common with other drugs,particularly the illicits. people give up when they havegood enough reasons to give up. they get married,they have the job they really want. particularly having a familyis often a key turning point, where people have enough reasonsto make that change. the costs arestarting to outweigh the benefits. are there proven interventionsto help people get off cannabis? in terms of psycho-social interventions,yes. cognitive behaviour therapyhas a very strong evidence base now.
let's not just glance over that. what is cognitive behavioural therapyfocused on? it's focused on helping people changethe way they think about cannabis and how they respond to those thoughts. norman: give me an example. i can't be creativeunless i use cannabis. i wouldn't be able to relax,to make music, whatever they see as thepositive expectancies about cannabis - i can't relax in any other way.
it's helping people move beyondthat catastrophising - it would be the worst thing in the worldif i had to stop. i couldn't get through withdrawal.i'd have nothing to do. helping them address the waythey're thinking about cannabis use. simple things. well, i say simple.of course they're not to the individual. identifying high-risk situations,helping them do behavioural things like bury the bong. rearrange wherethey typically smoke cannabis. norman: remove the cues and triggers.
exactly.keep away from cannabis-using friends. it's very important to separate, when you're working with peoplein treatment, their behaviour from their personality. if they've been using for a long time,they become entwined. norman: they become the drug?- yes. so to categorise cannabis useas a behaviour, then look at the positivepersonality traits of the person can be really helpful to them.
you won't find many psychotherapistsin aboriginal communities. no. these kinds of serviceswe've talked about there are scarce. and if they are on the ground,they're possibly delivered by clinicians who have other prioritiesin a busy rural or remote clinic. it's likely that somebody like this isalso heavily dependent on tobacco. what's the story between tobaccoand cannabis, and does treating one help the other,fares? most people mix the two drugs. - the majority, is it 90%?- in australia.
smoke tobacco together with cannabis. so when we want to treat the cannabis,we also have to treat the tobacco, which makes it doubly difficult. alan: that's truefor indigenous communities too. we don't have good evidenceabout how best to treat that. nicotine-replacement therapy,for example, at the same time seems to make sense,but we don't have evidence. norman: eases the pathway. given that we're talking aboutculturally determined treatments, often,
with indigenous communities, does cognitive behavioural therapy workwith indigenous people? we have no idea. this is one of the areas that have receivedabsolutely no research attention. i don't think there's any prima faciereason to suggest why not. but we need to move it up a notchto include family and communitymuch more broadly than we usually would, particularly to identify peoplethat aren't using in the community,
that might be safe peoplefor the individual to move into that extended socialnetwork that might be safer for them. i imagine alan would have more insight. i'm thinking of prevention strategiesin remote communities i've worked in. these are isolated places with populations of perhaps 2,000or 3,000 people maximum. the kind of intervention strategiesthat are needed at the moment with cannabis use endemichave to be population-based. they've got to be providedat the community level,
ideally with some sort of collateralsupply-control strategies to break the circuit. then there might be possibilitiesfor one-on-one treatment. are there different patternsof cannabis use around the country in aboriginal and torres strait islandercommunities? we don't have that systematic data. the work i've done has been primarilyconcentrated in eastern arnhem land, in the top endof the northern territory. in those communities, i surveyedin detail 200 or 300 participants
in a number of communities. recently,i've toured through most communities in torres strait and cape york,interviewing some key people and seeking their views about the issuesrelating to cannabis. there are familiar echoes betweenthe cape york/torres strait information. norman: such as? the kinds of issues people talk aboutare frustration with the trafficking and the huge financial impacts it makesin these communities, the acute psychotic episodes that areclearly connected with cannabis misuse
and the heavy financial burdens. i estimated in the northern territory,up to $1 out of every $6 in a community's bank account,if you like, was being relocatedinto the cannabis trade, quite apart from the more subtlemental-health effects. you would see that a lot, tess,even in a non-aboriginal community. yes, we do see a lotof mental-health effects. we actually collect data in the clinic, and we find that peoplewho come into the clinic
have a higher rate of symptomsof anxiety and depression than has been previously diagnosed. and that could be secondaryto their cannabis use or that could be an underlyingmental illness that needs addressing. what's your practice with peoplefrom indigenous communities? in the medical service where i work,in a large rural centre, we've done thingsmore on a cultural, community basis. norman: what alan is talking about?- similar. we've done things with sports,for example.
we've taken groups of young menin their early 20s, about 20 of them, and done weekly or second-weeklyaerobics classes, swimming. norman: community development?- yeah. and art therapy. we've taken families of cannabis users,and they've painted pictures. norman: sounds nice,but does it actually work? it's very difficult to evaluatethese things. we've got ongoing programs.we do what we can. norman: what abouttraining aboriginal health workers in cognitive behavioural therapy?
that would be great. there's been some work done in alcohol - cognitive behavioural therapyfor aboriginal people. it's been culturally modifiedfor aboriginal people with a lot of pictorial methodsand so on. strong minds, strong spirit. whether things like that could beadapted for cannabis, i'm sure it can. it's just,we need the effort and the resources. alan: i agree with fares.
we need those kinds of community-development activities at large. the question of evaluating them thoughis enormously challenging. they're very hard to control or direct because community developmentalways takes on a life of its own. but i'm confidentthat those sorts of strategies, in communities i've worked in,have an impact. whether you do individual counsellingor you're talking about communities, one of the prime objectives is to getpeople to engage in healthy activities rather than the unhealthy activitiesthey have been participating in.
for gps watching, this is aboutengaging the team around you, and the resource is whatever happensto be available in your area? yes, and whatever the person isinterested in doing. working with individuals,they have different interests. they will do best at being directedtowards those interests. jan, the predictors hereare about poverty and deprivation. yes. absolutely.social determinants are a major issue. however, we're seeing inthe indigenous work that alan has done and also in the wider community,
that a predictor of managingto get control over cannabis use is being involvedin vocational activities - employment, in particular. fares: housing. so the things that fix up the community,fix up the drug use. nick is a 17-year-old boy brought in to see you, fares, by his mother. she tells you he stays up late, often doesn't get to school, is moody,
anxious in the mornings. when he does get to school, he has arguments with his teacher. his school performance is dropping off, particularly in the last six months. he's not eating much, and seems to be acting quite strangely. he doesn't talk much, keeps to himself. what do you think?
it's a real worry. this boy,he's in that difficult age group. the other difficulty isthat his mother brought him in. norman: he doesn't want to be there.- no. no. he's probably coerced. i couldtell that from his body language. the first thing i would dois ask the mother to leave the room unless he insists on having her there. but i think he was quite relievedwhen i asked her to leave the room, and i had a chat to him just together. first, i would needto gain his confidence and trust
that anything he would tell mewould be confidential, that i'm here to help him,not to judge him, not to... norman: call the cops.- ..dob on him. yes. i'd assure him i'm nota policeman or a teacher or a parent, i'm a doctor,and that it's all confidential, and that if i broke confidentiality,i'd be breaking the law. having done that,hopefully he would open up. a proportion of kidswill take that on board and respond? definitely. yes.
a 17-year-old,i'm sure that he would do it. legally, confidentiality is assuredat that age, even from 14 up. i'd have a good chat to himand see how his private life is going, what his interests are,why is he having trouble at school and his appetite, not sleeping,acting strangely. i'll have to put it in his own language. norman:give me an example of the script. ok. i would say to him,how is it going at school? do you spend any time with your friends?
do you have friends?do you have a girlfriend? norman: what are you listening for? i'm listening towhat the teenager would say. i'm hoping he would tell me...i suspect he's abusing a substance, unless we're looking ata mental illness, such as schizophrenia, which at that age... he could still be justa normal teenager. it sounds like it's getting worse. i might not be able to do muchthe first time,
and i hope i can assess him again. but it sounds like i could probablyget some information off him. if he did tell me thathe's using cannabis... tell me how you broach that subjectwith a 17-year-old. i'll say, do you spend a lot of time byyourself? what do you do on your own? do you watch tv a lot? do you drinka lot of alcohol when you go out? i start with alcoholbecause it's sort of more acceptable. then i ask about dope. i'll justcall it dope. do you smoke a lot? do you smoke cigarettes?then go on to cannabis.
he would tell me. i'm sort of confidenti would get it out of him, hopefully. for the naive person whomight not know what's going on here, give us the technology of smoking dope. what's the patoisthat one needs to have? ah. i'll ask him about bongs and cones. that's most likely the wayhe would take it in. most people these days smoke those. - in the old days...- it used to be the joint, in paper. now they smoke it in bongs,and that's proven to be more harmful.
it's a water pipe made up either of $300worth of ceramic, a nice one, or an empty plastic drink bottle.oj, they call it. norman: and they put cones in that.what's a cone? a cone is a brass, metal piece that sits on top of the plastic tubing. they stuff it usually with tobaccoand cannabis, they mull it -hence the name of our program - and they stuff it in and they smoke it. it's an individual amount of smoke,
and it's inhaled very deeplyand it's very hot. it goes straight into the lungs. if he said, i smoke a bit,how would you assess how much? to him, a bit might be quite a lot. i'd say,how many times do you sit to smoke? how many sessions a day do you have? this boy, i'm guessing, will probably have a few before schooland a few after school. he would have four, five sessions a day.
then i would ask,how many cones per session do you have? and he'd tell me, six, seven,eight cones. we're looking at anything between30 and 40 cones a day, which is quite a lot of cannabistaken in. he might not be able to tell mein this detail. i'd ask him how much it costs him. he'd be buying them in buddha sticks -a stick wrapped in aluminium foil. that costs between $20 and $30,it depends where you are. norman: how many coneswould you get out of a buddha stick?
probably 10, 10 to 20. many kids smoke one or two sticks a day. so they're spending a lot of moneywhen you think about their income. do you ever askwhere they get the money from? i avoid that question.no, i don't ask them that. i do worry about it but... that's part of getting closeto the risky side of the conversation. you're focused on the drug use. yes. i want them to trust me, to tell mewhat i want to know to try to move on.
most people who use drugs enjoy it.they quite like the drug, don't they? well, certainly, people aren't stupid. they initially give as a reason thatthey want to enjoy themselves and relax or just try it and have fun. typically, that reason is lost as peopleprogress and develop dependence. soon they're smoking just to feel normal because they're going throughearly stages of withdrawal and are actually smokingfor withdrawal relief. norman: do you agree, tess?- yes.
sometimes people who havemoved to a dependence, they know thatthey're feeling anxious, irritable. they might be feeling in a very low moodwhen they don't have any cannabis. like jan said, when they have cannabis,it relieves all those symptoms. they just think they're doing itbecause they like it. the problem with a regular smoker,if they smoke regularly enough like this boy,if he kept doing it for a year or two, all it takes is four or five hourssince the last smoke to start getting into withdrawals,maybe overnight.
they wake up in the morningalready in withdrawal. norman: give us the symptomsof withdrawal, tess. symptoms include feeling irritableand anxious, having a low mood, perhaps nausea. sleeplessness is a very common symptom. feeling quite restless. sometimes people mightdo a lot of sweating, particularly when they're sleeping. fares: aggression.- depression, yeah.
norman:these are questions you might ask about how he's feeling in the morning. are there tools availableto assess how dependent he might be? yes, we have on our website atncpic.org.au some assessment tools there, includingthe severity-of-dependence scale, which is a lovely, five-item,quick scale which correlates wellto a full dsm-iv diagnosis. it focuses more on people's concernsabout their cannabis use.
so it resonates well with the user,rather than being in technical language. that's a very accessible instrumentfor people. when i read out that that case study,a lot of people would have said, this might be first-episode psychosis. how would you go about assessing that? it can be. and this is the concern -it can be aggravated by cannabis use. it can also be just psychosis. the symptoms don't seem to be yetsevere enough to diagnose psychosis. norman:but he's at risk of it, isn't he, tess?
definitely. he's at risk of itif there is a genetic predisposition to some type of mental-health issuein the family history. i thought it was clear, jan,from epidemiology around the world, that there is now an accepted causalrelationship between cannabis use and schizophreniain the general population. where you've got high cannabis use,like brixton in south london, you've got high rates of schizophrenia. yes, although the brixton situationis complicated by,
they have a high migration as well, which is also a significant predictorof schizophrenia. but i agree, the evidenceis certainly shifting in that direction. recent meta-analysis has shown thateven one episode of cannabis use increases the risk at a population levelof about 40%. when we talk about peoplelike this young man, using at an early age and using heavily, their rates of full-blown schizophreniaare at least double. it's certainlya dose-dependent relationship.
in terms of psychosis,the likelihood is even higher that they'll developpsychotic symptoms - something like five times the ratewith this sort of history. you're talking about permanentbrain changes in this age group? that's certainly hypothesised. there's been brain-imaging workthat's come out fairly recently which was with very high-level cannabisusers over a long period of time. it's now showing structural changesin the amygdala and hippocampus, which are very concerning.
there's similar work being seenin animal models as well. it's important, too,when you're talking about young people who are diagnosed witha psychotic episode, it's important to remember it does comeout around that age of adolescence. those young adolescents who do havepsychosis tend to use more and more. they get trappedinto cannabis use easily. i think we need to be alert, too, that once they've had that diagnosis,that experience, that cannabis use very clearlyexacerbates the symptoms
and makes the course much worse. it must be bloody scary. i've seen cases like thisin notes in remote clinics that have progressed to suicide attemptsand completed suicides. this guy's probably luckyhe's gone to a clinician. the withdrawal can make you quite aggro,can't it, tess? yes. we often hear of clientswho become very aggressive when they're withdrawing from cannabis,and even inflict physical violence. it can be a problem for families,
not only for partnersbut also for parents. if the young personis living in the parents' home, they can become violent,punch holes in walls, attack people. what sort of questionswould you ask young nick to see whether or notthere might be delusional behaviour? the usual questions of, has he heardany voices that weren't actually there? was he given any commandsthat were unusual that are new to him? did he see things that do not exist? does he have any thoughts of self-harmor harming others?
the usual questions of delusions -hallucinations, auditory and visual. we've got a question from a generalpractitioner on the north coast of nsw - 'is there any relationshipbetween smoking cannabis and smoking wormwood cigarettes?' not that i'm aware of. i've never even heardof wormwood cigarettes. i guess the kind of people who smokecannabis would try something else. like wormwood cigarettes. fares: they're not indonesian?jan: no, they're clove.
a question from a general practitionerin queensland - 'is there a link between infertilityand cannabis use?' there is some early evidenceof that link. it's been shown to affect testosteronelevels and sperm motility in males, and also to affect the menstrual cyclein females. once they get past the infertility,in terms of reproduction more generally, it does cross the placentaand it is excreted in breastmilk. a general practitionerin south australia asks, 'is there a link between impotenceand cannabis use,
and can that be used as a deterrent?' related to lowered levelsof testosterone. even more simply, it's the anxietyand depression that a man would have. if you're part of that ageingbaby-boomer, cannabis user, it might be the tobacco causing it. with males, you can use gynecomastia. similar to alcoholhas been shown with cannabis. - no-one wants that either.norman: absolutely. this comes from a general practitionerin country victoria -
'what messages do you usefor regular amphetamine users who use cannabis to come downafter a 12-hour bender?' mixing the two togetheris the worst thing they can do. i was going to mention amphetamine when we were talking about delusionsand psychotic episodes. that's probably more likely to happenif they mixed it. using cannabis to come downis definitely not the right thing. cannabis doesn't relax you,doesn't take away that anxiety that the amphetamine would give you,
nor does it take away the depressionyou may feel when you come down. it may make anxiety and paranoiaeven worse. tess, you've got this 17-year-old.fares has referred him to you. he's a heavy user.he doesn't really want to be there. fares has got him over the line,but he's really resentful. how are you going to look after him? i'm going to provide him withpsychoeducation around cannabis, but at his own pace. i don't think you can rush youth
into thingsthey don't want to be involved in. my priority at the moment would be tokeep communication lines open with him. even if i had to say, 'look...' i would acknowledgethat he might not want to be there, but we need to do thisto keep your mum happy at the moment. i would also, if the opportunity, depending on the setting,presented itself, try to engage his motherin some counselling separate to him. because at 17,the family will play a very big role
in directing that childback towards positive activities and a strong family environment. teenagers are very influencedby their peers, but the family influence will lastlonger and is stronger in the long run. you'll do some family therapy? no, i wouldn't. that's not my area. if i thought it would help,i would refer them to family therapy. but i would work behind the scenes withthe mother, if i got the opportunity, to try to help increase his self-esteemand his confidence.
but don't families need help? if you only treat the kidand not the family... definitely.a session with the mother is wonderful. i'd also refer her to a greatorganisation called family drug support. they've got a website, easy to find. they support each other,give information, do the things you were saying. it's like anorexia or other drug use - you've got to have a script to be ableto deal with your teenage child,
and know how to behaveand how not to behave. must be like walking on eggshells. it can be really difficult for families. the parents lose their self-esteem,they don't know what to do, they're worried for the children. it can spiral downwardsquickly if the family aren't supported. i was attending a drug conferencea couple of weeks ago, and there was evidence from the uk thatif you don't treat the person at all but treat the family,you can get excellent results.
in other words, forget about the personwith the drug problem. just treat the family,and you start to help the drug problem. that was part of an interventionwe ran a few years ago called the adolescent cannabis check-up, where we first worked with theconcerned other, typically the parent. it's called unilateral family therapy -coaching people over the telephone in how to approach the personwith the cannabis problem. it's very successful in helpingengage them into treatment. we have a resource on our website
called talking with a young personabout cannabis, which is freely available,which we used in our intervention. we found thatparents found it very helpful. it's very clear if you have a couple - one of them is tryingto come off cannabis - to explain to the other partner thatthese symptoms are going to happen, to be prepared for them,to educate them about the symptoms and to be patient and give them time. i tell them, this is not john doingthis, it's the drug coming out of john.
but sometimes the personliving with the person has to accept that they're not ready to come off,and you've got to get on with it, which is what unilateral therapy does. we also approach with young peoplemore motivational... as tess was saying, we're not hereto treat you or make you do anything, we just want to talk with youabout your cannabis use. that approach helps engage young people. tell me what you say. things such as tess said -
we know you're here to pleaseyour parent, and that's terrific. that's a great first step. tell us about your experienceswith cannabis. what are the good things? as we mentioned before, people typicallyhave what seemed at the time very good reasons for using cannabis. then we explore what might beless good things about cannabis. they do come up with things, particularly financial,with young people.
if they don't see the discrepanciesin what they're raising, we might say,you're not ready to think about change, but how would you know when thingsweren't going well with for cannabis? then often they raise thingsthey've already mentioned, and highlighting discrepanciesin those sorts of things are a good technique with young people. it works on the principle thatevery drug user, every dependent person, has a part in their subconscious mindthat doesn't want to use, a part in their mindthat they hate about the drug.
our job is to stimulate that part and bring out the negative aspectsof their habit to them, and let them verbalise it and say it. sometimes maybe write it down,bring it back next time, in order to reinforce their willingnessto change. otherwise people get defensiveand defend their drug use - no, it's not a problem. it forces them intothat kind of response. if they're heavily dependent,you've got to talk them through that.
they might be scared it's like heroin and they'll have to detoxin a major way. yes, it's always good to talk to themand explain to them the cycle of cannabis use, cannabisdependence, cannabis withdrawal, help them be aware ofwhat feelings are associated with that. ask, do they identify withany of those feelings or any of that informationto try to continue to engage them. let's go to our next case study, gail. she's 45 years old,
a single mum, two teenage kids. she lives in a rural, coastal town, in fact, your town, fares. she's been smoking cigarettes and cannabis regularly for about 20 years. she's got a productive cough and recurrent respiratory infections. she comes to you saying she's having trouble holding it all together.
she feels demotivated, she doesn't like going to the shops, doing what she used to. she just feels a bit worthless. she's depressed,and at times she's probably anxious, which is the flipside of the coin. she's going through mood disturbances,most likely related to the cannabis. either caused by the cannabisor aggravated by it over 20 years. so this is classicdual-diagnosis territory?
yes, and it's a classic case -single mother, difficult circumstances. norman:what are you going to do for gail? she will need treatment. like we said earlier, i will explainto her first about information. it wouldn't be as difficult asthe guy before. norman: she's ready for help?- she's further on the cycle of change. she's motivated to change. we will talk to herabout withdrawal symptoms, and help her throughthe withdrawal period,
which can last up to three to six weeks. people say that when you talk aboutcomorbidity, the dual-diagnosis story, that if you've got depression,you won't get people off drugs until you treat the depression,and the other way round. in other words,you've got to treat the mental illness. the question i have for you,jan and tess, is, is cognitive behavioural therapyenough to lift the lid, that you're going to treat bothat the same time, or is there a casefor a short-duration antidepressant?
is there any evidence for that, jan? cognitive behaviour therapystarted with mental health. it started as a treatmentfor depression. a skilled clinician should be ableto apply cbt to both conditions. norman: does it work through the fogof cannabis if she's a heavy user? if she's intoxicated at the time,that is certainly a problem. it's much easierif people come to treatment not heavily intoxicated, anyway. but if that's not workingin the first instance,
then someone like faresmight be the next port of call. even if she wasn't intoxicated,even if she'd stopped, she will be so anxious and depressed,she will not be sleeping, she will be irritable, that she will find it difficult toengage in cognitive behavioural therapy. she won't be ableto keep the appointment, let alone concentrateand do the homework and exercises. this is where i believesome pharmacotherapy as well as psychotherapy might help.
randomised trialshave been disappointing. that's right, so far. but we've done some workon anti-anxiety medication that i've been prescribingfor seven years. it's also used in south australia. short-term, mild treatment for anxiety, sometimes coupled withantidepressive behaviour would be good. here, i want to mention that the only accepted treatment for anxietyis benzodiazepines.
i would like to discourage my colleaguesin prescribing benzodiazepines for someone who's trying to stop... norman: you create a new set of issues?- yes. we're finishing up someclinical guidelines around cannabis, and we do mention,after much debate and angst, that's the line of last resort. you mentioned pericyazineand other antidepressants. we know they're used quite a lotoff-label for cannabis withdrawal and reduction of craving.
i've found that, anecdotally,very useful. people have less symptoms of anxiety,they can sleep better, they can engage better. norman: do you have troublegetting them off antipsychotics? very easy. it's only a small dose. we use a quarter of the dosethat's used for psychotic... which is one of the onesthe randomised trial showed nothing? no, pericyazine has notbeen subject to a trial. we've done a reverse study,and we're hoping that...
what's the outcome for someone like gailif she is motivated? i think it's very good. if we can manage to encourage herthrough whatever means, whether it's through medicationor counselling, to cease cannabis use, it could be a very short turnaround until the time she's so pleasedthat she's stopped using. norman: and she's readyfor other therapy. yeah, and her life has changeddramatically. she's somebody you could havea mental-health plan for?
this is one where a gp can access helpfrom a psychologist, who will be spending 12 times an hourand a half with her throughout the year. a gp could never do that,nor has the skill to do that. not too many aroundin aboriginal communities. we've interviewed women like gail. it's very unlikelyshe'd come to clinical attention unless she went to the clinicfor another reason. but you can be surethey're out in those remote places. yet again,the resources to help people like that
with culturally appropriate cbtin aboriginal, indigenous and torres strait islander communitiesis important. we're talking about two teenage kids.nobody's talking about men. i was going to raise that. norman: are they at risk?- absolutely. we don't have good studies,unfortunately, on intergenerational issueswith cannabis use, but we know that's what we're seeing. there's families that have been usingcannabis for two and three generations.
as the evidence is building aboutthe harms related to cannabis use, particularly in this kind of pattern, it may well be that for the first timeit's being recognised as a problem attributable to someof the families' difficulties. we've got a question from a psychologistin new south wales - 'is there evidenceto support the proposition that long-term cannabis useresults in memory loss?' yes, certainly memory and learningare one aspect. norman:is that an intoxication phenomenon
or long-term phenomenonwhen you come off? what we see is, those memory problemsimprove with long-term abstinence. it's a positive message that doesimprove over time when people stop. i was distracted when youwere talking about the teenagers - what would be the recommendationsto deal with these teenage children? first, the positive role modelof their mother stopping cannabis use and having better informationto share with them and for it to become a family discussionaround cannabis - i thought it was fine when i wasa teenager, but this is where it led me.
do you often see kids with parentsin this situation? sometimes we see kids with parents. i agree with jan. the most important thingis that the mother turns her life around and becomes a positiverole model for those children. what we've already spoken aboutaround adolescence applies. if they start to engage insmoking cannabis, she'll need to apply the same strategies and pull them backtowards positive, healthy activities.
what i don't understand yet is,what is the treatment goal? are we aiming for controlled use?are we aiming for abstinence? what's the story? it depends on the person,on the stage of addiction they're in. we don't tell themwhich one they should do. we try to reduce the harm. initially, we try to control the use,but we hope to set a goal. norman: it's not a pathof great success, controlled use. i agree. it's often more difficultto reduce than to stop altogether,
go through the withdrawal,then stay off it. however,trying to direct a client into a goal that isn't their goalisn't a path for success either. sometimes it's betterto let the client say, my goal is to reduce,and then review it as you go along if you can have more sessionswith that client. they often swing towards abstinence. what's the evidenceon goal setting, jan? no evidence, unfortunately.
we're at such an early stagewith cannabis. that's why it's so greatthat we've got a cannabis centre that we can start looking atsome of these issues. generally, i think tessa's right, that the advice should be cutting downwith an aim to quitting should be short-term. they should have a goalof two to three weeks as a quick date to be cutting down towards. that's the recommendation for thosewho ultimately want to quit.
often i find that it's more difficultfor them to try to keep cutting down and keep having this mental... you wouldn't do it with tobacco.they're addicted to tobacco as well. they'll want to go back to tobacco. it's impossible with tobacco. you can't. norman:abstinence is the aim with tobacco. i think it needs to be the aimwith cannabis too. sometimes people havesuch a strong relationship with cannabis that they really fear the thoughtof never using it again.
they really struggle with abstinencefor that reason. but as treatment progressesand they start to reduce, their thoughts around that can change. we did follow-up studiesafter three years in some eastern arnhem land communities. in the meantime, there had been targetedcommunity-development activities, youth-development activities and also stringentsupply-control strategies implemented. the results were that there were stillplenty of willing cannabis users
in the population, but what had changedwas their access to cannabis and the frequencywith which they used it. a lot of those core social problemsand community problems and some of the acute psychotic episodesalso dropped back in the follow-up. - but it was still around?- still around. plenty of willing users. hard to control.tell us a little bit about ncpic. it's an innovative responseof the government's to community concern about cannabis use. it's a consortium of key mental-health,
drug and alcohol researchand clinicians, criminal justice. so bringing a whole new perspectiveto the issue of cannabis. we have three main aims. one is to provideevidence-based information, because that's one issue we identified - people don't necessarily havegood-quality information about cannabis. we have a lot of resources downloadableon our website. we also aim to train the workforce. we provide free training nationally.
on our websiteyou'll see the types of training - from community awareness about what arethe harms associated with cannabis through how to deliver up to sixsessions of cognitive behaviour therapy. we're also developing new interventions. as a result of that, we now have freeinterventions available via the post. if you're a rural gp,you can't provide cbt, your client can access freeinterventions via the mail. we also are about to launchan intervention on our website and also through our freenational helpline: 1 800 30 40 50
people can call just to ask questionsabout cannabis, or, now, how to access interventions. cannabis clinics - you work in new southwales. are they in any other state? no, they're only in new south wales. they're an initiative of thenew south wales department of health. they were set up because there wasa large number of cannabis users who weren't accessing treatment at theestablished drug-and-alcohol services. it was felt thatif separate clinics were set up and marketed to that population,that would increase the access,
and that's exactly what's happened. around 50% of people who attendnew south wales cannabis clinics haven't had any treatment prior. they're referring themselves,or gps can refer them? yes.any health professional can refer them, as long as the person gives consent.they're free. norman: you give themevidence-based therapy? yes, we do, for around six sessions, but very flexible, dependingon the needs of the person.
norman:what sort of results are you getting? at sutherland, we have around 50% to 53%success rate, that is, people who have met their treatment goal when they finish. norman: how many centres are there? there's five centres across new south wales, with another one about to open. centres on the north coast,
in the central-west and on the central coast have satellite centresat a lot of community health centres. if anyone would like to see exactlywhere those clinics are, they could access that information through the sutherland cannabis clinicwebsite, which you can google. norman: and we'll have it on the ruralhealth education foundation website. fascinating, this discussion.thank you all very much. what are your take-home messagesfor those watching, tess?
i think that the take-home message is that parents play an important rolewith young people, as we talked about. that's somethingthat hasn't been talked about a lot, so i'd like people to remember that. also, that there are clinics out therefor people to access and gps to phoneif they want information. at least in new south wales. maybein other states in years to come. fares? my message to my colleagues, the gps, is that knowing that most peoplego first to the gp for any problem,
is that first of all,they need to ask the question. assess the drug and alcohol historyof the patient, especially these peoplewe were talking about. familiarise themselveswith the withdrawal symptoms because they're very important, and withthe treatment of withdrawal symptoms. avoid valium, or benzodiazepines,as i mentioned earlier, and know how to refer -to ncpic or to the cannabis clinics or to psychologiststhrough the mental-health plan. norman: jan?
i wanted to reinforce, to keepcannabis top of mind if you're a gp or a primary-health care practitioner,to ask the question and to know that resources are availablethrough ncpic free nationally and also throughour 1 800 30 40 50 number, where you can have referralto all kinds of interventions and any question about cannabiswill be answered. norman: alan? unfortunately, it appears,from our consultations and research, that cannabis has become endemic in manyremote and indigenous communities.
there's clearly a lack of servicesin particular for individuals, but most urgent is the needfor multiple-component, community-based intervention strategies that can build community capacityto raise awareness and to try to support familiesand other groups. because things that cure communitieswill help the drug problem. thank you all very much. i hope you've enjoyed tonight's programon cannabis in primary health care. if you're interested in obtaining moreinformation about the issues raised,
there are a number of resourcesavailable on the rural health education foundationwebsite: and there will be links to the websiteswe've discussed tonight. don't forget to completeand send in your evaluation forms, and please register for cpd pointsby completing the attendance sheet. i'm norman swan. bye for now. captions bycaptioning & subtitling international funded by the australian governmentdepartment of families, housing, community servicesand indigenous affairs�
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