Hello and good afternoon. Before we get started, I want to go over a few housekeeping items. Please utilize the chat box for any questions you might have. We encourage attendees to interact and share comments or questions in the chat box while our panelists are presenting. We will be taking some time at the end of our presentation to answer some of your questions. You have the option to upvote any questions that other attendees have asked so our presenters will be able to prioritize questions that are of great interest. Both the recording and slides will be shared in an email following this event. A CME evaluation survey will also be included. This session is available for one AMA PRA Category 1 credit. You will receive a follow-up email after the webinar's conclusion with instructions on how to claim your credit. Hello and welcome to Clearing the Smoke, Cannabis and Mental Health, a two-part webinar series presented by the American Psychiatric Association, APA, the American Academy of Addiction Psychiatrists, AAAP, and the New York County Psychiatric Society. I am Dr. Jose Vido. I'm a clinical assistant professor at NYU School of Medicine. I had served as the past president of the New York County Psychiatric Society, a DBE of the APA, and currently the chair of the membership committee of AAAP. This webinar is the second of a two-part series that will provide psychiatrists and other clinicians with the most updated information available on cannabis to help patients make informed decisions given cannabis increasing accessibility in multiple states. Today's webinar is a follow-up session to provide more insights and answer attendees' questions on cannabis and psychiatry addiction psychiatry patients based on the latest research. At the end of today's presentation, we will have a Q&A with our experts to explore common issues or questions that you and your patients may have regarding cannabis. Please use the chat box to submit questions. I am pleased to introduce our esteemed speakers. I also want to point out that they have volunteered hours of their time on this. They will each present, and we will then have time for questions. Our first speaker is Dr. Kevin P. Hill. He is an addiction psychiatrist, director of the Division of Addiction Psychiatry at Beth Israel Deaconess Medical Center and an associate professor of psychiatry at Harvard Medical School. He serves on the editorial boards of Cannabis and Cannabinoid Research and the American Journal on Addiction. Our second speaker is Dr. Arthur Robin Williams. He is an assistant professor of clinical psychiatry at Columbia University and a research scientist at New York State Psychiatric Institute. He is also the director of AAAP's New York region. Our last speaker is Dr. Smita Das. She is the medical director of Psychiatry at Lyra Health, and she practices in the Dual Diagnosis Division at Stanford School of Medicine, where she is a clinical associate professor. She is on the Council of Addiction Psychiatry at APA and the past president of the Northern California Psychiatric Society at DB of the APA. With that, I turn the presentation over to Dr. Kevin P. Hill. Thank you, Dr. Avito. I just want to thank everybody for taking time out of their day to join us, whether or not you came last week. I also want to thank the APA, particularly the APA staff, for organizing this, also AAAP. And I just want to say it's an honor to present with Dr. Das and Dr. Williams. So I've got 10 minutes to lead it off today. And what I wanted to do was take just a couple of minutes to answer a few of the questions that came up at the end of the last session relative to cannabidiol or CBD. And then from that, we're going to get into the meat of today's session. And what I'm going to talk about really is how to assess cannabis use in patients that you may have. So getting back to cannabidiol, we talked last week about the presence of over 400 compounds in the cannabis plant and over 140 cannabinoids, two of which that we most talk about are THC, delta-9 tetrahydrocannabinol, and cannabidiol or CBD. And they function as sort of a yin and yang. CBD can buffer some of the potentially harmful effects of THC. And we got into last week talking about the promise. And so we're going to review really critically where there is evidence to support the use of cannabidiol at this point, particularly as it relates to psychiatric disorders. So first bullet, as you can see, there are three FDA indications, Dravet syndrome, Lennox-Gastaut syndrome, and then seizures associated with tuberous sclerosis. And these are all seizure disorders, usually in a pediatric population. And why this is so relevant for us when we talk about cannabinoids in the evidence is because this was done the right way. There is absolutely rigorous evidence supporting the use of CBD for these three particular conditions. So as we move forward talking about other conditions, there's less evidence certainly, but there is some evidence for the things that we're going to talk about. The second bullet, again, we talked last week about how CBD has some anxiolytic properties. And so it's not surprising to see a growing body of evidence supporting the use of CBD in certain anxiety disorders. And so a couple of studies have been done in social anxiety disorder, which demonstrate that promise. We talked last week a bit about how in a patient with treatment refractory anxiety, again, you got to be clear about what the potential side effects may be for CBD, but it may be something to consider. And then the last bullet here, we talked last week again about how, although not all studies have been positive when looking at CBD for patients with psychotic disorders, there are RCTs that demonstrate CBD's efficacy as both a monotherapy and as an adjunct treatment for patients with schizophrenia. Next slide, please. And then beyond that, I think we also talked about this just a little bit last week. There was an excellent paper in American Journal of Psychiatry in 2019 by Yasmin Hurd and colleagues at Mount Sinai in New York, and they performed an RCT looking at CBD and its effects upon craving in patients with opioid use disorder who were abstinent from heroin in that case, and they showed a reduction in craving cue-induced anxiety. So that's an important paper. It's not really a treatment study for OUD, although there are folks that are doing that kind of work around the country, certainly. In addition to OUD, there was at least one published paper looking at CBD as a treatment in cannabis use disorder, Tom Freeman from the UK, another outstanding paper, again, very rigorously designed study. This one was published in Lancet Psychiatry, and what they showed was that, we talked about this last week too, the dosing. So at high doses of CBD, 400, 800 milligrams per day, there was, not only was CBD safe and tolerable, but there was a reduction in cannabis use as measured with THC creatinine ratios, and then also they were more likely to have abstinent days, and so that's a very promising study there. But beyond that, beyond the studies that we've mentioned, there really isn't very much evidence at all to support the use of CBD for psychiatric conditions or insomnia, and so that's just something to keep in mind, right? We do things, we treat patients off-label all the time, but you would like to have evidence, and so we lamented the fact that the rate and scale of the research really has not kept pace with the evidence. Next slide. So shifting gears, before we talk a little bit about how to assess someone with cannabis use disorder again, as we did last week a bit, we wanted to frame the special challenges associated with cannabis. It's an incredibly polarizing topic. I think that's evidenced by the hundreds of folks that have tuned in in the last couple of weeks. So there are people who are advocates for cannabis in every way possible. They think it's the greatest medication ever. They think it's completely harmless. There are a lot of folks who are staunchly opposed to cannabis, and so that creates a lot of misinformation, frankly, a lot of cherry-picking when it comes to the data. For example, lack of clarity around the addictive potential, right? There isn't a lot of clear evidence out there, and so people who are using and may not have problems, it's hard for them to appreciate the fact that there indeed are patients who are using multiple times a day to the detriment of their work, their school, relationships, etc., and so that makes it harder for a patient who may be struggling with their cannabis use to talk about it with other people, right? If your friends all use and they don't seem to be having a problem and none of them really believe that it's possible to have a problem with cannabis use, then it's hard for folks to come forward to talk about it with their peers or to seek help, and we'll talk more about that in a second. Next slide, please. So this looks different than other substance use disorders in many ways, right? There are not the catastrophic occurrences oftentimes, right? They're less likely to occur. It doesn't mean that they can't happen, but it's less likely to have some dramatic event bringing someone into treatment. The patients themselves, they may not be aware that they have a cannabis use disorder, and they certainly can be very ambivalent, just as they are about other substance use disorders, and then for those around them, parents, teachers, coaches, etc., it's very hard to tell oftentimes. It's easier to be using cannabis in a significant way, in a problematic way, and not have other folks notice. Therefore, the referrals that we get are usually of a different sort, right? It's very rare that patients with cannabis problems call me up, right? I don't have teams calling my office every day saying, hey doc, I heard I might lose up to eight points of my IQ if I don't stop smoking weed, right? That does not happen, and it never has happened, and so as you see in the last bullet, cannabis is probably the most common substance involved in those that get treatment for SUDs, but the referrals look a bit different. They're often from family, parents, the employer, could be the court system, so we have to keep that in mind. It's just a bit different in that way. Next slide. So in terms of screening, it really depends upon your practice. You know, I get referrals where cannabis is known to be the problem. We'll talk about what that looks like in a second. Most importantly, though, if you're conducting a psychiatric interview, we want you to do it in a thorough way. You have to specifically ask people about cannabis use because of the legalities of it, because of the fact that people don't think of it like they do cocaine or other substances, so you have to specifically ask about it, and then once they respond in the affirmative, you need to know exactly how they're using, why they're using, etc. If you're in a practice where it may be helpful, a primary care practice, for example, where it may be helpful to use screeners, there are good screeners available. So the DAS-10 drug abuse screening test and the QTIT cannabis use disorder identification test, a variation of the audit that we're probably familiar with, so there are screeners. They're available, and you know, you definitely should check those out if that's something that would be helpful, but the point is we want to be aware of people who are using in a problematic way, of course, so that we can help them. Next slide. So in terms of an evaluation, what does a thorough evaluation look like? Again, I think you need to use good psychiatric principles when doing this. When I'm meeting with a patient for the first time, and they've been referred to me for cannabis-related problems, I mean, certainly use motivational interviewing tactics there, because I know that they're ambivalent. Oftentimes, they don't believe that they have a problem, but there probably is something that their cannabis use is affecting that is important to them. So that's where you want to use MI techniques and evoke or have them identify a reason or reasons that they might be willing to put in the hard work that's going to be needed in order to make a change, right? This is something that they've likely been doing for years, and they've come to rely upon. They enjoy it. Obviously, they believe there are many benefits there, so it's critical for you to identify what is important that might be at risk. So I work with athletes, so it could be their career there, or they may want to get a scholarship, etc. Could be an academic career, could be somebody's job, somebody may want to keep their marriage alive, etc., but that's critical. One reason that a patient offers about why they may be willing to do the work is better than 10 reasons I can give them, right? So we have to understand sort of where they are and work on that. It's a careful history because of the somewhat different nature of cannabis use disorder and the likelihood that there isn't a dramatic event that may have brought them in. Collateral is so critical to really find out if they don't think that they've had a problem, is that something that other people will support? Have their grades been good, etc.? Building that alliance is crucial. I think that's probably the most important thing that you can do in an initial evaluation. Most of the people that I see, at least initially, don't want to do the things that I recommend, but if I've listened to them, and it's so important, as we talked about last week, to be sensible about this, to try to understand the at least perceived benefits of their cannabis use. So if you've done that, and you're reasonable, and by virtue of the questions that you ask, you help them understand that you know a few things about the topic that you've learned in this seminar and other places. I think that helps you build that alliance so that when they're ready to do the work, and that's invariably what happens. It could be a week, could be a month, or months later, they'll call you back because you did this in a sensible way. You made it clear that you care about what happens to them, and so hopefully they'll be able to come back and do that work with you or listen to your recommendations. So what do you look for? There could be social problems that are worsened by cannabis, right? That dramatic event, perhaps giving up important activities. If you played soccer for 10 years, and that second year student in high school is no longer playing, that might be a reason to look for cannabis problems. Use in dangerous situations, usually cars, and then use despite other obvious physical or psychological problems. So that's typically someone who has a diagnosis of ADHD or depression, medication's not working, and now we realize they're smoking multiple times a day. Next slide. And then finally, what does treatment look like? Most treatment is outpatient-based, so if it's serious, could be a partial, could be an intensive outpatient program, as Dr. Williams will talk about, behavioral interventions plus pharmacotherapy, residential perhaps, drug testing or biochemical verification is critical in ongoing treatment, and finally mutual help groups. Marijuana Anonymous is very useful for patients who have cannabis problems. Thank you. So great, thanks everyone for joining today. I will build on what Dr. Hill just presented. He gave a great synopsis, the overview of how cannabis use disorders compare, the nuances of cannabis use disorder and how it compares, clinically presents, and manifests compared to other substance use disorders. I'm really going to focus more on the treatment of cannabis use disorder, and I'll just to clarify, I think when Dr. Hill was saying there's a lack of clarity about cannabis addiction, I think what he meant is that there's really a lack of clarity in our understanding in terms of the public, the media portrayals, a lot of our colleagues, other clinicians are unaware that cannabis addiction can be so debilitating, that cannabis tolerance and withdrawal predictably do develop among heavy regular users, and that this really is a clinical disorder that needs to be accurately diagnosed and effectively managed, and there are treatments that I'll go over that can be very helpful. So let's go to the next slide. Remember there are 11 DSM-5 criteria for a substance use disorder. Two to three is mild, four to five moderate, six or more of these 11 criteria indicate a severe substance use disorder, and you know it's kind of interesting, we have the same 11 criteria irrespective of the drug of choice, and so they're the same criteria, and yet in terms of how the patient actually behaves, the way this comes across to others, the way it may come across to clinicians, there are some idiosyncrasies in terms of how, for instance, cannabis use disorder would present compared to a stimulant use disorder, heroin use disorder, where often, as Kevin was saying, there really are catastrophic events, injuries, infections, overdoses, ED visits. With cannabis use disorder, a lot of the symptomatology is more internalizing, sort of like negative symptoms in a sense, the patient's amotivated, less involved, not going out as much. When I get referrals for patients, usually not always men, but often younger guys in their 20s to 40s, it's a good friend. It's a family member who calls me in desperation and says, I don't understand it. My friend, my loved one gets up, you know, they start smoking, vaping, whatever it is before they even get out of the bed and they're stoned all day long. And they've stopped working. They've just stopped everything. And they're very concerned about them. So collateral can be very helpful. Often collateral is the presentation itself. Next slide. I think some of you are probably familiar with this, especially the addiction specialists. This is a great figure from a great article in the New England Journal that the heads of NIAAA, NIDA, and Tom McClellan, who was a former deputy drug czar under the Obama administration, wrote. And I know this is hard to see on Zoom, but the point is that the blue, there's three parts to this cycle of addiction. The blue is binge and intoxication. Pink is withdrawal and negative affects. Green is preoccupation and anticipation. And the reason I want to dig into this a little bit is that especially with, you know, you look at the newspapers, Dateline, you know, some sort of news show that's covering cannabis or other drugs. They love to show pictures of people using drugs, someone shooting up a plume of smoke, these really sensational visuals. And even our patients often think about relapse as about being about the drug use itself. It's when they buy, you know, a fifth of vodka at the liquor store. It's when they call their drug dealer again and get more drugs. It's when they're actually lighting up, shooting up, whatever it is. That's part of the binge intoxication third of the addiction cycle. But there are two other substantial pieces. And especially for those of you who've been treating patients with substance use disorders, I think we're all familiar that one of the big, in terms of people entering treatment and trying to get sober or remain continuously abstinent or to have meaningful reductions in their use, it's often the withdrawal and negative affect part of the addiction cycle. It's the negative reinforcement that leads people back to resuming use. It's the distress of not being able to fall asleep, of feeling anxious, of feeling irritable and restless that leads people to returning to cannabis use for instance. So all of this is setting me up for talking more about thinking about effective treatment options and aggressively managing cannabis withdrawal is so important to helping these patients stabilize or cut out their use. Otherwise people naturally will return to what has been helpful for them or what they think has been helpful for them in the past in terms of insomnia and anxiety and things like that. I don't know if we did emphasize this fully. There is a very well-characterized for the last 20 years in particular, a very well-characterized cannabis withdrawal syndrome spanning psychiatric and physical symptoms. The hallmark symptoms are insomnia, which can persist for weeks or even months for some patients, anorexia, anxiety, irritability, restless. There can be pain, especially stomach discomfort, but pain. And this can go on for quite some time. I was talking to a CEO of a large residential rehab in the New York area a couple of years ago, and he pointed out half among hundreds of patients in this rehab, half of them were on Seroquel at night because they couldn't sleep. In the hospital, I think anyone who's been on call in the hospital has been paged for patients who are irritable and can't sleep at night. Nursing, the staffs now, we do really good at detecting alcohol withdrawal because it can kill people. We don't really screen for cannabis withdrawal in the hospital. And yet there are lots of people who wind up being institutionalized in rehab, in a hospital setting, post-surgery, whatever it is. And the same way they're now without alcohol, we have plenty of patients who are without cannabis and they're in cannabis withdrawal and it's not detected or treated. This may be a little bit hard to see. What we've done here, this is in part from publications that Dr. Hill and I have had over the years. I'm laying out the DSM-5 criteria on the left. This is just five of them. And then on the right, giving examples of the clinical presentation. The next slide is the rest of this table with the other criteria here, focusing on problems from use, those five criteria, and examples of how this might present with cannabis. Let's go to the next slide. So here I'm going to focus on pharmacotherapy, and there are really three aims for pharmacotherapy. One, as I was saying before, is treating withdrawal. And I think this is something I talk to medical students and residents about a lot. I think our mindset, because of a generation or two of the way our healthcare has been structured, our addiction treatment's been structured, and frankly, the way that HMOs would reimburse for care, was focused on acute withdrawal, especially the alcohol model. Because again, that's what kills people, seizures, DTs, and the three to five days following initial sobriety. And the reality is that there's a growing appreciation throughout the addiction field for protracted withdrawal syndromes, whether it's from opioids, stimulants, in this case cannabis. So I was talking earlier about these cardinal symptoms of withdrawal, and in particular, insomnia and anxiety can really persist for patients for weeks or even months after they've stopped using cannabis. You have to treat that aggressively, otherwise people will return to cannabis use. Another aim for pharmacotherapy for treating cannabis use disorder would be, in general, anti-craving mechanisms. And then clearly, there are, for any substance use disorder, very high rates of psychiatric comorbidity. So if someone has a primary mood disorder, bipolar depression spectrum, someone has a primary anxiety disorder, PTSD, if we aren't treating the comorbidity comprehensively, that's just another reason that the patient would likely return to cannabis use. So you want to think about all three of these as opportunities in terms of pharmacotherapy. And all of these can also be treated on some level with psychotherapy and behavioral interventions as well. But let's go to the next slide. So some examples, I think these are very familiar medications to all of us. In terms of insomnia, clearly you would, for someone with a substance use disorder, it's generally advisable, at least in terms of first or second attempts at treating insomnia, to avoid substances with addictive liability, like benzodiazepines. There are lots of sleep aids over-the-counter or prescribed that can be recommended. In terms of anxiety, irritability, restlessness, depending on the patient's psychiatric history, other medication trials, again, there are lots of options that are not, that don't have addictive liabilities. Mirtazapine, of course, is great for sleep and for appetite. So I often use that. This is probably obvious to a lot of people. I often explain to patients, mirtazapine might be something that we use for a few months, one month, three months, to help stabilize sleep, to help keep your appetite going as you phase out or quit cannabis. Clearly over time, patients are prone to weight gain and increasing side effects. Let's go to the next slide. For cravings, there are several medications, again, I think all of these are familiar to us for different indications, that generally have anti-craving properties. So there's a lot available. And yeah, topiramate, bupropion, of course, is, welbutrin is marketed as Zyban for smoking cessation. Naltrexone is FDA approved for alcohol and opioid use disorders, but for some patients with cannabis can also have an anti-craving effect. Next slide. Treating psychiatric comorbidity, and I think the final slide. And then thinking about psychotherapy and behavioral approaches, no surprises here, CBT-MI approaches. So the final slide, I think, just lays out all of this together and happy to talk about, go to the next slide, talk about any of these aspects of treatment in more detail later on. I'm through at this point. Thanks. Great. Thank you so much, Dr. Williams. And it's wonderful to be here again today. And I really appreciate just all of the attendees also for making this a priority. I think this has been a vacuum. We've heard this in the on the district branch level, also on the national level, and there's been a vacuum of knowledge. And this is a really quickly changing landscape. So today I'm going to be focusing on advocacy as well as trying to touch on some of the questions that were brought up with regards to policy and epidemiology last week to follow up with some of what I had presented last week. So I want to really highlight, though, some of the things that Dr. Hill and Dr. Williams said about cannabis and cannabis use disorder. So, for example, it was mentioned that when people have a catastrophic outcome, then they usually present for help. And as an addiction psychiatrist, as physicians, as treatment providers, it's very frustrating when that happens, right? Because we oftentimes have tools that Dr. Williams and Dr. Hill mentioned to be able to assess and screen folks earlier so that they're not getting to those catastrophic places. And then in particular with cannabis, it is the sort of substance where, as opposed to, say, an alcohol use disorder or a opioid use disorder where there can be deadly outcomes very immediately, cannabis ends up being one of those substances that are used and the impacts are there. What's wonderful about the DSM-5 criteria is that they really make the criteria the same for all of the substances and the essences that impact on functioning and life have to be present. And so that impact is there, but for many users it's there in this kind of low-level way and then it'll escalate over time, but it's not a more acute or subacute sort of presentation. And so it becomes hard to piece those things together. I'll use my favorite analogy is nicotine, right? So tobacco use disorders, tobacco is responsible for more morbidity and mortality than alcohol and all other drugs combined. And yet we don't assess for it enough and we don't address it enough until it reaches the point where it is affecting somebody's health kind of at the end stage. So similarly, folks don't feel that immediate, oh no, substance use impact that might be felt with alcohol and opioids. And so it gets under addressed. And I think another part of this is risk perception. And we talked a little bit about this last week, but risk perception and use. And so generally, for example, with younger people, those are inversely related. And so I think there's a lot that we can do in the field of psychiatry and in medicine to help raise awareness. So I just want to really thank everybody who's attending because you are here to learn more, to add more tools to your toolbox of how to discuss this with patients. And even just asking, as was mentioned by my colleagues, asking about cannabis makes it clear that this is important to you. And I apologize, I merged the two top bullet points, but we have several APA position statements, American Psychiatric Association position statements, related to cannabis and cannabis use. Oftentimes there are joint efforts, for example, on legalization, joint effort with psychiatry and law and with the impact on children and adolescents, joint effort with the Council on Children and Adolescent Psychiatry. And to give a little bit about how APA position statements are created. And I think this is fun because several of us here are involved in our district branches, which is a great way to get involved in the local legislation and the local advocacy efforts. So if there is an existing position statement, there is every five years an expert review of that position, of the research, of the data that we have to make sure that we're kept up to date. And then that is then reviewed by the JRC and other elements of the APA to make sure that we're all in alignment. And then the position statement is passed. Another fun thing I think that is useful to know is that action papers, action papers can come from individual members, parts of district branches, and they can go to the APA. And those action papers sometimes ask the councils to support a creation of a position statement. So these are ways that folks can get involved. This was really useful to look at from the AAAP. It is their recommendations about how to do model legislation for cannabis. The site is down there. And really there's six elements that they have. And I'm going to, in the interest of time, go to the next slide. The AMA, the American Medical Association, also has some strong positions. They have put together a new cannabis task force, and a couple of us are on that, to engage physicians and the public in learning more about this. And they continue to maintain opposition to the term medical marijuana and to full legalization. And there's a citation for that paper there. Last week, it was also mentioned, one of the attendees mentioned this resource, which a lot of our bullet points also come from. It's the NASEM resource, which is the National Academy of Science and Medicine. And I think it's useful to highlight a few of the sections. This is from their executive summary. But the mental health section is of particular interest. The limited therapeutic effects for which there is enough data. And then also they highlight problem cannabis use and concurrent substance use disorders. A question was brought up about driving. This is, as we mentioned last week, while federally cannabis is still considered not a legal substance, on the state level, there is legalization in many contexts. And so these are kind of natural experiments that are happening, and we're getting more data from state to state. So for example, Colorado is well known because of their early movement in legalization. And this is just an association, these are associations, but 17% of all DUI arrests by the Colorado police involved marijuana. And so we'll see over time how on a state by state basis, fatalities, driving under the influence and so on are affected. Currently, 10 states have zero tolerance, four states have per se limits, which are similar to, for example, the alcohol driving limit. And so again, this is more to come, hopefully in the next five years, we'll learn more about this. I think eValley or vaping product use associated lung injury is very interesting. This spiked at the end of 2019, I had a whole bunch of patients come into my tobacco clinic at the end of 2019, beginning of 2020, who had either needed help quitting vaping or had transitioned to cigarettes because they were vaping before. And these eValley reports came out. And ultimately the most recent update from the CDC was that it's vitamin E acetate that's usually used in cannabis oils that was related to this lung injury. So here's a list of resources. We are very fortunate again, that we have reputable resources such as NIDA and the CDC and SAMHSA. And these links, I tried to put them all out there so that you all can access them later. And then position statements. There are several allied organizations that we work with closely that have position statements and just a wealth of resources as well. So part of this is we're hoping that you all can familiarize yourself with the resources. And last slide, please. This is the APA cannabis toolkit. This is newly put out and we welcome feedback, input, suggestions for this. But we wanted to, because of the interest, we wanted to have a central place where folks could go to get the best evidence and best literature and best information about cannabis with help with regards to their patients. So if you go to psychiatrists, then practice and then professional interests and then addiction psychiatry, it's there in one of the sections called cannabis. So the bar on the left-hand side shows you kind of the path to get here. And so with that, I will end and I believe we will now be open for answering questions. All right. Well, thank you all for your wonderful presentations and insights about cannabis use and treatment. So we will now move on to questions and answers. I see a lot of questions regarding about slides and recording. I do want to remind everyone that both recording and slides will be shared in email following the event. CME evaluation surveys also will be included. But we did get some questions submitted in advance and from our previous session. So I will start with the questions previously submitted, and then we will also move to the questions in the chat. The first question is, what are the psychiatric effects? Does it interact with medications? Sorry, open this to the panelists. That's Dr. Vito. This was a question about psychiatric effects of cannabis or cannabinoids in general. Correct. You know, there's so much interest in cannabis and cannabinoids and CBD in particular in the last two years. And THC, I perceive much more risk with THC for several reasons. And which in general, clearly for whole plant products, there's plenty of THC. And I often find myself in conversations with patients and sometimes with colleagues, but talking about it's similar to alcohol or benzos, where there are plenty of patients who, you know, have a drink in the evening or occasionally, they don't, clearly most people who drink alcohol don't become addicted to it, don't have debilitating problems because of it. Same thing for benzodiazepines. At the same time, for people who are reliant, not necessarily reliant, but using alcohol, benzos, cannabis for anxiety, to be able to fall asleep at night. For some people, they use it intermittently and it's helpful. But for plenty of people, they start using it and they find that if anything, they need to use more and more. And yet their anxiety persists. They have breakthrough anxiety, rebound anxiety between use episodes. They find that their sleep actually isn't that great. We know, you know, with benzodiazepines, it's a little bit easier to track than alcohol or cannabis because it's literally both in insurance claims, prescription claims, it's also in PDMPs. We have different data sources to really track people over time using benzos. And we know that people get on benzodiazepines and stay on benzodiazepines. And in general, the older someone is, the more likely they are to be on a benzo and the longer they've been on it, the more likely they are to be on higher doses. And I think that that trajectory is not always, but is often similar for alcohol and cannabis as well. And so patients may find some relief from this. I think like with other sleep aids or sleep aids in general, if people use them intermittently, that might be sustainable. But for people who find that they're really relying on these, using them every day at higher and higher amounts, over time, they start to really paint themselves into a corner and don't necessarily have symptom relief. And in terms of the psychiatric effects of cannabis, over time, people, you know, we have plenty of anecdotal evidence, survey-based inconvenience, survey-based data suggesting that people use cannabis for psychiatric symptom relief. And yet when you follow up people, most of these larger, more rigorous studies suggest that the patients using cannabis go on to have worse depression, worse anxiety, and are actually more likely to be using opioids and higher doses of drugs in subsequent periods. Great, thank you. The second question that came up from last session was, is cannabis actually addictive? And what medical conditions can I use it for? I appreciate that. My colleagues did go over cannabis use disorder. I think this is one of those interesting topics when I speak to non-medical audiences and I go through epidemiology of substance use disorders, and then they see cannabis flash on there, you know, I'll get the question, wait, I didn't realize that you can actually be addicted to marijuana. And I think that that is a very common misconception is that cannabis is actually a substance that we do have a cannabis use disorder in the DSM as highlighted by Dr. Hill and Dr. Williams. And we know that cannabis, all of us have treated patients who have been impacted by cannabis. And many people in the audience, I'm sure, looking at the questions have had those patients come through. So yes, it is an addictive substance. It does affect, as Dr. Williams mentioned, it does affect the circuitry in the brain that is reinforced by substance use disorders. And among cannabis users, depending on the study, anywhere from nine to 30% of folks develop a cannabis use disorder, again, depending on which study you look at. But on the lower end, you know, it is almost one out of every 10 people who uses cannabis can develop a cannabis use disorder. So it's, again, something that's under-recognized because it doesn't have those immediate impacts or those kind of, those catastrophic impacts that we sometimes associate with other substances, but it is still important to ask about and assess for. Great, thank you, Dr. Dust. Since you talked about the impact on the brain, this question is really for you. What are the impacts on the developing brain and what are the long-term impacts on learning and memory? Yeah, that's a great question. We did go over this just briefly, and there's one of the position statements for the American Psychiatric Association is on cannabis on the developing brain. So it's specifically this. And so there is concern for, about the impacts. What's nice also, I'll just do a plug here for the position statements. Oftentimes there's a resource statement as well. And that resource statement is just a compilation of all of the research that we went through to come up with the position statement. So that's also available generally on the American Psychiatric Association website. So a couple of the things that were mentioned already, for example, impacts on IQ. Studies are mixed, but there are impacts on IQ. What we know, for example, I think kind of the thing as an addiction psychiatrist that's most interesting to me, aside from the effects on coordination, brain IQ, intelligence, is the impact is also on substance use disorder. So earlier use of cannabis is related to later substance use disorders, including cannabis use disorder. And so that period of the adolescent to the early adult brain, that development is so important with all substances, and that includes cannabis. It'll be really great soon to have the ABCD study to help inform more of our research. And that's a study by NIDA that's following children throughout their development through imaging questionnaires about use and many other things. But that hopefully will shed some more light on some of the areas where we've had vague or less clear research that doesn't have conflicting other research. Yeah, actually, I'm really looking forward for that NIDA study. So we'll definitely be looking for that. Thank you so much. The next question is for Dr. Hill. You talked about this at the beginning. The question is, how do I screen? Is there any treatment available? How do you screen? Well, it depends upon the practice. So again, if you're in a primary care practice, I think it's crucial to add a screener, and that could be part of an intake packet that you may have. We talked earlier about the DAST and the QTIT. QTIT is a question questionnaire developed specifically for cannabis. Very helpful variation of the audit. In terms of treatment, I think Dr. Williams talked about that. I mean, if someone meets criteria for a cannabis use disorder, there are a host of treatments available. No FDA approved pharmacotherapies, but we've got NSTL-cysteine positive paper for gabapentin by Barbara Mason out of Scripps. Cannabidiol, as I mentioned, Tom Freeman from the UK had a positive paper there. So there are multiple treatments available. It's never hopeless, right? We have people who are having significant problems as a result of their use, but every one of them has an opportunity. If they're willing to accept their issue and get the right help, they all have an opportunity to do well. Great, thank you so much. The next question is, what's on the horizon regarding cannabis? What do you guys see moving forward? Are there any new studies that you guys are seeing regarding cannabis? Always dangerous to prognosticate, Dr. Hill. Yeah, so I would say, echoing one of the points that we made last week, it chagrins me that we're not moving faster ahead in terms of the science, right? As I mentioned last week, we have multiple states, including the Commonwealth of Massachusetts and myriad companies that are essentially printing money related to their sale of cannabinoids, including cannabis and CBD. And a lot of those entities are just not interested in moving the science forward. So there are groups that are working hard at this. I know of many, I'm involved in some studies too. So we're moving the science forward, but given the incredible interest, right? We've got hundreds of folks, a thousand folks who turned in in the last two weeks here. Given that level of interest, it's a shame that we can't move forward more quickly and really get the answers, right? There's so many questions here. Is this an effective pharmacotherapy for chronic pain? We really don't know at this point. And I'm hopeful that we'll have, you're asking about where we're gonna go. Hopefully we'll have some of those answers, but we'd get them more quickly if more of the stakeholders who should be involved in helping us get those answers would be involved. Yeah, I totally understand what you're saying. Sometimes it can get frustrating because we don't have it. And I could see that there's definitely an interest. Right now we have at least 415 participants on this webinar. So there's definitely an interest among ourselves as well. Next question, what advice do you have for treating adolescents, young adults who have longstanding ADHD now complicated by heavy cannabis use? Wow, this is a very common question and a very important question. There seems to be a patient phenotype with patients, especially younger patients with ADHD, who really gravitates to cannabis. And I'd be remiss not to make a couple of points just with Frances Levin as our division chief, a lot of her career has been dedicated to this intersection. If you have a patient with ADD, you have to treat the ADD basically with a stimulant. Otherwise you have untreated ADD. And untreated ADD is one of the biggest risk factors for drug use and substance use disorder development. So you have to screen for, diagnose, treat ADD. And if the patients are using cannabis, as is common enough for any teenager, but certainly a teenager with psychiatric comorbidity or ADD, you'd want to address that. The NAC, the N-Acetyl-Cysteine study that Dr. Hill mentioned, I think I had on my slide, I had NAC listed, there was a positive study and it was for youth. It was for teenagers and young adults. Dr. Gray out of MUSC in South Carolina oversaw that study, ran the study, and then he tried to replicate it in adults. And it was actually a negative finding in adults using N-Acetyl-Cysteine. But there is, I think in his, it was a double-blind randomized trial versus placebo. And the young adults who were randomized to NAC had two and a half times the rate of cannabis negative urines. So it was a large, very meaningful effect size for these youth. In terms of ADD, in general, there are plenty of anecdotes. And whether it's alcohol, benzodiazepine, any other intoxicant, clearly for some people, there may be benefits, whether they're short-lived, unclear if it's sustainable in certain ways. But it's another thing to ask about, not to rant too much, but another thing to ask about with these younger folks with ADD who are using cannabis, as always, try to understand why they're using. What do they get out of it? Are they anxious? Are they anxious because they have treatment refractory ADD or because they have an anxiety disorder? You know, what's going on there? So, you know, comprehensive evaluation. I'll just say one thing since we're talking about young adults, because I do think there's a, not necessarily a consensus, but I think there's growing awareness that addiction really is a developmental disorder. And the younger someone starts using, in this case, cannabis, the more likely they are to get addicted. There was a great paper that just came out looking at age of initiation and the likelihood of conversion within 12 months to cannabis addiction. And the younger someone is, they're much more likely. So the textbook used to be that people who use, who start using cannabis regularly in adulthood, one in 11, go on to meet criteria for cannabis use disorder, but it's one in nine or one in six for teenagers. But these days we have much more potent products like we've been talking about that are available through many different kinds of routes of administration. And the rates, you know, if anything, we think population-wise, the number of people addicted to cannabis has doubled in the last 20 years. That's a huge increase. We're talking about 7 million people, five to 7 million people in the United States. So the point about teenagers and the developing brain is that I think as psychiatrists, we all know that the brain in adolescence is an overgrown forest. And a lot of what happens with neuromaturation is effective pruning of the forest. And we know from all sorts of different animal and preclinical studies that the cannabinoid system is directly implicated and THC directly disrupts the pruning of that overgrown forest. And so I think we need to have a certain amount of humility being open to the possibility that teenage use of cannabis will not only impact neurocognition, but also as Dr. Das was saying, risk for any other addiction down the road. You know, we are getting a lot of questions about adolescence. Here's another question. Jose, may I just add though? So Dr. Williams makes excellent points, but I think it's a very, the question about ADHD is a variation on one of the themes that I mentioned earlier in the critical importance of identifying what is important to the patient, right? They're not coming in saying that their cannabis use is a problem, right? But they may feel that their depression is, right? So we know that substance use disorders, cannabis use disorder in particular, usually does not occur in a vacuum. So there is ADHD or depression or anxiety, et cetera. And so the frustration that a patient may have when stimulant number two is not working or their antidepressant is not working, that is something that we need to seize upon in addressing the cannabis use. Hey, I know you're hoping for more out of your escitalopram, but when you're smoking every day, I just worry. I wonder if this may be holding your antidepressant back or your stimulant back. I think that's a critical discussion to have with a patient because again, they're not identifying their cannabis as a problem. Oftentimes they think it's a treatment, but at the end of the day, when they're not doing as well as they would like to, then that's an opportunity really to address all of the issues here, including their persistent cannabis use. And just wonder with them, might this be the thing that's really holding them back? Yeah, very, very good. Definitely important that you had mentioned that. Next question. How fast can withdrawal symptoms occur with cannabis? Can it be similar to nicotine within several hours if there's heavy use? I think certainly anxiety, restlessness, irritability can happen pretty quickly if people, and I think everyone's aware now, especially if you were at the session last week and today, that we have people who are using 80, 90 plus percent concentrates that they're smoking. So just like they're smoking it, so it's going straight into the bloodstream through the lungs within seconds is in the brain. So this is highly reinforcing, has immediate physiologic effects. And the same way you have this sort of intoxidrome or the onset of symptoms, not always, but that typically also predicts the offset. And part of what increases addictive liability is not only the acceleration or the slope of the curve in terms of the onset of the effects, but it's also the offsets. You look at cocaine or Adderall, which dissociates very quickly from the receptor, it's very different than other medications that might be physiologically active and they sit on the receptor, the activity kind of plateaus and then slowly decreases. So I think the point is with these more potent, especially smoked products, it could be very rapid that people have withdrawal symptoms. Sleep clearly is something that over a day or two, especially if someone stopped abruptly, would be problematic. So it depends on what the symptom is, but it could be certainly same day, next day. Okay, our last question. What would you say to a patient who wants to use CBD for relief of anxiety? I'll take that. I mean, that's a question that I often will address in a consultation. So every patient's different certainly, but I think it involves a thorough assessment of what they've already tried. So what might they have tried with their psychiatrist behaviorally or pharmacologically? And it's no secret, most people who come and are wondering about cannabidiol as a treatment for anxiety have not made multiple appropriate trials of behavioral and or medication treatments. But if they have, then again, we talk about the significant risks as I alluded to last week. And I'm willing to talk about that, the idea of using CBD as a treatment for treatment refractory anxiety. But I think it's crucial to point out that it's not a first line, it's not a second line treatment. So we have multiple medications and behavioral interventions that are effective for anxiety. Let's make sure that we've exhausted those first. Thank you, Dr. Hill for really stressing that point. Anybody else from the panel who wants to answer that? Okay, so we are at the end of our time for today's discussion. This event was made possible by the APA, Triple AP and the New York County Psychiatric Society. This is one of the many of the membership benefits of this organization. So thank you again to our speakers for today's presentation and to all of you for joining us live. Have a great rest of your day. Thank you.

Clearing the Smoke

Cannabis and Mental Health

Effects of cannabis on the developing brain

Treatment of cannabis use disorder

Psychiatric effects of cannabis use

Screening and assessing patients who use cannabis

Current state of research on cannabis

Thorough evaluation and treating comorbid conditions

Lack of research on cannabis and mental health