Cannabis In the Spotlight: What the Clinician Should Watch .../media/Images/Swedish/CME...•...

20th Annual Pain Management Symposium 10/14/2016

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Cannabis In the Spotlight: What the Clinician Should Watch Out ForbyGreg Rudolf, MDSwedish Pain ServicesCascade Behavioral HospitalBoard of Directors, WA Society of Addiction Medicine


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Societal Attitudes Toward Marijuana• American society is in a state of ambivalence regarding beneficial vs detrimental effects• Conflicting federal vs state law, variable state laws• Evidence still weak for many clinical indications of medical marijuana under state laws

• Physician liability is still unclear

• Marijuana use is on the rise• REASON FOR CONCERN re: use among youth, or heavy adult use

• Elevated risk of lower educational attainment, unemployment, and psychiatric symptoms

• Increased prevalence of high‐potency strains• Decreased perception of risk

• Health professionals need to be aware of the evolving use patterns, policy, and science


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Now….

A Brief PRE‐TEST.

Would you be more comfortable recommending medical cannabis to…


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PatientA


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OrPatientB?


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ClinicalCase:BobRequestsSupportforUseofMedicalCannabis

• Bob is 30 yo, white, presenting for CPE to you and to establish care

• Has h/o bipolar disorder, GAD, and chronic insomnia. Also has h/o chronic low back pain.

• Reports he is using marijuana 3x/daily via smoking route, and “it’s the only thing that helps”. Wants to get a license for medical MJ use for his mental health issues and for his low back.


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ClinicalCase(continued)

• On exam:• Bob is casually dressed, appropriately groomed• Cooperative, poor eye contact• No psychomotor agitation/retardation• Normal speech rate, volume; TP linear, goal‐directed• Appears dysphoric, describes mood as “down”, no SI/HI, no perceptual disturbances or delusions

• Insight/judgment are fair

• Back exam reveals diffuse mild tenderness in L4‐S1 region, no red flags. Appears myofascial etiology.


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ClinicalCase(continued)

• Bob’s psychiatric history:• Diagnosed with bipolar by the physician at the student health center at his college

• No discrete episodes of mania/hypomania• No psychiatric hospitalizations

• Various PCP’s have prescribed medications including BZDs, lithium, various anti‐depressants

• None helped, all were discontinued within 1 month

• MJ use history extends back to age 15• Considers this his treatment for anxiety and insomnia• Uses smoked joints, edibles and dabs daily

• Has experimented with other substance use but not used consistently

• Family history notable for treated anxiety disorder on both sides


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ClinicalCase(continued)• Bob says he is “tired of buying it illegally”• Several friends use medical MJ for a range of issues• Has been using increased amounts lately and his anxiety and insomnia have increased• Attributes this to lack of adequate access to the right strain/formulation

• Not using NSAIDs, acetaminophen, topicals• No trial of massage, acupuncture, PT• No mindfulness/relaxation practices• No counseling

• What is the relationship between Bob’s cannabis use and his mental health issues????• Mental health issues aside, is he a reasonable candidate for authorization for medical MJ for low back pain?


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Marijuana’s Effects on the Mind• Most commonly abused illicit substance among youth in the US and Europe

• Short‐term effects of Delta‐9‐tetrahydrocannabinol (THC) involve same mesolimbic dopamine pathways underlying other substances of abuse• Low potency, partial agonist of CB1 receptors in multiple brain regions, including nucleus accumbens and ventral tegmental area

• Use is associated with rapid release of dopamine>>>>EUPHORIA• May produce calm/relaxation, intensity of sensory information• Variable effects on social behavior (disinhibition vs social withdrawal)

• No evidence of enhanced creativity, especially at more potent dosing


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Areas of the Brain Affected by Cannabis


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Marijuana’s Adverse Effects on the Mind (Short-term Use)

• Impaired short‐term memory• Impaired ability to learn and retain information• Impaired motor coordination and increased risk of injuries• Altered judgment with possible increase in high‐risk sexual behavior

• Paranoia• Psychosis


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LongerTermAdverseEffectsofAdolescentCannabisUseontheBrain• Effects of Delta‐9‐tetrahydrocannabinol (THC) on the developing brain can disrupt critical human faculties including reality testing, reason, impulse control, priority setting, relations with others, and goal striving.

• Compromised educational attainment with increased likelihood of school dropout

• Meier et al 2012 showed that people who started smoking marijuana heavily in their teens and had an ongoing cannabis use disorder lost an average of eight IQ points between ages 13 and 38.• The lost mental abilities did not fully return in those who quit marijuana as adults.

• Those who started smoking marijuana as adults did not show notable IQ declines.


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OtherAdverseEffectsofMarijuanaUse(Long‐term)

• Increased risk of psychotic disorders, including schizophrenia, in persons with predisposition to such disorders (more on this later)

• Addiction: 25‐50% of daily users, 17% of those who begin in adolescence, 9.1% of overall users (more later)

• Chronic bronchitis symptoms• Decreased sperm counts• Cardiovascular effects including tachycardia and postural hypotension


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HowisCannabisUsed?• People smoke marijuana in hand‐rolled cigarettes (joints) or in pipes or water pipes (bongs). They also smoke it in blunts—emptied cigars that have been partly or completely refilled with marijuana.

• To avoid inhaling smoke, more people are using vaporizers. These devices pull the active ingredients (including THC) from the marijuana and collect their vapor in a storage unit. A person then inhales the vapor, not the smoke.

• Users can mix marijuana in food (edibles), such as brownies, cookies, or candy, or brew it as a tea. • Delayed effect: 30‐60 minutes

• A newly popular method of use is smoking or eating different forms of THC‐rich resins (“marijuana extracts” such as hash oil). This is called “dabbing” and typically involves very high dose THC.

• Topical oils, gels, creams, lotions


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YoungTeenWithAVapingPen


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EdiblesandMedicalMarijuana

• In states with “medical marijuana” laws (now 25 plus DC, Guam, and Puerto Rico), 40% of high school seniors who reported using marijuana in the past year used it through a food product (“edible”)• 26% seniors used edibles in states WITHOUT medical marijuana available

• Edible “doses” may contain higher amounts of THC than smokers typically use, but onset is slower so more is typically ingested


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Marijuana“Edibles”


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IsMarijuanaAddictive?• Contrary to common belief, marijuana can be addictive

• Research suggests that 30 percent of users may develop some degree of “problem use”, which can lead to dependence and in severe cases takes the form of addiction (marijuana use disorder)

• People who begin using marijuana before age 18 are 4 to 7 times more likely than adults to develop problem use

• 1 in 6 adolescent users develop use disorder by age 24

• Marijuana Use Disorder (DSM‐5) is diagnosed when the person can't stop using even though it clearly interferes with his or her daily life

• Lifetime prevalence 11.8% men, 5.4% women

• Existence of cannabis withdrawal is unequivocal (DSM‐5)


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IsMarijuanaa“GatewayDrug”?• Some research suggests that marijuana use is likely to come before use of other illicit drugs.

• Marijuana use is also linked to addiction to other substances, including alcohol and nicotine, which typically come first.

• Animal studies show that the THC in marijuana makes other drugs more pleasurable to the brain.

• Although these findings support the idea of marijuana as a "gateway drug," the majority of people who use marijuana don't go on to use other "harder" illicit drugs.


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RiskFactorsforMarijuanaUseDisorder

• Early onset of use• Family history of any substance use disorder• PTSD

• Childhood sexual abuse is robust predictor (other SUDs too)• Bipolar disorder• Adolescent “Externalizing Disorders”

• Include ADHD, Conduct Disorder (CD), and Oppositional Defiant Disorder

• Mediating factors: • Parental disapproval• Parental supervision• Academic competence• Availability• Higher Perceived Risk


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CurrentTrendsAmongYouth:from“MonitoringtheFuture”• Monitoring the Future Study: 41,000+ teens surveyed yearly, 12th grade since 1975, 8th and 10th graders added in 1991• Funded by NIDA, nationwide; past year, past month substance use

• MJ use remained stable overall in 2015• Past‐month use in seniors was 21.2%• Daily use in seniors was 6% (similar to 2014)

• 81% of these users said MJ is “easy to get”

• MJ use significantly greater than cigarette use at all grade levels

• There has been a shift in perceived risk• Only 36.1% think regular use is harmful vs 52.4% in 2009

• Only 16.4% believe occasional use is harmful


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PerceptionofRiskofMJUseAmongYouth


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YouthAttitudesTowardRegularMarijuanaUse


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Whatare“SyntheticCannabinoids”?• aka “Spice”, “K2”, “Incense”, “Kronic”• Similar psychoactive effects to MJ but often more severe

• High potency, high affinity CB1 full agonist; no CBD component• Higher prevalence of hypertensive urgency, psychosis plus reports of convulsions, MI, ARF, and overdose death

• Not detected on routine urine drug screen; lower cost• Named DEA schedule 1 controlled substances 2012• There has been a significant decline in past‐year use of synthetic cannabinoids since the survey has been tracking its use• Only 5.2 percent of 12th graders reported its use in 2015, compared to 11.3 percent in 2012.

• This is associated with an increase, over the same period, in the perceived risk of taking synthetic marijuana once or twice among 12th graders.


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THCvsCBD(Cannabidiol)forMedicinalUse• Currently, the two main cannabinoids from the marijuana plant that are of medical interest are THC and CBD.• Plant contains at least 70 known cannabinoids

• THC, which is psychoactive, increases appetite and reduces nausea• The 2 FDA‐approved cannabinoids (Marinol, Cesamet) are used for this indication

• THC may also decrease pain, inflammation, and muscle spasticity.• CBD is a cannabinoid that does not affect the mind or behavior.

• may be useful in reducing pain and inflammation, controlling epileptic seizures, and possibly even treating mental illness and addictions. There are no currently FDA‐approved CBD‐based products.

• 15 states have laws that specifically recognize the therapeutic potential of CBD, but none allow for a clear path to access

• NIH‐funded and other researchers are continuing to explore the possible uses of THC, CBD, and other cannabinoids for medical treatment.


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WhyDoesTHCPotencyMatter?

• Nationally, potency of MJ has more than doubled since mid‐90’s• Avg THC potency for plant buds 17.1%, while avg potency for concentrates/extracts 62.1%

• Potency rates of up to 95% have been recorded

• In CO, higher THC potency in edibles and concentrates have been tied to increased frequency of ED visits/hospitalizations

• States in general do not limit THC content


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EffectsofCannabisonMentalHealth• Independent effects can be difficult to disentangle from confounding biological, psychological, and social factors

• Not causally linked to other SUDs, though often begins following EtOH and nicotine use

• Relatively small % of MJ users progress to other regular illicit drug use

• Not associated with direct causation or cure of mental health problems• Strongly associated with panic disorder, ADHD, social anxiety• Use in adolescence may increase risk of anxiety and depression in adulthood

• May be a risk factor for violence and suicide, but not directly linked causally to either


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CannabisandPsychosis• There is overwhelming evidence that MJ doubles the risk of schizophrenia in adolescents, but this is an association that is a “component cause”, not necessary or sufficient as sole cause

• Psychosis can be caused by either intoxication or withdrawal from cannabis• Differentiating from schizophrenia in a long‐term heavy user (even months) can be difficult and requires extended abstinence from cannabis

• MJ use more prevalent in schizophrenic patients than in general population

• Patients with psychotic disorders who stop MJ and other substance use after first psychotic episode are likelier to have improvements in treatment adherence, positive symptoms, mood, and global functioning


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WhataboutBob? BacktoOurClinicalCase• After careful consideration of his history and clinical presentation, you engage in Motivational Interviewing to explore his openness to questioning the role of marijuana use in his life• You share a concern that his use may be problematic

• You recognize that he would likely encounter cannabis withdrawal if attempting to quit• No pharmacotherapy currently exists for this or for treatment of MUD

• You recommend CBT/MET‐based individual counseling• You share that there is some preliminary data for use of cannabinoid agonists gabapentin, and N‐acetylcysteine for tx of MUD, but you elect not to Rx any of these for now

• You recommend other evidence‐based interventions for his low back pain


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[email protected] 206‐890‐8039

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