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Marijuana, SMI, and Violence: Practical Guidance f ...
Presentation And Q&A
Presentation And Q&A
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Hello and welcome. I'm Dr. Benjamin Dress, Professor and Rosalind Carter Chair in Mental Health at the Rollins School of Public Health at Emory University. I'm a health systems expert for SMI Advisor. I'm pleased that you are joining us for today's SMI Advisor webinar, Marijuana, SMI, and Violence, Practical Guidance for Psychiatrists. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Now I'd like to introduce you to the faculty for today's webinar, Dr. Deb Pinals and Dr. Charles Scott. First, Dr. Charles Scott. Dr. Scott is Chief Division of Psychiatry in the Law, Forensic Psychiatry Fellowship Training Director, and Professor of Clinical Psychiatry at the University of California, Davis Medical Center in Sacramento, California. He is board certified in General Psychiatry, Child and Adolescent Psychiatry, and has added qualifications in Forensic Psychiatry and Addiction Psychiatry. Dr. Scott is a past president of the American Academy of Psychiatry and the Law, and is also a past president of the Association of Directors of Forensic Psychiatry Fellowships. He has served as a member of the AAPL National Task Force to develop guidelines for the evaluation of criminal responsibility and competency to stand trial. Dr. Scott is one of four National AAPL Forensic Psychiatry Review Course Faculty Instructors, and in 2008 received the AAPL Award as the Most Outstanding Forensic Psychiatry Fellowship Program Instructor in the United States. Second, Dr. Deb Pinals. Dr. Debra Pinals is a Clinical Adjunct Professor at the University of Michigan Law School. She serves as the Director of the Program in Psychiatry, Law, and Ethics, and is a Clinical Professor of Psychiatry at the University of Michigan Medical School. She's also the Medical Director of Behavioral Health and Forensic Programs for the Michigan Department of Health and Human Services. She is board certified in Psychiatry and Forensic Psychiatry, and is a diplomat of the American Board of Addiction Medicine. From 2008 to 2016, she was the Assistant Commissioner of Forensic Services, and between 2012 and 2014, she was the Interim State Medical Director for the Massachusetts Department of Mental Health. During her career, she has been a Clinical Psychiatrist in Community Mental Health, Inpatient Settings, Forensic and Correctional Facilities, Emergency Rooms, and Court Clinics. Dr. Pinals and Dr. Scott, thank you for leading today's webinar. Thank you so much, Dr. Drost, for inviting us to speak, and I want to start by just letting the audience know that neither I nor Dr. Scott have financial relationships or conflicts of interest to this presentation to report. Next slide. So today, we're going to be talking about SMI, marijuana, and violence. And upon completion of this activity, what we're hoping is for you all as participants to be able to identify emerging forms of cannabis products with increased THC potency, to also describe the relationship of cannabis use to psychosis, and to discuss specific factors that increase the risk of violence in persons with serious mental illness who use cannabis. Currently, cannabis is legal in approximately 16 states in the District of Columbia, and it's still completely illegal in six states, but the remainder of states have a combination of approved medical use or other decriminalization laws. Next slide. Marijuana is the most commonly used psychotropic drug in the U.S. after alcohol, with 48.2 million U.S. users reported in 2019. Also, in looking at people's reports of their past year of drug use, 53 million people, 20 percent, reported past drug use, with marijuana being the most commonly reported drug of use. What's increasingly becoming clear is the impact of marijuana on young people. In people 12 years of age or older, the increases were 11 percent in 2002 to 17.5 percent in 2019. And the past year initiates of ages 12 or older increased from 2.2 million in 2002 to 3.5 million in 2019. So more and more younger people are engaging in marijuana use. In terms of diversity, equity, and inclusion issues, it's really important to know some of the trends that we're seeing, especially in adolescent populations. In the Monitoring the Future survey that looked at patterns of use between 2006 and 2015, among 10th graders, Blacks had reported increased use in the past 30 days, more than non-Hispanic Whites. And there was increased use in Black students that was greater with larger class sizes. For 12th graders, all racial groups, except for non-Hispanic Whites, reported increased use. And the increased use in Black students was greater in states with medical marijuana laws prior to 2006. Also, in terms of evolving trends in adults, cannabis use and cannabis use disorder is increasing in adult populations, with significantly greater increases in cannabis use and disorder in men, young adults, Blacks, persons of low income, those that have never been married, and urban residents. When we look at cannabis use by mental illness, this is also very relevant for our conversation for today. For those individuals with no mental illness compared to individuals with serious mental illness, statistics show, and the epidemiology shows, that individuals with serious mental illness are much more likely to report cannabis use than individuals with no mental illness. And even individuals with any mental illness are also more likely to report marijuana use within the past year. But those vast differences make it more relevant for us to have this conversation today to help you understand the impact of cannabis use on individuals with serious mental illness and how to address it in your clinical populations. I'm going to turn this now over to Dr. Scott, who will talk to us initially about cannabis psychopharmacology. All right. Thank you, Dr. Pineles, for that excellent review of the epidemiology. I'm going to move now to talk about unique aspects of cannabis and hopefully clear up any confusion between the different cannabis products. First of all, there are over 144 different cannabinoids in different cannabis plants, and they act on different receptors in the body. And so some of the cannabinoids have little or no psychoactive effects. So not all cannabinoids are the same. The ingredient that we think of as marijuana that's psychoactive really is delta-9-THC, and that's the major active ingredient. So it's also helpful to be mindful of the relationship of different receptors in the body and cannabinoids' action on those. So THC acts on the CB1 receptor as a partial agonist. In contrast, cannabidiol, also referenced as CBD, is an indirect antagonist of THC. And then finally, cannabinol, known as CBN, is a THC byproduct, but it's only mildly psychoactive, and it's primarily an agonist at CB2. So looking at this visual depiction of the different compounds and where they act, you can see again that THC is a partial agonist at CB1. CBD has sort of questionable interactions with receptors, and CBN is at CB2. Why is this relevant? It's very relevant because the ratio of cannabis products your clients may be using between THC and CBD is highly relevant in understanding the psychoactive effects. In other words, the higher the THC content to CBD means that you're going to have greater psychoactive effects. And users sometimes know this. So look at the display here where they're looking at the concentration of THC and CBD. Those who want a more potent form are going to be looking for a higher ratio of THC to CBD. Now, the many different cannabis types your clients may be very familiar with, they could have preferential effects on their mood and how they feel. So it's important to ask what types they prefer using. One particular type that may have an increased or that does have an increased potency is known as sensamella. And this is where you have female cannabis plants that haven't yet been pollinated. So there you see in the white circle what are known as trichomes, and this is where it's a much higher concentration of the THC content and can get up to 7% to 14%. And a particular form is known as skunk. And this is a crossbreed of sativa and indica. It's very potent, highly adaptable, and can be grown indoors. And so very easy for people to grow and produce on their own. Now, this slide I find very interesting because it looks at the average THC percentage in federal seizures of imported marijuana from 1985 to 2013. And what's the key teaching point here? Weed is getting much stronger as the slide announces. So your marijuana intake or your grandmother or grandfather's intake from 20 or 30 years ago would have had a much lower potency, maybe even below 4%. And now on average, it can be triple that. So this is why sometimes there's confusion, people thinking, well, marijuana really isn't that strong. May have been true 20 years ago, but it's getting much more potent. And here's some of the buds that we typically think of when we think of preparing for THC. But this would be in the process for inhaling it. So this is known as either smoking it, almost like you would with a cigarette, so it's a direct burn, versus putting it through a bomb where it's vaporized. It's using the dried plant parts or buds. And again, the potency depends on the cannabis type. So it can vary greatly between the type of cannabis product. In general, it has a fairly rapid onset of action, but also has a shorter duration of action. And these two pictures illustrate the different ways one could inhale THC. The gentleman smoking it directly is almost like smoking a cigarette, so it's a burn of the THC product. Whereas in contrast, the bong is where it's inhaled through a vaporized product. Now, you can also ingest THC as well. We oftentimes think of, for example, marijuana brownies. And through ingestion, the effect may not take place until one or three hours later. So that's in marked contrast to if you're inhaling it through smoke product. The other interesting thing is there's a variable THC concentration in the ingested forms. So even within the mixture of the brownie pan, for example, there can be variable THC concentrations. And as such, there can be a risk of overdose and a higher risk of psychotic symptoms. One of the reasons traditionally that you might put a THC product into something like a brownie is because THC traditionally was not water soluble. So it had to be produced in a compound that had a high fat content. As such, it does have a delayed onset of action. So people may want, after they take one brownie, they don't feel the effect. Then they might say, well, I need a couple of more. And then suddenly it builds up and they can become very ill and very psychotic from that. Now this is something that's interesting that's happening with THC. Remember how I just said that traditionally THC was not water soluble, and that's why you had to put it into something like a brownie. Now there are processes that can make a powder out of the actual leaves. It's dissolvable. The effects are in 20 minutes, and now it has a longer duration of action. It is both tasteless and can be odorless. So you can imagine this could be of quite concern as an emerging date rate drug, for example. And it's diet friendly if people are watching their carbs, for example, because it doesn't have to be mixed with a fatty compound. There are many different forms of THC powders being produced with different concentrations of THC. So you see here, this is produced from Colorado, the Ripple, which is a powder. It can be added to smoothies. And rather than having avocado toast, now you can sprinkle your THC product directly on your morning breakfast. There are other forms of concentrates as well that even concentrate the THC further. And this involves collecting what again is known as the trichomes. If you see those kind of silvery tips at the top of the bud, that's a highly concentrated THC product. And the concentrates can contain 80% or higher THC concentrations. So let's do a little flashback for what I talked about earlier. If 4% was the average concentration 20 years ago, 14% is what is in seized collections. We're now making products with 80% concentrations of THC. So dramatically higher. These can be produced in a form known as hashish, which is the very sticky concentrated resin of the marijuana plant. It's much more powerful, can be used and broken up into pieces to be smoked. And one thing that you can help identify if it's a concentrated form is it may produce a particular odor. Even more alarming is something known as butane hash oil. And it is a cannabis concentrate that is made using butane oil to really help distill and concentrate this. And again, contains up to 80% THC. And here's a picture of the lab equipment that may be needed to make this butane hash oil. On the left, you see a very sophisticated, almost professional chemical designed production methodology to get this high THC content. On the right, you see kind of a more homemade, not nearly as sophisticated attempt seized by the DEA. And what's happening is, and this is illustrated by both of these pictures, both of these pictures are people who are trying to make BHO or butane hash oil at their home. And because of the chemistry involved and the butane involved, it's highly flammable and severe deaths and burns can result. If you're successful in making your different concentrates, there's a wide range of names that people reference these. So when you speak with your patients, be familiar with things such as shatter, bubble hash, crumble, butter, or sugar wax. This all indicates a high concentrated form. And how do they use these concentrated forms? There's a process known as dabbing. With dabbing, you get the concentrated form, you take a dab of that, and then you put it into a device, which is shown on your slide, where you then can heat it up and then inhale it in a much more concentrated form. This leads me to talk about then vaping. Vaping can also use dabs as I've described. And one of the concerns is in adolescents in particular, vaping is an increasingly popular way to use cannabis. About 60% of adolescents will use cannabis to vape, and a variety of THC products can be vaped. Everything from your lower concentration, not leaves that I talked about, to the higher concentration dabs. But the concentrates are the most common form vaped by adolescents. In other words, they are preferentially inhaling these very high concentrated forms. And so what are the risks as a result? Well, oftentimes there are harmful additives added to these cannabis oils. One in particular is vitamin E acetate, and that can result in serious respiratory problems. And this has been referenced as popcorn lung. And here's an example from an x-ray of a young man who was smoking, or I'm sorry, vaping this type of cannabis product, and they could have serious respiratory problems as a result. I want to shift to make it clear in this presentation that there's another form of cannabinoids known as synthetic cannabinoids. Sometimes people call this synthetic marijuana, and therein lies the confusion. This is not cannabis in the traditional way that we've been talking about just now. Sometimes it's known as K2 or Spice, comes under a variety of additional names, such as Cloud9 and Joker. It can be sold on the internet, at gas stations, on the street, and sometimes they're packaged and very kind of attractive, almost looks like it'd be a little package of Kool-Aid or some other product, and can be sprinkled on regular leaves, and then therefore can be smoked. It's also very cheap compared to marijuana. However, it's not your traditional marijuana. It is not THC. It is a synthetic chemical, and there's a range of diverse designer chemicals that are considered synthetic cannabinoids. Why is it even called a cannabinoid if it's not related to THC? It's called a cannabinoid because it acts as a full agonist at the CB1 receptor. As a reminder, THC is a partial agonist at CB1 receptor but this is a full on full agonist. And that is why you get much more dramatic and usually much more adverse consequences. It does not contain any cannabidiol or cannabivirin. So what this means is there's no counter to it to help counterbalance the agonist property so it makes it even stronger. That fake is safe, that these are safe is a complete myth. The other thing you need to understand, it is not detected on any of your urine drug tests of any kind and as a result, if you have a client and they say they used marijuana or synthetic marijuana and you run a drug screen and it's negative, this is because they may have been using a synthetic cannabinoid. It can have severe medical complications because they're oftentimes laced with toxic substances. In particular, there's one compound used in rat poison that is an anticoagulant. So many individuals using this will have severe bleeding problems because of what it's laced with. Last product I'm gonna talk about is something known as HU210. It's known as HU210 because it comes out of Hebrew University where it was a designer product. And this is 100 to 800 times more potent than THC. Can you imagine that? A product that's 800 times more potent and it has an extreme extended duration of action. So it's stronger and longer. So that is something that would also be part of information you would ask about. So to sum up this portion, what are some baseline clinician screening questions you should think about? First of all, clearly asking someone if they use cannabis, you're gonna see as I proceed through this lecture how important it is to ask when they first began using, the frequency of use, make an effort to ask the specific forms that they use. And if your client is aware of this THC CBD ratio, many are. And again, the less CBD in the product, the more potent the product your client will be using. Clearly ask if they've ever had any adverse reactions with the use as well. And if they have the use of other substances in addition to the THC. All right, now we're getting to a very interesting question that poses the following. Is there a link between cannabis use and psychosis? Particularly relevant for individuals with a serious mental illness. So one of the first studies to look at that question comes from Sweden from a researcher known as Andreasen. And here's a picture of this researcher. And he did a very interesting study looking at Swedish conscripts into the military. In fact, he was able to look at the entire population history of 50,000, 18 to 19 year old conscripts. And about 92% had filled out surveys about their drug use with specific questions looking at marijuana use as well. His study indicated that cannabis use wasn't increased risk factor amongst others, but wasn't increased risk factor for developing schizophrenia. And again, the frequency of use with heavy users had actually a six time increased risk of schizophrenia compared to non-users. Now you might think, well, there are logical arguments against this study. And if you're brainstorming, how could you refute the findings? You might come up with four key challenges. And this was also noted in a book published by Berenson in 2019. Your first challenge to this finding might be, well, perhaps the genetic predisposition to schizophrenia also predisposes to drug use. So the two go hand in hand from an underlining genetic predisposition. The second argument could be, no, it's not that cannabis use leads to schizophrenia, it's that these individuals were vulnerable to schizophrenia and as they develop schizophrenia, it led to cannabis use. Perhaps the research findings were spurious, completely accidental. Then finally, the cannabis use is actually a marker for environmental stressors. And those same stressors also lead to the vulnerability to develop schizophrenia. So follow-up studies have tried to address some of these challenges that there may be a cannabis link to psychosis. And this question therefore is, what comes first? Cannabis use causing psychosis or increasing the risk? Or psychosis has individuals then use cannabis perhaps in an attempt to self-medicate. To help answer this question, the Archives of General Psychiatry published an excellent article that became known as the Dunedin Study. And it became known as the Dunedin Study because it was conducted in a population in Dunedin, New Zealand by Dr. Patricia Buckfeld and Dr. Phil Silva, pictured here on the slide. And here is how they designed the study. They were very interested in following a population of children born in Dunedin between April 1972 and March 1973. And they followed this controlled population from birth and then all the way through three, five, nine, 11, 13, 15, 18, and 21. So several follow-ups throughout the developmental stage. And pediatricians were involved in the follow-up and looking at a lot of different factors that these children may have been exposed to. A psychiatrist was brought in at the age 11 timeframe and they screened for psychosis at age 11. Now we know that certainly psychosis is very rare in an 11-year-old, but they were careful to try to do any kind of screening for early onset signs or symptoms. And of course they were then screened thereafter. They did this to try to answer the question, what comes first, psychosis leading to cannabis use or cannabis leading to psychosis? And then they also screened for cannabis use beginning at age 15. And here are the results. Those who had used cannabis at age 15 were four times likely to develop schizophrenia or schizophreniform disorder. So that helped at least address one of the challenges to this potential link as well. So when we talk about cannabis psychosis, I wanna go again to certain products that may increase the risk, particularly if it's in high doses in food or drink versus smoked, a higher risk. And now that we have that cannabis powder that's water-soluble, it'll be very interesting to see if we see increased risk of psychosis in our patients. The higher the potency of the product, the greater the risk. And there's significant literature showing that individuals with schizophrenia, this has a particular detrimental effect on worsening their psychotic symptoms as well. We had mentioned earlier synthetic cannabinoid psychosis. And for many individuals, this may represent their first psychotic presentation and they can have extreme agitation, anxiety with panic, hallucinations, psychosis, and even catatonia as a first presentation. So there've been publications and news shows that describe individuals that have this synthetic cannabinoid psychosis almost like zombies where they can have waxy flexibility and extreme catatonia that looks like a very dramatic first onset schizophrenia, but it really is related to the synthetic cannabinoid. Okay, I want you to consider this vignette and imagine that you have a parents of a 17-year-old who comes to you and they're seeking your advice. They're worried because their 17-year-old son is starting to scratch his arm and has some self-injurious type behavior. And they noted that he became psychotic after using marijuana. And again, he had the self-harm behavior that followed him becoming psychotic. So we have a couple of key factors in this vignette. Young man using marijuana, became psychotic, and then had self-harm behavior. Your question might be if the parents ask you, what is the likely outcome for my young son who had this presentation? And the outcome is somewhat alarming when you look at the article published in American Journal of Psychiatry that looked at individuals who developed a cannabis psychosis about 47.4% who experienced cannabis psychosis ultimately in follow-up developed schizophrenia or bipolar disorder. Young age was linked to developing schizophrenia so they were more vulnerable. And for those who demonstrated self-harm during their cannabis psychosis, this was an independent risk factor for developing schizophrenia and bipolar disorder. All right, the last section of this presentation, we're gonna focus on cannabis use and violence. So I'm gonna pose to you some different potential linkages. First of all, I think the literature is clear, particularly in individuals with a serious mental illness, that cannabis use increases the risk of psychosis. We do know from multiple published studies that psychosis is an increased risk factor for individuals with serious mental illness to become violent. And therefore the question becomes, does cannabis use increase violence even independent of psychosis? But certainly particularly if it's causing or leads to individuals developing a psychotic symptom. So one of the important studies that looked at this comes out of the Cambridge study of delinquent development. And what they were examining was a group of delinquent youth in an area of London. So this picture is meant to portray delinquent youth many years ago outside of London. And so it represented the complete population of eight-year-old boys attending one of six schools. So they captured the entire male population here. And these boys received evaluation and follow-up for their marijuana use at the following ages, 18, 32, and 48. And at each interval, they evaluated their marijuana use, their self-report of violence, but also their history of violent convictions. And what did they find? They found that marijuana use was associated with a ninefold increase in violent behavior at all three intervals. And even controlling for other factors that you might naturally think could play a role in violence the marijuana use still came out as an independent factor for increasing the risk of violence. Okay, well, what about cannabis use and violence in those less than 30? Few minutes ago, we talked about how the adolescents are using this at a greater frequency. So a more recent published study in the American Journal of Psychiatry in 2020 specifically examined this as well. And here they looked at a meta-analysis of nearly 300,000 people who were less than 30. And they were trying to understand their cannabis use in any relationship to violence. And in this study, violence was defined as an aggravated assault, a sexual assault, sexual aggression, fighting, or robbery. And here are the results. There was a moderate association between cannabis use and violence. The relationship was unchanged after adjusting for confounding factors. And key point here, the violence risk was higher for persistent heavy users. And you're gonna see this come up again and again in this webinar about how important it is to ask about frequency of cannabis use. Now, an additional study was looking at specifically cannabis use for those with a serious mental illness and then potential relationship to violence. So this is particularly relevant to our patient population. And here is how the study design went. They conducted a meta-analysis of 12 articles. And this included nearly 4,000 subjects. And they were examining the relationship of serious mental disorder to cannabis use and violence. For your understanding, this included non-substance induced psychotic and mood disorders. And violence was very broadly defined in part because this was a meta-analysis. The 12 articles define violence differently. So they had to have a general broad definition of violence. So what were the results? There was a moderate association between cannabis use and violence in persons with a serious mental illness. And the odds ratio was about three times for their finding of this. There was a higher association with cannabis misuse versus use. So again, this is important. By cannabis misuse, they're talking about heavier doses, higher potency, more frequent use versus milder, less frequent use. And there was limited evidence in this particular study on the direction of association. By this, I mean limited evidence on did cannabis use result in the increased risk of violence in those with SMI or was the individual with SMI that used cannabis was the risk of violence independent of the cannabis use or not. So they emphasize that there was need for more research in that particular area to answer that particular question. All right, in the last several minutes, what I'd like to do is to present a vignette. I call it Weed and Meat are Good because it kind of summarizes key risk factors that you should think about if an individual is referred to you with a serious mental illness and either they are concerned or perhaps parents or other loved ones are concerned about their cannabis use. So here's the vignette. Ryan is a 19 year old man and he's been referred for a diversion evaluation. You could also imagine that Ryan has been referred to you in an outpatient clinic and his wife or parents are concerned about his use. He was arrested for domestic violence complaint against his girlfriend, Tiffany. And the police, when they arrive on the scene, find that Tiffany has a bloodied lip and you learn that this was the first time that he and Tiffany were dabbing. Again, you now know that dabbing represents a highly concentrated form of THC, up to 80% concentration, and it can have really significant effects because of its high potency. After he began dabbing for the first time, Ryan began accusing her of spying on him and he developed a psychotic belief that Tiffany was working with the FBI to get him the death penalty, all right? He had not had this particular delusional belief prior to this. When you gather the history, he tells you, don't worry about it, weed and meat are good, but you don't stop there. You say, I need some more questions. So when did you first start? And he tells you that he first began using cannabis when he was 14 years of age. He uses at a frequency of about five times per week, so that's a heavier frequency. He does prefer the higher potency forms, such as butane hash oil. And he combines this with alcohol and opioids. He does have also a bipolar diagnosis and he has not been taking his medications. So he clearly has a serious mental illness as well to his cannabis use that he's described. So what would be, if you were asked to evaluate in any setting, what is Ryan's risk factors for cannabis use and violence, considering the context of a serious mental illness? I would like you to consider an acronym known as SATIVA. And a psychiatrist I work with at UC Davis developed this, and I think it's a very useful acronym that summarizes risk factors for our population. So the S of SATIVA stands for serious mental illness. So does Ryan have a serious mental illness? The answer is yes. He has bipolar disorder. That's a separate risk factor for those who may be using cannabis. Next, the A of SATIVA. The younger age, the greater the risk for cannabis use and violence. So he started at age 14, so that's an independent risk factor. T of SATIVA stands for the type. So higher potency types, as we've described, higher risk of violence, but greater the intensity. So his frequency was five times a week. So he is now up to four risk factors. And this is interesting. As far as the V of SATIVA, having a victim or a domestic violence intimate partner, if there's a history of this with cannabis use, but even if there isn't yet a history, intimate partners for those who use cannabis, there is an increase of domestic violence as well. And then finally, if there's another drug also used with cannabis, and remember he used both alcohol and opioids along with that. So if you're in your clinic or you're in a diversion program or perhaps you're trying to assess a person's risk of violence with their cannabis use, please remember the acronym SATIVA and ask about serious mental illness. Did they start at a younger age? What type do they use? What's the intensity of use? Have there's been a victim of domestic violence associated with it and any other drugs? At this point, I would like to turn this over to Dr. Deb Pinos, who will do a summary of what we presented for you. Great, thanks Dr. Scott for that excellent review. What we've heard today is that we need to be mindful of the increasing potency of the current marijuana products that are out there. We need to think about how to do a careful risk assessment since cannabis can increase the risk of violence in individuals both with and without SMI, but SMI confers a unique additional element because cannabis can increase the risk of psychosis in individuals with and without SMI. So with that, I wanna turn this over back to Dr. Druss. And again, thank you all for listening to this presentation. We're happy to entertain questions. Thank you both for a really wonderful presentation. Now we're gonna have the opportunity for the audience to ask questions. Please feel free to submit your questions by typing them into the question area in the lower portion of your control panel. Before we shift into Q&A, I wanna take a moment and let you know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. Download the app now at smiadvisor.org forward slash app. So first question is whether you have any recommendations for either psychopharmacological or behavioral treatments for cannabis use, particularly in groups with serious mental illness. Right, I'm happy to, this is Dr. Scott, take the first response to that. Unlike alcohol, where we do have medication-assisted treatment specifically to help decrease cravings and use, currently, there's really no large evidence-based medication to help decrease cannabis cravings and use. So that being said, though, there are evidence-based approaches from a behavioral standpoint. And so this can include contingency management, cognitive behavioral therapy, motivational interviewing techniques. So those are the primary methods. The other thing that can be very useful, particularly if you're working with individuals that may be involved in the criminal justice system, or if you wanna have careful monitoring of your patients, if they're willing to comply, would be ongoing monitoring of urine drug screens as well so that you can catch any kind of early relapse, but also knowing that that will not get your synthetic cannabinoid identification in the urine drug screen. Great, and the only thing I would add to that response is, and you sort of alluded to this, Dr. Scott, is that it's really important to do a very thorough substance use history, as well as a history to understand what the mental illness is. But there's a high likelihood of co-occurring conditions, just like in the cases that were presented today. So if you do have somebody that's also using alcohol regularly, and could benefit from medications for their alcohol use disorder, or somebody who's using opioids and could benefit from medications to treat an opioid use disorder, these are really important adjuncts that should be considered as well. Great, thanks so much. Perhaps building on that, can you say more about recommendations for monitoring for THC products? Well, I'll sort of emphasize some of the comments I made earlier. So you can monitor for THC products in many different body fluids. So urine drug screen is one. It's important to note that for urine drug screens, you may or may not have a positive urine drug screen depending on the frequency and the potency of the product used. So if someone may come up with a negative urine drug screen, but if they used it several days before and they're not a heavy user, it may not tell you whether or not they're using marijuana at all. So the frequency, the doses, and the potency can play a role. For chronic heavy users, though they could have had several days or if not weeks off if they've been heavy users and may still have a positive urine drug screen because of a longer duration of action if they've been using it for a long period of time. So part of the accuracy of your urine drug screen is gonna be tethered to your history about the type they use, the dose, and the frequency. One other thing to keep in mind is because THC is fat soluble, it's oftentimes stored and it is stored in the body fat. So if someone is trying to do the right thing and they're really trying to be abstinent and they're not using THC, but they're also having a weight loss program and they're really attempting to lose weight, so rapid loss of weight or significant loss of weight can release THC into the bloodstream and ultimately it can be detected in the urine drug screen even if they're not using. So you have to be aware of both factors that may lead up to false negatives and false positives. Along that line, if you're in any kind of clinic or you work with a program that is doing urine drug testing, you also need to be aware of what are known as adulterants. These are things that can be added to the urine, for example, to mask detection of different drugs to include THC. And so oftentimes these can even be bought on the internet and they're not routinely tested for, and so you'll get a false negative. We now have separate testing for adulterants that may be added. So certain labs will not only look at things like urine concentration or dilution or if the acidity is off, indicating an adulterant, they have a specific different test strip to see if something's been added to the urine to make it a false negative. So that's something you can think about as well. So those are the key. Yeah, Dr. Pinos? Yeah, no, sorry. I think one other thing just to think about in doing this is that it's really important that we be aware of, first of all, just to going back to the motivational interviewing concept, we may not be on the same page as our patients in terms of what they want. And that statement, we didn't mean is good, is really kind of a marker for often what you're facing in that clinical scenario. So number one, we may not be on the same page to those techniques of how we talk to people to help understand what their goals are and how they can achieve their goals and how their use may be thwarting those goals can be one thing to keep in mind. The other thing is really just the stigma of substance use and the traditional approaches to substance use, which has been to shame and make people feel that they are doing something wrong or bad, as opposed to looking at this as a condition that contributes to problems in their long-term functioning and with clinical approaches that can help them achieve again, the best that they can for their lives. So I think really how we approach these things while we're doing testing, while we're doing monitoring and being honest about what the information is that we're getting and how we're trying to help them, I think are really important parts of that dialogue with patients with SMI. Yeah, that's really great and helpful. I wonder if you could say a little bit more about what that might look like, say with motivational interviewing and kind of reframing some of the kind of the benefits from the service user's perspective, from the patient's perspective. Yeah, you want me to do that Dr. Scott or you wanna jump in on that? No, you start off and then I've got some thoughts as well, but you take it. Yeah, I mean, I think the weed in me is good. I think trying to understand the patient's perspective of, well, tell me about that. What are the things that are good for you about it and trying to understand sort of where it is that they may also want other things in their life that and having them do kind of a self rating scales about how important is it to them in their life? Why is it so important? Trying to understand why it's important in their life and perhaps then understanding what it is they're trying to, they don't like the, for example, in the case, maybe there was underlying psychosis that was painful to deal with. And maybe that is an issue that needs to be dealt with with other psychopharmacological strategies. Right, and I agree with, yeah, I agree with everything you said. So, if we're thinking about that last vignette and motivational interviewing, he would likely be in that pre-contemplation stage. He's not even contemplating yet that he might have a problem. So we try to match our interventions with the stages of change and where this individual may be. So in a pre-contemplation approach, it's providing information, going over that decisional ambivalence, risk and benefits, and having him talk not only about the bad parts of it, but why he enjoys the marijuana, that good and the bad, and then trying to move him further through that stages of change to at least contemplation that there may be an issue for him that's not in his best interest. Great, thanks so much. That's really, really helpful. I'm wondering if we could sort of, if we zoomed out to kind of a public health perspective on this, there's currently a growing use of medical cannabis in the US for treating conditions such as pain or anxiety disorders, as well as, you know, an increasing number of states that allow use for those purposes. So how do you think about, at a population level, weighing some of these potential benefits and the kinds of downsides that we've been discussing, either across the whole population or at-risk subgroups? Sure, yeah, I'm happy to kind of tap into that. Sure, yeah, I'm happy to kind of take the first response to that. So one of the references that's provided is in the Frontier Psychiatry. I think it's Delazizo is the first author, and they do an excellent review of kind of the key question here from a public health policy with the emerging legal approval and use of both medical marijuana and recreational marijuana. Does this pose potentially an increased risk of violence at large, and are we seeing that as a result? And there are really kind of two theories or approaches or ways to look at it. One is if marijuana has been illegal and there's some adverse criminal activity and violence associated with that, legalizing it may actually decrease some of the kind of systemic violence associated with the illegality of the drug. And there has been some evidence that would support and suggest that. The second, though, aspect is for those individuals who are vulnerable, and remember those particular risk factors that we concluded the talk with, is there a potential increase of risk of violence for those who may have an underlying vulnerability? And there's also some evidence to suggest that there is. So one study that we didn't have time to cover, but I'm just gonna mention very briefly, is specific to individuals with schizophrenia. It comes from the CADI trial, which is the Clinical Antipsychotic Trials for Intervention Effectiveness. And there they looked at about 965 patients. They followed them longitudinally to look at specifically cannabis use and violent behavior, and even controlling for other drugs such as alcohol and stimulant use. There was a unidirectional association in this 2020 study looking at cannabis use in individuals with schizophrenia who had an increased risk of violent behavior. So I think it can be both. I think for certain groups, it may decrease the risk of violence, particularly systemic violence related to the drug trade, but for vulnerable people, we may see an emerging increased risk. Yeah, all the more reason that those assessments are gonna be so key in thinking about how this is impacting the individuals. I think that if so, it's both the public health issue, but then as clinicians working with individuals, taking each case and understanding these relationships like we've been presenting today are gonna be so important to help reduce those risks. Great. Well, thank you so much. That was a great response, and I think it really is important to look at it from all of those levels. So we're getting ready to wrap up. Just wanna point people to the opportunity. If you have follow-up questions about this or any topic related to evidence-based care for serious mental illness, our clinical experts are now available for online consultations. Any mental health clinician can submit a question and receive a response from one of our SMI experts. Consultations are free and confidential. SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We'd encourage you to explore the resources available on the Mental Health Addiction and Prevention TTCs, as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opioid epidemic. Thank you for joining us. Until next time, take care. Thank you for participating in today's free course from SMI Advisor. We know that you may have additional questions on this topic, and SMI Advisor is here to help. Education is only one of the free resources that SMI Advisor offers. Let's briefly review all SMI Advisor has to offer on this topic and many others. We'll start at the SMI Advisor website and show you how you can use our free and evidence-based resources. SMI Advisor's mission is to advance the use of a person-centered approach to care that ensures people who have serious mental illness find the treatment and support they need. We offer several services specifically for clinicians. This includes access to education, consultations, and more. These services help you make evidence-based treatment decisions. Click on consult request and submit questions to our national experts on bipolar disorder, major depression, and schizophrenia. Receive guidance within one business day. It only takes two minutes to submit a question and it is completely confidential and free to use. This service is available to all mental health clinicians, peer specialists, and mental health administrators. Ask us about psychopharmacology, recovery supports, patient and family engagement, comorbidities, and more. You can visit our online knowledge base to find hundreds of evidence-based answers and resources on serious mental illness. All content in our knowledge base is reviewed by our team of national experts from the American Psychiatric Association, Harvard, Emory, NAMI, University of Texas at Austin, and more. Browse by key topics or search for a specific keyword in the search bar. Access our free education catalog to find more than 100 free courses on topics related to serious mental illness. You can search the education catalog by topic, format, or credit type to find courses that fit your needs. SMI Advisor also offers live webinars each month that let you learn about evidence-based practices and participate in live Q&A with faculty. Check out our education catalog often to find new courses and earn continuing education credits. For individuals, families, friends, people who have questions, or people who care for someone with serious mental illness, SMI Advisor offers access to resources and answers from our national network of experts. The individuals and families section of our website contains an array of evidence-based resources on a variety of topics. This is a great place to refer individuals in your care for information about their conditions. They can choose from a list of important questions that individuals who have SMI typically ask. SMI Advisor worked with experts from the National Alliance on Mental Illness to develop these important questions and many of the resources in this section. Watch videos on important topics around SMI, such as what to know about a new diagnosis. They can also find dozens of fact sheets, infographics, and links to other important resources. To access even more evidence-based resources for individuals and families, visit our online knowledge base. All content in our knowledge base is reviewed by our team of national experts from the American Psychiatric Association, Mental Health America, and the American Psychiatric Association. For more information, visit our website at www.smi.org. You can also access resources from the National Alliance on Mental Illness, Mental Health America, National Alliance on Mental Illness, and more. 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Video Summary
This video is a webinar titled "Marijuana, SMI, and Violence: Practical Guidance for Psychiatrists." The webinar is produced by SMI Advisor, which is an APA and SAMHSA initiative aimed at helping clinicians implement evidence-based care for those with serious mental illness. The faculty for this webinar includes Dr. Charles Scott, Chief Division of Psychiatry in the Law at the University of California, Davis, and Dr. Deb Pinals, Clinical Adjunct Professor at the University of Michigan Law School and Medical Director of Behavioral Health and Forensic Programs for the Michigan Department of Health and Human Services. The webinar discusses the relationship between marijuana use, serious mental illness, and violence. It covers topics such as the increasing potency of cannabis products, the impact of cannabis use on psychosis, and the association between cannabis use and violence. The presenters discuss the need for thorough assessments of cannabis use in individuals with serious mental illness and provide recommendations for monitoring and managing cannabis use, including behavioral interventions like motivational interviewing and seeking adjunct treatments for co-occurring substance use disorders. The presenters also address the public health perspective on cannabis use, weighing potential benefits and risks at both the individual and population level. The webinar concludes with a Q&A session, where the presenters respond to questions from the audience.
Keywords
Marijuana
SMI
Violence
Practical Guidance
Psychiatrists
Webinar
Potency of cannabis products
Cannabis use
Psychosis
Thorough assessments
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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