January 14, 2021
Slide handouts
Transcript:
Michelle Wagner
Good afternoon. Thank you all for joining us. We have a wide and varied audience today. So, whatever your interest in this topic, we welcome you. I’m Michelle Wagner and I’m with NAMI, New Hampshire working on the first episode psychosis early serious Mental Illness Initiative. Thank you for joining us for today’s offering and the onward and each webinar series. Today’s topic is cannabis use and psychosis, science and practical consideration. This episode is being recorded. You’ll be able to find the webinar on the education page of onwardnh.org, which you’ll see in the chat section this Is a zoom.
Webinar that’s the platform we’re using so for all of you attending your camera is off and you are muted. We cannot see you nor hear you. So, any questions you have, please put them in the question-and-answer section, the Q&A section. Kim Murdoch, no, I mean New Hampshire’s communications manager will be helping us field questions at the end of our speakers’ presentation. How today’s flow will go is that first Doctor Miller will speak, then Dr. Crowe and after that we’ll have some time for questions and answers. Now a little bit about our speakers. Our first presenter is Doctor John Miller. Dr. Miller received his Bachelor of Science degree in Biochemistry at the University of Massachusetts Amherst, where his research interest was molecular biology. He completed medical school at the University of Massachusetts Medical School, Worcester. Served his medical internship at the Medical Center Hospital of Vermont and then completed his residency training and adult psychiatry at the University of Massachusetts Medical Center, Worcester. He is a diplomat of the American Board of Psychiatry and Neurology. Doctor Miller’s areas of clinical interest include psychopharmacology, our evolving understanding of how receptor binding properties differentiate psychotropic medications. Psychiatric benefits and complications of meditative practices and how to enhance brain health. He is the founder and medical director of Brain Health. Which is committed. To educate clinicians of all specialties on the appropriate diagnosis and treatment of mental illnesses, he maintains an active website, www.brainhyphenhealth.co note that’s not dot, .COM its.co. And you can find that link in the chat. As well, he maintains that website to provide free access to lecture handouts, publications and resources relevant to the mission of brain health. Over the past 25 years, he has lectured extensively throughout the United States on the pharmacological treatment of mental illnesses. He works in the outpatient setting as a staff psychiatrist at Seacoast Mental Health Center in Exeter, NH. He is a psychiatric consultant at Exeter Hospital as well as at the Insight Meditation. Society in Barry, Massachusetts. Doctor Miller serves as the editor in chief for psychiatric times. Our second speaker today will be Frederick Crowe. Doctor Crowe is the assistant medical director of the Massachusetts Mental Health Center, MMHC, where he oversees emerging young adult services. His primary clinical interest is in early psychosis, which began during his community psychiatry rotation at the prevention and recovery of early psychosis program. Prep at MMC. Given this interest, Doctor Crowe pursued a child and adolescent psychiatry fellowship to gain a better developmental understanding of adolescence and increased experience working with families. During fellowship, he co-founded Rise, Recovery and Shared experiences. The early psychosis program at Cambridge Health Alliance Doctor Crowe previously worked as medical director of the Adolescent Inpatient Unit at Cambridge Hospital. Prior to returning to MHC. I welcome you both. And now we will turn it over to Doctor Miller.
Dr. John Miller
Thank you very much. And if the person sharing the slide now could unshare it and I will upload my PowerPoint presentation please.
Michelle Wagner
Oh, let’s see if we can.
Dr. John Miller
So, I think Kim, I think are you, is it from your computer that you’re sharing this slide you’re going to need to unshare?
Kim Zoom Host
Yes, it’s uncharted on. Mine, but it appears to be quirky. So Michelle, if you’re able to stop, share it there. Cause I’ve stopped on mine.
Michelle Wagner
OK. Yep. OK, try again, Kim. Sorry for this folk. Zoom glitches.
Dr. Frederick Crowe
Doctor Miller, I think if you just tried to go ahead and share yours, that should work.
Dr. John Miller
No. Yeah, I couldn’t. Yeah. I wasn’t able to do that. It said that someone else was sharing. But we’re good. We are ready to go.
Dr. Frederick Crowe
Oh OK.
Dr. John Miller
OK. Can everybody see that? OK.
Michelle Wagner
We can see it.
Dr. John Miller
Great, so welcome. And this is a really important topic and I want to thank Michelle Wagner for setting this up. And I want to really thank Fred Crowe for participating with me in this really important topic. I’m going to focus on the science of cannabis, how it interacts with the brain, what we currently know and what we know is a work in progress. So we have a lot to learn. As with many areas of medicine and psychiatry, but we have learned a lot over the past few decades. Briefly, I want to start with an overview of when we use the word cannabis. It’s actually not a very descriptive or helpful term, and there and and there’s a an important reason for that. So cannabis actually has been used by us humans for 5000 years or more and primarily comes from a plant with the genison species cannabis sativa. Now this plant has the leaves and the flower and depending upon the subspecies, depending upon the plant you extract the leaves from. There are over 100 different cannabinoid molecules, and so when we talk about smoking cannabis or smoking pot. We know that you’re smoking the leaves from this plant, but we don’t know what of the 100 molecules are actually in what you’re smoking and that becomes very important because those are about 113 cannabinoids and they all do very different things. Now, what we learned early on is that the primary molecule that gives you the euphoria is THC Delta 9 tetrahydrocannabinol. And I will simply refer to it as THC throughout this presentation. The second most common is CBD, or cannabidiol. And what’s really interesting is cannabidiol has opposite properties of THC. And as we’ll see, THC binds to the receptors in the brain that our own cannabinoids, anandamide, being the most common binds to in CBD, does not. So cannabidiol, cannabis, cannabidiol, CBD does not even bind to the cannabinoid receptors. But it has a very significant role in in, in terms of what it does to the brain and the body and how we use it medically. So the remaining 100 plus cannabinoids, we still don’t know a whole lot about and they have different properties, some buying tighter, some buying weaker, some stimulate some block. And unfortunately because cannabis is a schedule one drug in the United States, which means it’s illegal. The research of cannabis has been incredibly stunted, and that’s been part of the reason why there are so many unknowns that remain, but fortunately that’s slowly changing. Now this is an important sequence of bullets here in the 1960s, when cannabis was being used recreationally in the youth around the country. That was from the original cannabis sativa plants and basically the leaf. The leaves from that plant contained a balance 50%. THC and 50% CBD, which actually was only 2% of the leave, was THC and 2% was CBD. The people who. Developed and bred, the plants quickly learned that the THC is the euphorigenic component, and so over the years the any plant that had more THC was was selected for, and currently plants the plant. Leaves that we see on the street often contain 15 times more, up to 30% of THC in in the current St. Exhibits now simultaneously until recently. They bred down the CBD, so be and the reason for that was the use was recreational euphoria and not some of the medicinal properties that CBD has. So this is an interesting finding that when you look at the ratio. Of THC to CBD in in pot or cannabis that’s sold in this. Read in 1995 there was 14 times more THC than cannabis CBD in in pot, and then 2014. Twenty years later it went to 80 times more THC to CBD, and so you can see the market, the, the, the recreational drug market, kind of. Resulted in this enrichment of the cannabis plants. However, the bottom line is when you buy something on the street or from a friend or whatever, you, unless you do an analysis of that leaf, you don’t know how much THC, you don’t know how much CBD and you don’t know which of the other hundred plus cannabinoids are in that leaf. And that’s what makes the research so confusing. So hard. And there’s also a form of THC called wax, and it’s basically 50% pure THC combined with the waxy substance that people usually take sublingually. And that is extraordinarily potent. OK, now let’s look at what, what is the legal status? So technically cannabis is a schedule one drug per the federal Drug Enforcement Administration. So that means it’s illegal with no clinical benefits per the FDA and the DEA. And as I mentioned earlier, this has really restricted our ability to research. Cannabis, especially with any federal grant money, which is basically proof. Significantly, in June of 2018, the FDA approved cannabidiol, CBD, the brand name Epidiolex for the treatment of two rare seizure disorders in children and adults. And so when that happened, the DEA said, WOW, we can’t. A drug that’s FDA approved can’t be illegal. And so they reclassified just the CBD, not the THC and not the other 100 or so molecules but, but cannabidiol. CBD was rescheduled as a Schedule 5 drug. Now, what does that mean? Well, for us, in clinical practice, if we prescribe A controlled substance, that means the Drug Enforcement Administration. Rates it and it rates it from. 1:00 to 5:00. In drugs that are schedule one or drugs that are illegal like LSD, heroin, bath salts and cannabis Schedule 2, which is which is the most restricted legal drug, are the stimulants like Ritalin and Adderall schedule 3 opioids considered less abusive than the stimulants? Schedule 4, the benzodiazepines like Valium and Ativan, et cetera. And then schedule 5 is where cannabidiol is so you can see it’s just very mildly scheduled. So that’s on the federal level on. The state level. Basically every year. The the rules change from state to state and as we move forward, it’s always important to know whatever state you’re in. What are the laws? Because in some states, both recreation and medical cannabis is illegal. In other states it’s illegal medically but illegal recreationally and in other states it’s illegally. Both medically and recreationally. So you have this confusion that results, and if you’re driving from Colorado, where it’s legally. Both recreationally and medically. And then you drive into Utah, make sure you don’t have any cannabis with you because it’s illegal there and just crossing the state line can create some trouble for you. So let’s look at these two most common components that we know the most about of the 110 or so. Cannabinoids in cannabis, so let’s start with THC. So we know that with the acute use of THC, people experience euphoria in hand sensations. There tends to be a decrease in activity. Some people experience anxiety. You can have panic attacks. It can cause acute memory impairments, perceptual distortions that can be. Enjoyable or scary, and for some people they feel. Banaya, on the other hand, cannabidiol demonstrates oppositional effects. It’s not euphorigenic, and it actually seems to help anxiety. It actually has been shown to treat psychosis in people with schizophrenia, and that has been shown. To possibly improve negative symptoms or cognitive symptoms in people with schizophrenia, it has antipsychotic properties, anti-inflammatory and as we saw, it’s FDA approved to treat 2 seizures. Orders. So both of these are derived from cannabis. They’re both cannabinoids, but they do very, very different things. And one interesting study took hair samples from people who were chronic daily cannabis users, and they found that the individuals that had high levels of THC in their hair. So the hair will show you the usage of drugs over long periods of time, like 6 to 12 months. So people that had high THC in there, here hair had higher degrees of depression, anxiety and memory impairment and people that had higher levels of CBD had lower psychotic leg symptoms and improved memory. So that’s a real important take home. THC and CBD, they’re both cannabinoids. They both come from the cannabis leaf, but they’re very, very different molecules with different portfolios, so. Because of the delay in studying the cannabinoid system in the human brain, it wasn’t until 1990 that the first cannabinoid receptor was described and delineated, and we we call that appropriate cannabinoid 1 receptor. It’s the primary cannabinoid receptor in the human brain. In THC binds to this receptor and displaces the naturally occurring cannabinoid, and if we look down below at my asterisk here. The human brain and the human body creates 2 cannabinoids, and we call them endogenous, which means we create them inside our own bodies for a purpose, for our bodies, to function appropriately, and the names of those two. One of them is called anandamide and the other one is called. Two arachidonic glycerol, but we just call it two AG, so anandamide and two AG are important for the normal functioning of neurons in the brain as well as bone marrow functioning for the immune system as well as the gut in other activities. And they’re interesting because they, as we’ll see with a cartoon I’ve made, they kind of work in a different way as other neurotransmitters. But ultimately, when you affect the cannabinoid system in the human brain or body, what you end up doing is changing the amount of other very important. Of brain chemicals and body chemicals, and that includes glutamate, which is an excitatory neurotransmitter, GABA, which is inhibitory dopamine, which helps with mood, which can cause psychosis, which helps with cognition and motivation. Norepinephrine fight or flight hormone. Serotonin, anxiety, and acetylcholine cognition. So all of these neurotransmitters will be increased or decrease depending upon the degree of THC or CBD. Hence a complicated network and lots of possible downstream. Effects the 2nd cannabinoid receptor cannabinoid 2 receptor is primarily in immune cells that GI tract in the spleen and like cannabinoid, one THC binds to it. But CBD does not. Now what does CBD do? Well, we have some hypothesis, but the bottom line is we still don’t really know fully what it does. It does seem to help an endemic be more present. It does seem to preserve an endemic and it does seem to counter the effects of THC. So let’s look at this cartoon. This is a very gross simplification. And the top orange structure is nerve cell one, the bottom orange structure is nerve cell 2. The arrow shows you the flow of information, so all of these G’s are the a neurotransmitter. So this cell is using a neurotransmitter G to communicate. And so when we look at the. The nerve cell one at the top. It has these vesicles that contain the neurotransmitter. And to the left of it is a receptor that when it’s activated and you see this Pentagon, this dark green Pentagon and the light green receptor when that is activated then that nerve cell releases gene or transmitter into that space. It diffuses across the space. It binds to the blue. V’s and that causes the signal to be complete. Now the cannabinoid 1 receptor is attached to this complex. It’s the light green V in this complex in the first nerve. Well, and what happens is when there’s a lot of neurotransmitter in the system, the second cell says, you know what, you need to slow it down. So what happens is it creates the anandamide and anandamide is the endogenous cannabinoid. Anandamide is what our brains use. To bind to this cannabinoid 1 receptor. That’s why it is. Tests and so that gets released, it shoots up, it binds to the cannabinoid receptor, which then tells this system it get it stop releasing G so there’s less G and then the signal gets smaller. So you see how it was originally bigger. Once the anandamide is there, it’s slow, it’s releasing. The G and the signal gets. Smaller. So now we’re in the system and we have the anandamide. And you take. A good hit of some cannabis that’s high in THC, or you eat an edible that has a lot of THC and the THC comes on board. And what happens is it will display, so it’ll bind displace and lower the amounts of an endemic. And that then? Intrudes into this system and I’m going to do it again. The THC binds and the G gets even smaller and the signal decreases even further. So when you smoke cannabis that has high concentrations of THC, it’s affecting all of these nerve cells, communications that ultimately impact. A lot of important chemicals in. Right. So what happens? Why is that relevant? In general, we know that about 10% of people that start using THC will ultimately develop cannabis use disorder. More relevant to this talk, individuals, especially pre adolescents and adolescents, as the brain is developing. If they have other risk factors for psychosis or schizophrenia or psychotic disorders, if they have other risk factors and they start smoking a lot of cannabis with a lot of THC. Really early in in their early adolescent preadolescent adolescent years, all the way up to their early 20s that has been shown to increase the risk of developing psychosis. And if it also will cause the psychosis, if they’re predisposed to happen sooner than it would have if they didn’t use. A lot of high, high amounts of THC. There’s also a range of studies, and there are there. There are studies that show all possibilities, but there is some good studies. We’ll look at one of them. That is suggesting that heavy cannabis use. So we’re talking about people who smoke cannabis on a daily basis. That has a lot of THC. The more THC, the greater. The risk may have some irreversible effects on memory and cognition if it’s used a lot while the brain is wiring itself and it is clear. That in regular high concentrations that THC is neurotoxic to the pre adolescent and adolescent brain and so that first 20 years of life when the brain is forming that seems to be the risk time. Now let’s look at this. All of what I’m telling you I have referenced in I have listed in my reference articles and this whole lecture handout is going to be available as a PDF file with all of this information on the website once we’re done. So everything here is referenced, everything is available. The slides are available for you. What doctor Andre did in this review was looked at a lot of published data looking at what’s the risk of heavy cannabis, and I would emphasize that this primarily means lots of THC, high concentration THC use. What’s the risk for causing psychosis and consistently what’s seeing is that when you take people. Who smoke cannabis heavily and compare them to people that don’t smoke cannabis heavily. And they ultimately all end up with a psychotic disorder. The heavy cannabis users end up developing their psychosis almost three years sooner than if they did not smoke cannabis. So it seems to contribute to the unmasking of the predisposition to psychotic disorders. Interestingly, if you look at the same type of population and you look at heavy alcohol used during this time that if the heavy alcohol users they have an earlier onset of psychosis by only 0.3 years. So now look, don’t don’t get me wrong, alcohol is also a very toxic. Drug and if you use alcohol every day for years, you are going to damage your brain as well as your liver. In your heart. But what we’re looking at here is 1 specific variable and that is the relationship to psychosis. We also know that 1/3 of individuals who have a what we call a first psychotic episode. So we don’t know what that’s going to end up turning into. It may go away, it may end up being the beginning of schizophrenia or bipolar disorder or depression with lots of possibilities. But that 1/3 of people with that first psychotic episode of cannabis users. So what’s also interesting, and from Doctor Andre’s analysis, is there’s a clear correlation. The more cannabis that’s is smoked, the greater the risk of unmasking an underlying propensity to psychoses. And so if you look at your average marijuana smoker compared to your average non marijuana smoker in your adolescent years, you will double your risk of having psychoses. If you smoke the average amount of your average cannabis user, on the other hand, if you’re a heavy cannabis users, so you smoke. A lot of cannabis. You’re in the top 20% of use. You increase the risk of having a psychotic episode 3.4 times, so you’re going from two times. If you’re an average user to 3.4 times, and if you’re in the top 5%, it goes to four times higher. So a 400% increased risk of bringing out that underlying risk. And how about yes, sure.
Kim Zoom Host
Like, can we pause here? Ohh, just for if we go back one slide. We’ve had a couple of questions very specific to this slide. So, I just wanted to jump in. So in terms of usage, we’ve had and a question about can you quantify what heavy cannabis use and lots of THC?
Dr. John Miller
Just one.
Kim Zoom Host
Is this individual understanding? It’s difficult to know how much TS THC is in street cannabis but are we looking at folks who use daily multiple times per week and what amount and then another person had a similar question. Could you repeat what’s considered high amounts in the 1st 20 years of life? So, there’s quite. A few questions around that.
Dr. John Miller
Yeah. And unfortunately, the answer is, we don’t have good enough data. To give a good quantification and the reason for that is it’s still a Schedule 1, so it’s hard to study. Second is a lot of these studies that have been done, we’re done in the late 90s, the 2000s up to 2015 and they did, they did not analyze the marijuana. That was used and they they could basically a heavy marijuana user. I would say as a general gross generalization is someone who’s smoking, say 5 joints a day, every day for years. So that’s a heavy cannabis user, whereas your casual user who may smoke recreationally a couple of times a week off and on during their developmental. Adolescent and pre-adolescent years, that probably is not going to cause this increased risk. So, it really is about the brain’s exposure to THC. And so if you use wax every day, which is 50% THC, that’s going to greatly increase your risk. It doesn’t mean you will get psychotic, but it will much more increase your risk than someone who’s smoking a week. Herbal plant formulation that has, say, 3% or 4%. THC in. And again, interestingly, the cannabidiol, the CBD actually is protective against psychosis in way back in the early 60s when there was smoking the original cannabis plant, there was an equal amount of THC and CBD, 2% of each. And it’s believed that back then. The CBD would help protect against the psychosis that the THC would cause, but over the course of the past 30 years there’s been this steady enrichment so that in all of these studies there is no. good quantification of #1. What was it that was smoking? How pure was it? What percentage of THC and #2 the ultimately, the term heavy is it is a subjective one that was that could have been different from study to study. But I think it is fair and and and and. Doctor Crow can comment on this when he talks. It is fair to say that someone who’s smoking THC daily for years, that’s somebody who’s a heavy user, heavy cannabis user and and and as you can imagine if you’re smoking daily for years, the THC is always in there, displacing the anandamide and affecting the way these. Nerve circuits are wiring to each other and ultimately affecting the wiring of the brain and interestingly which when I get to my next slide, will emphasize when you look at the cognitive changes they occur. Her from use during the 1st 20 years of life and for people who start smoking cannabis at the age of 25 or later, you don’t see cognitive changes and if there are some in the short term from short term acute use when they stop using, they get better the cognition improves whereas. During the years of brain development, heavy cannabis users who’ve lost cognitive functioning, it does not improve based on a lot of the studies that have been done. But again, we’re early in on this on this particular topic. Is that a is that?
Kim Zoom Host
That’s great. Thank you for addressing and for both Doctor Miller and Doctor Crow. We have many questions waiting for you during the Q&A session. So we’ll hold those for now.
Dr. John Miller
Awesome. More, more questions, the better. OK, so I’m almost done. So cannabis and cognition. So the one of the best studies that I have found was this study that was done in New Zealand. So it was actually started a long time ago 1972-73. And in New Zealand, which is a small country, they enrolled over 1000 individuals, and they started following them at birth 197273. Three in every two years they would follow up with these individuals and and monitor their cannabis use. Now obviously a 2 year old’s probably not going to be smoking cannabis, but when you get to the 10-12 fourteen 16-18 year olds, that’s when you start to see it coming into. Play. They follow these people every two years up to age 38. So, so that’s 2010. So 1972 to 2010. So, every two years they monitor their cannabis use, 95% of those individuals stayed in the study the whole 38 years, which is remarkable. And then at ages 8/11/13 and 38, they tested their IQ’s and what they found. Was that people that had ongoing cannabis use during their adolescence at. Age 38. Had lost about 8 IQ points and and that up to about age 18 or 20. And even if they stopped smoking pot in their early 20s, those that IQ deficit persisted at age 38, whereas when they began using cannabis and adulthood after the brand had fully developed, there was no decline in the IQ score. So this is just one study. There are other studies that contradict it, but the bottom line is there’s a signal here that THC can affect cognition, possibly irreversibly, when THC is used heavily during the early years of brain development. And so to wind down here, the term cannabis simply describes the source of a plant and and that cannabis those leaves can have over 100 different types of cannabinoids in them, most of which we. Don’t know a. Lot about the two most common THC and CBD’s work very differently and are oppositional. In THC seems to increase the likelihood. Of bringing out. The vulnerability of psychosis where CBD has been shown to decrease psychotic symptoms and improve cognitive symptoms in people with schizophrenia. The endocannabinoid system has always been here. It’s very complex. It it it it, it affects brain wiring, it also impacts the immune system. It does lots of things. It’s important in chronic heavy use of THC during pre adolescence and adolescence, there’s enough data that I feel comfortable saying that. If you are. At risk for developing psychosis, it will shorten the time of the first psychotic episode once. If you have a diagnosis of a psychotic disorder and you continue to smoke cannabis, it will decrease the time to relapse and make it harder to treat. So again, in that at risk population and on the other hand, cannabidiol, CBD has actually been shown to improve psychosis and cognition. Bottom line, we still have a lot to learn and hopefully the schedule one DE a status will change so that it’ll be a lot easier to study this complex area. So we can answer a lot of your questions with more informed, good science and and guide ourselves in our fellow citizens to more appropriate understanding and then use of cannabis and it’s different. Cannabis cannabinoids. There is my references. Thank you very much. I would like to turn the screen back to Michelle Wagner, who will introduce Doctor Crowe, our next speaker.
Michelle Wagner
Great. Thank you so much, Doctor Miller, that was very informative and now? We will in. Fact turn it over to Doctor Frederick Crowe. Thank you, Doctor Crowe.
Dr. Frederick Crowe
Thank you very much. Just trying to make sure to get. Myself off mute. And so. I really I really appreciate your. Introduction and overview of the science Doctor Miller in terms of cannabis and psychosis and so in terms of my talk, I’m going to shift to more kind of a. So that’s what we know about the science. What on earth you do when you’re sitting in the room with a patient and a young person. To try to work on these issues. And so overall what my hope is is to really kind of. Provide some really practical guidance in terms of things that I’ve found helpful to help engage young people, particularly young people struggling with psychosis. To really consider their cannabis use and the effects that it’s having and coming up with ways that decrease the risk of that use. And so in this. We’ll kind of highlight. Well, I think it’s an important topic. A general overview of harm reduction. And then hopefully give some clinical pearls in terms of how to go about assessing cannabis use as well as some specific strategies in terms of harm reduction when it comes to cannabis. So First off, in terms of financial disclosures, as I always say, I don’t have any and as always, this continues to make me feel as though I’m missing out. On something, but then moving forward, I do think that with a talk like this, it is important to have some personal disclosures. And so. UM. As it had come up in Doctor Miller’s talk, certainly Colorado was a place that was early in terms of the adoption and legalization of recreational cannabis. I’m I’m actually from Colorado. I very much love and Miss Colorado. That being said, I’ve gone to Med school in New Hampshire and really appreciate. Being able to do this, talk to people in New Hampshire because I’m very fond of the state and I now live and work in Massachusetts and love it as well. But going back to to what I consider home with Colorado. It’s something that it was interesting when Colorado was legalizing this at the same time, I couldn’t help but in some ways be be proud that my state was thinking outside the box and so just want to note that I’m from. Colorado in terms of this mention of there here I also want to go ahead and disclose that. In my 5th grade class, I was the only individual who actually did not. Graduate from there. And that certainly had nothing to do. I was not off in the bathroom getting stoned during our presentations. Rather, I’m not the best at turning in my worksheets. And as you can tell from the the pictures that Michelle had sent out that she found on her own, I’m still not the best at turning things in and hence my much younger appearance in that picture. But I put that up here because even though the science is pretty clear that and and I want to be totally clear in terms of my own viewpoint on this, I do not in any way think that young people with psychosis should be using cannabis. I think that it’s something that can very much be detrimental to the course and prognosis of their illness. That being said, I think. Just encouraging them to say no or just blankly kind of. Trying to do finger wagging at them or something is not going to get you anyplace. And so that’s where some of the things that I’m going to cover in this talk, I should go ahead and say this is actually only my second webinar. I did a similar one in February of last year and while this is just my second one, unfortunately given COVID, I’ve now gotten much more comfortable. With sitting in a window less room talking to my computer screen and not feeling like it’s anything. So I also should go ahead, I think, since we’re talking about early psychosis and it’s important to get kind of in the mindset of. Adolescents and young adults. There I should also go ahead and disclose that that I myself have used cannabis and I think in this kind of talk, it’s important to think about the context in which that came up. And so for me, I’ve actually been kind of a very. Rules for use. My parents didn’t really dabble in new substances and kind of I was like, I’m never going to do those things. Lo and Behold, High School came about. One point I ended up drinking. That’s a story for another talk. And even once I drank, I was like, there is no way that that I’m going to use any drugs, including weed. That’s just not who I am. That’s bad. And then there was one time my senior year of high school where my. Parents went out of town for the one and only time during my high school career, and of course I did what any typical 17 year old would do, which was have a party. And of course, I invited a girl that I had a. Crush on Julie B. And I was very surprised and excited that she not only showed up, but she was one. Of the first people to show up. And when I started talking to her then she was like, hey, Fred, do you want to smoke some weed and? Just like that, everything else that had been kind of my values and my identity went out the window and it. Was just about. Like this young girl? This is a girl. That I’m attracted to and have a crush on. And like anything she asked me to do, I’m going to go along with it. And so I just mentioned that because I think similar things come up for people all the time and the people that we work with. Really, there’s this immediacy that adolescents and young adults, that young adults, that it’s critical to keep in mind. So in terms of the reason to. To talk about it. It’s something where the use is quite prevalent. Across all populations, including young people with psychosis. Along those lines, it’s also been pretty clear in some of the large research studies that that have been done lately on coordinated specialty care that. And in particular, the race study, individuals who use a lot of cannabis actually respond. Less well the treatment than individuals who don’t. That being said, I think that overall it’s a very complicated issue and it’s not in any way black and whites and along those lines, there are some individuals and patients that I work with where I I get extremely worried about their cannabis use. And then there are other individuals with whom I’m like, well, at least you’re not drinking, or at least you’re not using opioids. Or just in general they use it. In a way that it’s not becoming problematic. Lastly, since my focus is really on working with with young adults, and I think it especially applies with. Young adults who have early psychosis engagement is really critical and central. And there I think that young people are very quick to pick up on any feelings that they’re being judged or that providers are just coming across as parents or other individuals who are going to, in essence, condemn what they’re doing and what they’re interested in. And so having been from Colorado and albeit from a distance. Observing how things went forward with legalization of cannabis there. It’s been interesting.
Michelle Wagner
Fred, you inadvertently muted yourself.
Dr. Frederick Crowe
OK. Can people hear me again?
Michelle Wagner
Yes, we can.
Dr. Frederick Crowe
OK.
Speaker 5
So let me see if I can go back toggling between the zoom controls. One moment.
Dr. Frederick Crowe
Thank you very much for the heads up, Michelle, because I could have kept doing that and talking to myself for quite some time.
Michelle Wagner
And I was struggling to unmute as well. So I’m right there with you.
Speaker 5
OK, so people see my slides again.
Michelle Wagner
Yes, we can.
Kim Zoom Host
Yeah. OK.
Dr. Frederick Crowe
Thank you so. It’s been interesting for me living in Massachusetts and being from Colorado, having seen things from Colorado from afar in terms of how legalization has rolled out there, and particularly given that I’m a psychiatrist and. In Massachusetts and a child and adolescent psychiatrist within the early psychosis community here, amongst a lot of providers, it really was a situation where it seemed like the sky. Phone and as I said before, I certainly think that there are a lot of concerns and risks associated with cannabis use in young people overall, but particularly young people with psychosis. But with that, certainly it’s it’s become increasingly clear that the trend overall is moving in the direction of legalization. And I do think that there are actually some potential upsides that are worse. Keeping in mind and not losing sight of. Amongst those, I think that no one goes in to see any kind of healthcare provider excited and eager to share the illegal activities in which they partake. I also, while I’m sure that there are plenty of. Drug dealers out there who are good people, and I undoubtedly recognize that as a psychiatrist, there are plenty of people who would consider me to be. A drug dealer. Outside of psychiatrists, I do usually think that for my patients, the well, not often. Even with my patients, I usually think that that with psychiatrists, I should say the fewer interactions my patients have with. Drug dealers to better along those lines. I think drug dealers don’t check ID’s. I also think drug dealers are frequently likely to sell other substances and I think that there’s lots of issues that can come up with that. And then I also think that people don’t know what they’re getting when they’re buying things on the street. And it’s one thing that I don’t know if they’ll have time for. Yeah, but. With a lot of dispensaries, there is at least some level of regulation and choice. I should go ahead and say the caveat that. I I am quite concerned and do worry about the potential for big cannabis in the way that certainly big tobacco has been and continues to be a major issue and. Alcohol remains a major issue and there we’ll just mention that like it’s kind of telling that some of the individual, some of the groups that provide the most funds and support of lobbying against cannabis legalization are actually alcohol distributors. So there in moving on to just kind of the general overview of harm reduction. This is a definition from harm reduction International, which focuses primarily on the substance use aspects of harm reduction. The kind of central points and key things here are that with harm reduction, the focus is on decreasing. Negative outcomes and risks, while not focusing necessarily on the decreased consumption of substances. And so. Just to kind of give some background with regard to where. Harm reduction first came about and some examples of it. It’s something that first started in the 1980s and came about as an alternative to abstinence only programs in particular for alcohol dependence. In today’s world. It’s most routinely thought about in relation to IV drugs. But the thing that I think is critical and I think especially for a lot of providers working with young adults, it really does extend well beyond substances of abuse. And there are many instances where we think about. Harm reduction and so there. Here I just kind of have the things that people typically think of in terms of hardware reduction with regard to substance abuse and then kind of others. And there I can also mention while I’m a child and Allison psychiatrist and I’m married a pediatric. We have two young kids and lots of times we are absolutely lost in terms of what we are actually doing with our children, but it’s worth mentioning that in almost any physical or well child check where kids go to see their pediatrician, the major focus is actually on harm reduction throughout that in terms of identifying these various ways. In which there are these risks that come about. Every single day and there are things that people can do to help mitigate those risks. And so as far as just some of the the key principles with harm reduction.
Dr. Frederick Crowe
One of the key things to point out is it one of the criticisms with harm reduction is that it ignores risks. And there I, in my own view, really see that as being a misconception as to what harm reduction is. In that. In the spirit of harm reduction I. Think it? You really are looking at the fact that there are risks everywhere and with everything that we do here on this slide, when I mentioned. Praise the positive. It’s it when you’re working with a young person or even not a young person, even someone older who’s participating in some kind of behavior that is detrimental to their health, and they identify it as a goal. It’s huge that they identify that as a goal and slips and issues achieving that goal are par for the course. As a result, really like if a young person comes to me who said that they want to decrease their cannabis use and they meet with me on a Tuesday and are telling me how they’re disappointed and feeling bad about themselves, cause they went to a party on a Friday and had to slip. But they’ve not smoked for a week before that. My focus will be on providing validation and praise for the fact that they went a week without using and certainly like. The fact that they use is still something to to pay attention to, but not at all where to lead. And really, you want to encourage people with the positive changes that they’re making. Lastly on here and very importantly, the fact that. Typical approaches to substance use can have lots of unintended negative consequences, and there when we’re talking about early psychosis. In my view, essentially all of these young people have a chance for recovery and our work is really trying to help identify their goals and help reduce any barriers towards recovery and recovery often involves returning to work, returning to school and charges related to substance use or drug possession. Are things that very much get in the? Way of those goals. Then just mentioning kind of the developmental context in working with young people with early psychosis, harm reduction as a model just fits with what we know about young people. In that. They want to figure out who they are. They don’t want people letting them know what to do, and in that I think that that’s it’s it’s very different to tell people what to do versus to provide them with education and information as far as what the situation. And it’s and in that. I also think it’s important to know like what do they actually want to hear. And so if a young person’s not wanting to hear anything about the risk of cannabis use, telling them about it isn’t. No one’s going to listen or pay attention here. I also think that it’s worth. Mentioning that in as is the case with many things and as is becoming as is painfully aware in the world today, when people have different viewpoints on a controversial topic, people go to very different sources to find their information. And so, while myself and Doctor Miller and other providers might look to the scientific literature to see what the latest research is in terms of cannabis and psychosis, the young people that we work with are going to be going to places like high times and leaflets and there if you actually go with their websites, you’ll see that they have links. Harm reduction websites and very much actually indoors harm reduction perspectives. I also want to mention that. There is a true difference between primary and secondary prevention and I would talk to a young person very differently if they have, or if they haven’t used. Cannabis before. In terms of assessing use. Here setting the frame is just critical and with I often work with young people who are quite difficult to engage and so my focus is really just on them feeling comfortable with me as a trusting and caring adult whom they can come to for her honest and accurate information. And so there I try to layout relatively early on in my treatment, if not at the first session that they’re working with me is not going to be contingent upon they’re abstaining from substances. It’s not going to be a contingent upon adhering to medications. And that I really just want to know honestly what’s going on. I’m not gonna judge them, but that if I don’t honestly know, like, I don’t want to increase their drugs, that can have horrible side effects when they’re exacerbations. Actually due to an increase in cannabis use. And then thus that needs to be kind of the focus when the time. That’s right. And so with this going back to no one wants to tell their doctor. What they’re doing? Illegally, I try to make sure that I. Don’t separate out. Cannabis use as its own review of systems. Rather, I try to incorporate it into my clinical interview at other points, and so there when I’m talking to young people and asking about their interest, and I know this can be different in its own way and having been in New Hampshire, people are much more interested and willing to participate in outdoors. Here where I work in Boston like. If someone tells me that they like to go for walks in the woods with their friends right away, I start thinking like, oh, this is someone that maybe likes to go out and smoke weed, but doesn’t want their parents to know that. They’re smoking weed, so if I find something in the course of conversation, try to just go with that and get an understanding of it I also. Typically, with weed, given its prevalence and also its relation with psychosis, and that’s a population I usually work with, that’s where I tend to start, even before alcohol and frame the question not as like. Do you smoke weed or not? But do you smoke much weed and more not to normalize it and to make it OK, but to just kind of open the dialogue so that people feel comfortable sharing what they’re actually doing as far as it not just being a yes or no question like. There’s a difference between someone that drinks a glass of wine every day and someone that drinks. Quart of vodka every day and also understanding what motivates use is also critical. I know we’re almost running out of time, so I’ll actually leave it for questions. Key things here eating just takes longer. It’s more unpredictable. But smoking in general is not good for your health, so from a harm reduction standpoint, there is some utility and needing. That said, don’t just eat the whole brownie. You can easily overdo things. In terms of colloquially and just kind of what people are thinking in terms of indica, the phrase that’s useful is in the couch. And those strains tend to be more relaxing, tend to have higher levels of CBD, so tied back to what Doctor Miller was saying. I do think that these tend to be somewhat safer if someone’s using it as compared to. Sativa strains that tend to have higher levels of THC. And then here. Just people pacing themselves and recognizing like young people are not known for their patients, and even with inhaled cannabis, it takes 15 minutes to get to the peak effect, so it’s easy even with smoking for people to overdo it. When you talk about edibles and it takes several hours for the onset, it’s very easy for people to overdo it. And so. Again, if people go to dispensaries that while things are not as consistent as one. Like there is a better chance of knowing kind of what they’re getting. And that’s where I will often let my patients know, like, don’t hesitate to bring in a menu. I’m happy to go over it. If you’re going to use it. And I just want to leave the door. Open for communication. Thing I’ll point out here is in terms of the social use. Since isolation is a big thing that comes up for people with early cycles, is if one of the primary motivations for using is to remain social. I think that there are still ways around that, and it’s something that, like if they’re not, if they’re not wanting to use or are wanting to use less, they can take a. Very brief hit or a very brief puff, and then pass the joint and no one’s going to get upset with them for that. So that’s my piece. I know. Sorry for going long. Happy for any questions.
Michelle Wagner
Thank you so much. We are actually at time. So I’m wondering if we can copy those questions out of the chat and Q&A and then get both you Doctor Crowe and Doctor Miller to answer some of those questions for us. And along with the recording pardon.
Kim Zoom Host
Really, really great news. Michelle is that when Doctor Miller was speaking, Doctor Crow was answering questions and when Doctor Crowe was speaking, Doctor Miller was typing furiously. So nearly all of the questions have been answered. And again, the webinar recording, and the slide decks will be available. At onward and H. Dot org I did just post that in. Chat it’s on the education page and Michelle, I’ll just put your e-mail in the chat too. If folks have specific questions they still. Need it answered.
Michelle Wagner
Yeah, please do, because obviously we should have held more time for this presentation today. So thank you all. Thank you both Doctor Crowe and Doctor Miller for joining us today. Stay tuned. Our series will continue. So we look forward to you joining us next month for the onward and H Webinar series, take good care and be well.
Dr. John Miller
Thank you, everyone. Pleasure.