Thank you for coming to our presentation. My name is Tiffany Benjamin. I'm a third year psychiatry resident. I'm here with my colleagues, and I'll allow them to introduce themselves. I'm Dr. Walea Aji-Shafei. I'm Dr. Kimberly Peoples. And we're representing Harvard University Hospital's Psychiatry Residency Program. Today, our presentation is entitled, Old Plans, New Leaves, Clinical Considerations in an Evolving Cannabis Landscape. So before we get started, we would like to have a pre-test assessment, just to see what everyone's opinions are to this particularly heated issue at this time. So if you can take out your cameras and scan this QRS code for us, I'll give everyone a little piece of information. So our first question is, regular marijuana use increases the risk of which psychiatric disorders? And our option choices were schizophrenia, anxiety disorder, depression, and all of the above. If our polls were working, you'd be able to see your opinions. But we're going to go over these questions at the end of our presentation. And so we're hoping that you are able to garner knowledge throughout the presentation, and we'll see what those answers are at the end. Hi, sir. The end is quiet, and the question comes up about multiple psychotic compounds. Right. We're having some difficulties with that. I'm sorry. So we're just going to just hold in the back of your mind the answers to these next three questions. OK. And now, what are the most effective pharmacological and or behavioral interventions for treating cannabis use disorder? And our option choices are jonavanol, synthetic endocannabinoid replacement therapy. We have combination therapy, which is a combination of CBT and motivational enhancement therapy. We have buspirone, and we also have naltrexone. And then finally, we have, what is a psychoactive compound found in cannabis? And it seems like this particular slide was working. And most persons chose delta-9-THC. And our other options were CBD, synthetic CB1 agonists, and 2-AG. And we have no financial disclosures. So for our objectives for our presentation is we hope you all gain an understanding of the distinction between cannabis and marijuana and the pharmacokinetics associated with the various routes of cannabis consumption. We also aim to identify the common co-occurring mental health disorders associated with cannabis use and explore future areas of study, as well as to increase the awareness of the discrepancies between the evidence for cannabis harm reduction models and popular perception. So for our case presentation, we have a 16-year-old male who lives with his sibling and is in the 12th grade with a past medical history of hypertension and a past psychiatric history of generalized anxiety disorder, major depressive disorder, and cannabis use disorder. He presents to the clinic for management of depression and anxiety. He had one previous suicide attempt a year ago and was hospitalized. He reports smoking three to four grams of resin hybrid and flowers daily, which started about four years ago. Also vapes nicotine, where he says one 5% nicotine salt vape lasts him a box a week. And occasionally, he drinks a glass of wine and tequila. He's currently prescribed fluoxetine, 60 milligrams daily, profenazine, 2 milligrams daily, and clonidine, 1 milligram daily. And he follows up with a therapist biweekly. So to highlight some of the key terms in this case, we have a patient who has a prior history of generalized anxiety disorder, major depressive disorder, and cannabis use disorder, retreating him for depression and anxiety. And he had one prior suicide attempt. Smokes about three to four grams of resin hybrid and flowers for four years and is also known to be vaping nicotine. One vape lasts him about a week, drinks wine and tequila on occasion, and is on a number of psychiatric medications and is seeing a therapist. So our plan for him was monthly medication management follow-ups. This patient refused to stop using cannabis, so we provided psychoeducation at each appointment he came to. And obviously, we obtained monthly urine drug tests to check his cannabinoid levels because we were checking to see if his symptoms of depression and anxiety changed based on the concentration of THC within his body. So for our results, the patient first started coming to us in July of last year. And he had a concentration of 345 nanograms per milliliter of carboxy-THC. In November, he had 128 nanograms per milliliter. And then in December, it was 290 nanograms per milliliter. And as I mentioned earlier, this was to track his depressive symptoms and his anxiety. From January of 2024, the patient was lost to follow-up. So for our first objective, it's the aim to understand the distinction between cannabis and marijuana and the pharmacokinetics associated with the various routes of cannabis consumption. And Dr. Adjisafe will tell you a bit more about this. Good afternoon, everyone. I'm Dr. Adjisafe again. I'm going to go ahead and continue here. All right, so cannabis is one of the most widely used illicit drugs globally. Its prevalence varies wildly across countries and regions. And according to the survey on drug use and health, it's about 41 million people age 12 and older reported using cannabis in the past year when a survey was done in 2019. And the survey also showed that 31.2 million people reported using cannabis in the past month. I'm sorry. Something is going on with my PowerPoint. It seems like part of it is showing and part is not. OK, there it is. OK. Now, OK, so I talked a little bit about the prevalence. But age of initiation, we know these days it seems like a lot of people start in their teenage years experimenting around age 12. And in terms of gender differences, historically it's been known that men use more cannabis. But in recent years, the gap has narrowed. And I think females are using more cannabis. And in terms of socioeconomic factors, studies have shown that more people of low socioeconomic background tend to use cannabis more frequently than people from high socioeconomic backgrounds. OK, so impact on health. I'm sorry. I'm so nervous. Oh my gosh. So OK, so it's widely known that cannabis is usually, it's known now that it's generally safe because it's legal. People can think because it's legal, it's beneficial. And it appears that, like, studies have shown that people who use more cannabis, they tend to, they have increased risk of harm if they use it more frequently. I'm going to let Dr. Benjamin talk a little bit about the impact on health. I just wanted to highlight that a little bit. All right, moving on. OK, so just reviewing the basics about cannabis and marijuana. So cannabis and marijuana is often used interchangeably. And does anybody know the difference in the audience? So cannabis is basically an umbrella term. It's sort of a broader term that encompasses all the plants belonging to the cannabis genus family. And an example would be cannabis sativa, indica, rhodoralis. And these plants contain various compounds, but the one that is common and the reason we're here today is THC and CBD. And THC is what's responsible for the psychoactive effect. And CBD is also used for therapeutic effect. Now, the term marijuana typically refers to cannabis plants that are specifically cultivated for their psychoactive properties. It's usually used recreationally. It's for the high, when it's consumed. It contains higher level of THC compared to other cannabis plants and is primarily used for recreational or medicinal purposes. And this is just an image showing that cannabis is just an umbrella term. And marijuana would be either a leaf or flower or stem from cannabis that's cultivated for recreational purposes. And how does cannabis affect the endocannabinoid system? So I'm going to go ahead and talk a little bit about the endocannabinoid system. And this comprises of the endogenous cannabinoids, which is the anandamide and the 2-AG, the exogenous cannabinoids, which is from the plant, which contains THC and CBD, and also the cannabinoid receptors CBD1 and CBD2. And just a little back history on this endocannabinoid system, 1960s is when THC was first identified. And it took several years after that before the endogenous target in our own body was found, which is the CBD1, which we know is one of the most abundant G protein couple receptor in the CNS. And also, I think several years later, and I believe that's in 1988 and 1990s, they discovered that our own body produces an endogenous ligand, which is the anandamide and the 2-AG. 2-AG, I wrote that down because it's hard to pronounce, 2-Arachidonoglycerol. But those are just the endogenous ligand that's produced that binds to CBD1 in our body. And subsequently, over years later, CBD2 was also found. But CBD1 is primarily found in CNS. CBD2 mostly in the immune cells. And as you can see in this slide over here, those are the CBD receptors. THC, which is the compound from plants, binds to the same receptor as the one that anandamide, our own endogenous ligand, binds. And so when that happens, signaling occurs, which can increase or decrease neurotransmitters in the CNS. And again, we do have a lot of CBD1 in several areas of the brain. For instance, in the hippocampus, which is responsible for our memory, people who overuse or abuse or are dependent on it may have memory issues. There was a study about the fact that students who get exposed to cannabis use very early in their teens tend to have less likelihood of going on to higher education. And so there's sort of a direct effect there for people who use it more frequently or excessively. Go on to the next slide. And this is just another slide just depicting that the brain chemical produced by our own endogenous ligand here is the anandamide. And as you can see, it looks very similar to the THC that's from the plant. They both bind to the CBD1 receptor. So while the CBD concentration have remained fairly consistent over the years, the concentration of THC has steadily increased over the past decade. And this is just showing the percentage of THC and CBD in cyst cannabis samples between 1995 and 2021. And in 1995, as you can see, the level here is like 3.96. And fast forward all the way to 2021, the amount of THC in the marijuana cyst is about 15.3. Also, it's important to note that like, you know, studies have also found that CBD influences the effect of THC, including just blunting the acute effect of THC without affecting the subjective perception of the intoxication and may influence arm. And again, as you can see in the cyst, in the cyst plant, you can see that the cannabis, the CBD level remains just about the same, even though THC level continues to increase over the years. So, I'm just going to briefly touch on different routes of administration. We have the inhalation route, smoking and vaporization, the non-inhalation route, the edibles, topicals and sublinguals, and synthetics. And that I'll mention a little bit about that later. And the synthetic ones are just, you know, just like our body produces an anamide, plants produces THC, some people can actually do this in the lab as well and get K2 and spice would be, or K2 or spice is an example of a synthetic one. So a smoking route, again, smoking delivers THC and CBD to the bloodstream via the lungs resulting in rapid onset of effect. Bioavailability is about 30 to 60% for THC. And the effect is typically felt almost immediately within minutes of inhalation and this is due to rapid absorption through the lungs. It peaks very quickly and declines very rapidly, typically lasting about one to three hours. So vaporization involves eating cannabis flower or concentrated extract at a low temperature than combustion, producing the vapor that's been inhaled. And it does come in various portable devices, there's a lot of fancy ones these days. Bioavailability for vaporizers is about 34 to 56% and onset generally very rapid as well, just like smoking, typically within minutes of inhalation. Effect lasts for a similar duration of time as smoking and peaks, occurs very quickly, subsiding within a few hours as well. All right, so cannabis infused edibles can include food, beverages containing THC and CBD. Again, ingestible cannabis would undergo metabolism in the liver resulting in delayed onset compared to smoking and vaping. Bioavailability for edibles is lower, 4 to 12% of THC due to metabolism in the liver and the effect of the edibles are delayed, again, compared to the smoking and vaping, which is about 30 minutes to two hours of onset. Duration of effect can last from four to eight hours. And so other not so common ones, the topical creams and lotions. So cannabis infused topical products such as the creams, lotions, balms are applied usually directly on the skin. They're primarily used for localized relief of pain and inflammation and for skin conditions. Rapid onset, so sublingual include tinctures and sprays and they have rapid onset bypass and first pass metabolism in the liver. Sublingual products offer precise dosing and are often used for medicinal purposes. And lastly, I just included a slide on synthetic cannabis, which is K2. Some of us may have experienced patients coming into the hospital with endorsing K2 use with alternative medication or negative adverse effects. But K2 is also known as spice. It is a cannabis product that typically consists of dried plant material sprayed with synthetic cannabinoids. The specific chemical used can vary widely and manufacturers frequently change the formulation to evade legal regulations. Synthetic cannabinoids carry significant health risks, including the potential for addiction, overdose, and can also cause adverse effects. And lastly, it's just a quick takeaway. It's just for clinicians, I know in clinical practice, we would often ask patients, do you use cannabis or do you use marijuana? Oftentimes, I write it as cannabis use disorder or marijuana use disorder. But I think for clinicians, we need to just understand that there is a difference between the two, although we do use the word interchangeably. And then marijuana is a cannabis product that's defined by the Controlled Substance Act as containing greater than 0.3% of THC. And again, the binder CBD1 receptor in the CNS, which is the most abundant between CBD1 and CBD2. And I'm going to go back and pass this over to Dr. Benjamin to continue, and she'll talk a little bit about mental health disorders associated with cannabis use and explore future areas of studies. So we're going to discuss a little bit about cannabis use disorder and how it reacts with other co-occurring mental health disorders. So cannabis use, they found amongst patients with schizophrenia, is associated with a more adverse course of their psychosis, as well as an increased risk of major depressive disorder. And we're going to discuss each of these in the future slides. So how does cannabis use affect depression? So the endocannabinoid system is responsible for a number of things. It regulates mood, it regulates condition, cognition, feeding behavior, pain perception, stress response, and inflammation. So what they found in mice models is that a hypoactive endocannabinoid system can contribute to depression. And studies have shown that regular use of cannabis results in about 1.5 fold increase in a major depressive episode compared to persons who don't regularly use cannabis. Other studies have also shown that cannabis, while used in adolescence frequently, tends to have a higher likelihood of these persons developing depression in their young adulthood. But interestingly, there was one particular research study that showed that low doses of cannabis tend to have anxiolytic and antidepressant properties, while higher doses are associated with more anxiety and depressive symptoms. So we can see cannabis wrecking, having a double-edged sword. Now what about cannabis use and bipolar disorder? There wasn't a lot of research that was found specifically for this particular mental illness. But what they did find in one particular study that's the most used substance for persons with bipolar disorder, and they estimated about 38% of persons who have bipolar disorder tend to abuse cannabis. And patients with a concurrent cannabis use disorder with a bipolar disorder are associated with earlier age of onset, as well as a greater annual number of manic depressive episodes. Of course, we need more research in this particular field. Now how does cannabis use affect psychosis? And I know there's a lot of information and perceptions and beliefs about this. But what certain studies have shown is that patients who have never tried cannabis are more likely to experience negative symptoms. Also they found that cannabis use is associated with an earlier onset of psychosis. And this is daily frequent use of cannabis I'm referring to. A multinational study was done, and they found that when they analyzed the data, that patients who use daily high-potency cannabis tended to have more positive symptoms in their first episode of psychosis. They found it was a dose-effect relationship with the dimensions of the symptoms in first episode psychotic patients, as well as dimensions of psychotic experiences in population controls. So psychotic experiences in non-clinical populations are associated with a current use of cannabis, but are independent of the extent of the lifetime exposure to cannabis. Also, interestingly enough, 50% of first episode psychosis patients who use cannabis experience a shorter time to relapse that results in hospital admissions and increase within the first two years of illness, with the risk increasing exponentially to about 80% by the eighth year. Systematic reviews and meta-analyses do not show a causal relationship between cannabis and psychosis. And in fact, they find that there's, in a meta-analysis study done, there was a bidirectional relationship between cannabis use and psychosis. One particular study examined how cannabis use during early adolescence affect the neuropsychological changes they saw in the brain. And it was found that it was associated with a reduced brain volume, as well as cortical thickness, along with neurofunctional changes, such as in the memory and learning. They also found that several of these brain regions were linked to the pathogenesis of a number of other psychotic disorders, like schizoid and schizophrenia. One study out of Ontario found that non-medical cannabis legalization, in particular when it was commercialized, resulted in increase in population level in cannabis-induced psychosis. They also checked to see if the number of ED visits increased, which they also found, due to the commercialization of cannabis. And of course, with this, we need to start looking at higher healthcare costs. So when we talk about legalization and changing in policies, we also need to make sure that we have the right data and see how is this going to affect our community and our population at large. Something else we need to consider is medical marijuana and its impact on severe mental illness. So a number of persons with severe mental illness have co-occurring medical disorders, and they use cannabis to treat a variety of issues, whether it's PTSD, or pain, seizures. Persons who have cancer use it to increase their appetite, and for a number of other reasons as well. And what we found is that the benefits of CBD tend to be emphasized compared to THC, because a number of persons report it decreases their anxiety, it makes them relax. But what really happens when you inhale or consume cannabis is that cortical dopamine tends to decrease, and that contributes to cognitive dulling. So that anxiety-reducing effect they have is really because of dopamine being reduced and not because of any other additional cause that has been brought to the forefront as yet, if so. So it's unclear whether cannabis affects the use of other substances with persons who have severe mental illness, so of course we need more research in this area. And what they found over time with persons with these medical illnesses as well as severe mental illness, they found worsening psychosis, they found an increase in anxiety, they found cognitive impairment, and also addiction. So some of the takeaway points from this is that cannabis use has been associated with an earlier onset of psychosis and an increase in annual manic-depressive episodes and anxiety. It's been associated with a reduction in brain volume and cortical thickness in adolescents, and prescription cannabinoids can result in acute psychosis or a prognosis of chronic psychosis or cognitive dulling in medical patients. So we're going to go on to our final objective, and this is to increase the awareness of the discrepancies between the evidence for cannabis harm reduction models as well as popular perception. Now this is my question to you, my audience. What is the public's perception of cannabis use? See, that's therapeutic, correct? Anything else? Cure for all. It's natural, right? What else? Anybody else? Cure for all. Cure for all. Healing of the nation. Some people, there's songs about that. Anything else people are thinking about with cannabis use? Or how it affects anything, whether it's mental illness or medical illnesses? What you've heard? Calming, calming, calming. Calming, helps. Hear someone say it helps them sleep. Anything else? If it's prescribed, it must be good. If it's prescribed, it must be good. Okay. Yeah. Great responses, thank you so much. So we're gonna talk a little bit more about this, and at the end, we can add on a little bit more if anything else comes to your mind. So what is the public's perception and societal attitudes towards this? So cannabis use is viewed differently across different cultures. So westernized cultures, Asian cultures, mainly use it for medical or recreational use. We talk about Rastafarianism, they use it as their sacraments. And, you know, different parts of the world use it either sometimes in food, they use it just for sleep. So it has a number of benefits based on the culture you are in. Now over time, we found that the perceptions have shifted. So as someone rightfully stated, that many consider cannabis benign compared to alcohol, tobacco, or other drugs. And predominantly what we've been seeing is because it doesn't have that dramatic withdrawal or intoxication effect some of these drugs do have. But what we also need to remember is that cannabis is absorbed in our adipocytes. So over time, as you are weaning off of it, there's a slow release. You don't have those shocking withdrawal symptoms that you would see in other substances. So it tends to gain a more favorable perception because it doesn't seem to jar anyone or have any overarching signs of intoxication. So what is contributing to this shift in perception from let's say early in the 1930s? So media coverage is huge, especially when we look at music. So jazz musicians like back in the days of Duke Ellington in the 90s and 30s to 40s would sing about cannabis or marijuana. And over time, that was leaked into hip hop music in the 70s and 80s. And then we see that prevalent in reggae music about the benefits of cannabis and it's calming and it's healing and has a number of great properties. We look at cannabis laws. We look at President Nixon. He was tough on the war on crime and the war on drugs. And this is like in the 70s going up to the 80s. We look at the political climate at the time. All of these are factors that are affecting how people tend to view cannabis. And finally, we're looking at the awareness of the potential medical benefits like so many of you have stated. So proponents of cannabis use argue that smoking cannabis provides relaxation, it's pleasurable, enhances the sense of well-being, contributes to stress relief, and many say it helps to deal with the hard realities of life. But let's talk a little bit about legalization and decriminalization of cannabis use. What are your views about legalization of it? Anybody? On the perceptible groups? Could you say a little bit more about that? Okay. And definitely research has shown that there is cognitive slowing in terms of response time with persons who are intoxicated with cannabis. So it definitely contributes to that not slowing down when the red light comes on. And we're going to talk a little bit of harm reduction. What are your concerns about medical marijuana? Mm-hmm, yeah, okay, sir in the red cap Well, I think it's. So there really wasn't much of, and I know regularly they would have a hash day, oh, the hash bash at the University of Michigan. You know, I think another thing is I was very concerned as to how this was Okay, so just so I'm going to repeat some of your statements so persons online can follow along. Okay. So, persons seem to have an array of opinions on this. Some persons are concerned about how widely accessible it is, especially to adolescents, especially in New York, especially with the changes that we're seeing in cortical volumes in the brain and cortical thickness. Other persons are saying, you know, the criminalization of it should be, was a problem because there are so many people being incarcerated. Others are saying that in terms of medical marijuana, they're a bit concerned because there are not enough guidelines towards prescribing it. Some persons are also stating that there are different routes of using cannabis and that is something that they like about it. And in terms of penalties of cannabis, you know, sometimes depending, I think it was in Michigan, sorry, you were saying they had a $5 penalty for using it. So is that really a consequence? People are concerned about, in terms of the legalization of it, are the number of road accidents that we all need to be taken account of because of the cognitive slowing with when someone is intoxicated with cannabis. Does anyone else have? Dr. Caldwell, go ahead. I was going to say, if you're talking about how the, you know, if you're talking about how the, you know, if you're talking about how the, you know, if you're talking about populations that are most harmed by Canada's policies are not the most prohibited from legalization. And then I think another issue, when you look at populations like Canada and how they have very strict rules about advertisement that we don't have here in America. You know, it's like me. You know, it's very geared towards the youth here in America, and that's legal, whereas in other countries, you don't see that at all. Right, so just to reiterate that, in terms of legalization of cannabis, minority groups are the ones who are affected by the mass incarceration. They're not experiencing any benefit from it, because these persons are still in prison. And Canada, they have strict regulations in terms of advertising substances, which we don't have in America, so that also shifts with population perception. Okay, I think the gentleman behind you, go ahead. Okay, go ahead, sir. Wow. So we're seeing a significant increase in 15- and 16-year-olds on water, on scooters. OK. So someone is saying in Canada there is no restriction between 15- and 16-year-olds using it, accessing it, riding scooters. So we're also worried about the likelihood of them getting into accidents. Yes? Is there behind you? Okay, to summarize what you're saying, is that since the legalization of marijuana, they found that number of arrests have decreased, and they are trying to use the money or the tax dollars from this to channel it into those subsections of the population that are most effective. But do you have, are you aware of any particular strategies or plans, how they plan to do this? Is it, like, what is going to be changed? Is it more education for these communities, or better schooling, or? Chairman of Sessions, myself, we probably should have all come to the microphone. I just forgot that it's being recorded. Okay. Also, you wanna get your money's worth if you buy the on-demand, where you can replay this. Well, I'm most familiar with Maryland, because that's the state I live in, and disclosure, the governor pointed me to the Cannabis Public Health Advisory Council, which tries to make recommendations how to implement the law. So that's why I know more about it. But other states do the same. States that have more recently legalized cannabis, as compared to some of the earlier states, like California, Washington State, Colorado, who legalized it 20 or more years ago. In my opinion, frankly, a lot of the motivation was tax money, same reason that states legalized gambling. But more recently, certainly in Maryland, it's been different. As I said, the law intentionally sets aside a certain proportion of the facility licenses, because frankly, there's a lot of money to be made in owning a cannabis dispenser or grower. I mean, I agree with what you said. A lot of the data show it's not the legalization per se, where the law passes, but whether you commercialize it or not, you know, allow private businesses, because I don't wanna get too far afield, come next Tuesday afternoon. But if you have private enterprise running it, just like the alcohol industry and tobacco industry, it's gonna be a national drive to maximize profits and not pay attention to public health, which we as physicians should be concerned about. Getting back to your question, though, as I said, there are complicated formulas in the law. One is setting aside a certain number of licenses for marginalized, both racially and in terms of socioeconomic status, people. You know, minority-owned businesses is one way they do that. And the other is to devote some of the tax money. One, some of it goes back to the counties to pay for substance use prevention and treatment, which is, in my opinion, speaking as a private person, not as a member of the council, underfunded in Maryland, as it is in most states, probably. And also for community development, and it's defined by neighborhoods, so it's neighborhoods with a certain proportion of the population below the poverty level or with limited education. I don't know the exact parameters. Okay, thank you. Thank you for sharing that. Let me just take one more before we move on. Go ahead, sir. Could you come to the mic, please? Thank you, appreciate it. So I'm curious how the massively increased potency of marijuana plants has impacted both risk and other aspects of use, because it's not the same plant that we grew up with in the 60s. I will say that. It's hundreds times more potent. And in New York City, particularly, you see you walk down every street and there's a lot of public use. Every street corner, every alleyway, whatever. And many of the people using it, as has been mentioned, are kids. And so I think the risk may be dramatically different for vulnerable populations with high potency drug. And I think also the, you know, you can grow your own, the illicit sources, and how essentially any drug like alcohol proof, alcohol proof is strictly monitored. Is there any kind of impetus in this direction in the legalization movement? And how also would it be controlled since illicit sources can make whatever they want? Yeah, thank you. Oh, and synthetic marijuana too, another problem, but. Yeah, thank you. Okay, so I can just provide a very quick observation I've seen to your first question. So on our consult service at Howard, we are seeing a number, an alarmingly increase in the number of young adults coming in with first onset psychosis by just using cannabis alone. No family history, no prior history of any kind of psychotic or mood disorders. And, you know, we are also have a number of question marks like could this be due to the potency of the cannabis, why this is the case? Of course, we look at genetics and everything else, but we are as well just as concerned. But we'll talk about this a little bit later. We still have a little ways to go, but thank you all so much for your participation. I really appreciate it. I think we had a very fruitful discussion just now about this. So like all of you suggested, if we are to legalize this and we were to appropriately go through the correct protocols of ensuring that businesses that capitalize on cannabis, we are ensuring that consumers are getting what they pay for than what they're getting off the corner of the street. We don't know what it's mixed with. If we get the right money, the taxes, we can allocate those right resources into funding appropriate programs for communities that are most affected by the mass incarceration or for even further research on cannabis use. And of course, decriminalization of it, whereas you said that arrests have decreased, there's still a sizable portion of underrepresented, I mean, sorry, underprivileged minority populations within the prison. And that's something we really need to look forward and seeing how policy can be changed to ensure that these families can be reunited or we have programs in place to ensure that recidivism is not as big of a problem as it is for many of these people. So this particular graph was done by the Pew Research Center of January, 2024. And it was just looking at US adults, what they say about marijuana use, about legalizing it. And what they found is that 88% of people suggested it should be legal for medical and recreational use. They found about 10% of persons saying it should not be legal at all. And around 32% said it should be legal for medical use only. And within that 88%, there are certain groups of people that were for it. They found Democrats more likely to be for the legalization compared to Republicans. They found younger persons, more than older persons, are more likely for the legalization of it as well. And like I said, there are a number of motivations and factors which go into people choosing to be on which side of the debate in terms of legalization of it. And now we're gonna have Dr. Peoples. So, education for children as well as parents. So getting it from a dispensary versus an unregulated source, Yeah, so just being able to trust what the dispensary says. Go ahead in the red. Oh, okay, so like using fentanyl strips for opioid use disorder. Okay, yes, educating them on when to stop using edibles and things like that. Right, so lack of regulation. So edibles are healthier than smoking right here. Accessible use of vapes, way in the back there. Okay, the source of the cannabis and where it's coming from. Okay, those are all harm reduction strategies. Those are good harm reduction strategies. So there was a 2022 systematic review and meta-analysis that looked at some harm reduction strategies and sort of graded them based on their evidence. So the first grade of conclusive evidence was based on many supportive good quality studies with no credible opposing findings and firm conclusions can be made. A grade of substantial evidence was based on supportive findings from good quality studies with few or no opposing findings. A grade of moderate evidence is based on supportive findings from several fair good quality studies with few or no opposing findings. A grade of limited evidence is based on findings from fair quality studies or mixed findings with most favoring the same conclusion. And a grade of no or insufficient, which would be the evidence is based on single poor quality studies, mixed findings, or even nonexistent. So these were some of the harm reduction strategies that they reviewed in their evidence that they assigned. And here it's important to point out that none of the strategies received a grade of conclusive. So it's difficult to apply these strategies in clinical practice with any certainty. The strategy that received the highest grade of substantial was to refrain from frequent or intensive use. And that just goes back to cutting the amount of cannabis use. It appears to be the one that we can apply in clinical practice with the most certainty. And since our case patient was an adolescent, I thought it would be important to review some of the things that are happening in school systems. So there was a 2024 randomized controlled trial conducted in Australia that looked at students between 16 and 19 years old. There were 950 participants randomized into a control group and an intervention group. The control group received health education as usual, and the intervention group received a three-class online intervention which aimed to teach young people the basics of neuroscience and practical strategies to help reduce substance use-related harm and promote self-help. And so what they found in that RCT was that students in the intervention group showed significantly lower annual growth in binge drinking, recent MDMA use, recent cocaine use, and prescription drug misuse during the trial. Evidence was limited in terms of yearly growth in cannabis and nicotine use. And the students in the intervention group also maintained higher levels of drug literacy knowledge, harm reduction, and help-seeking scores during the trial. So specifically as it relates to cannabis, evidence was limited, and they didn't give much about why that was or what limitations the study had, but they did show just an overall benefit in the harm reduction for substances as a whole. So takeaway points from the entire presentation. The concentration of THC and CBD in cannabis products has been increasing. Increased amounts of THC can worsen mood disorders and psychosis. Public perception of cannabis use varies, but generally there is less negative attitude towards cannabis use, lowered risk awareness, and increase in cannabis use. More evidence-based harm reduction strategies are needed to mitigate the adverse effects of cannabis use, and current risk awareness is not enough to prevent people from using cannabis. So I know our question poll wasn't working, so I'll go through some of the questions and the answers to these questions. So the first question, regular marijuana use increases the risk of which psychiatric disorders? So we have schizophrenia, anxiety disorder, depression, or all of the above. And the correct answer to this question was all of the above. And then the next question, what are the most effective pharmacological or behavioral interventions for treating cannabis use disorder? So the correct answer here would be combination behavioral therapy and motivational enhancement therapy. Okay. This, I don't, oh, it's showing there. It's not showing on mine. So what is the psychoactive compound found in cannabis? And you guys were correct when you said THC. So acknowledgments to these individuals who have worked tirelessly to help us with this presentation. And these are our resources, these are our references. And we'll take any questions from the audience. Okay. So we have a few questions from our online listeners. So I'm just going to repeat some of them. So this first question is, well, actually it says comment. It's not a question but a comment, that a drink made out of fresh cannabis has the effect of reducing the risk of cancer? And the answer is yes. It says comment. It's not a question but a comment, that a drink made out of fresh cannabis leaves consumed in parts of Pakistan causes acute delirium and the experience is quite frightening for the user. Most common symptom is feeling of drowning. User has no memory after they sober up. That's quite interesting. Thank you for sharing that. Okay. Go ahead, sir. Hi. My name is Hans de Haan. I'm from the Netherlands, which is a country which over the last 30 years, 40 years, has decriminalized use of cannabis and marijuana. We're still one of the richest countries in the world and one of the most productive. So on a larger scale, it hasn't really impacted our country as such. But it does have impacted certain specific groups. And I would advise you, Americans, American states, not to have illusions about legalizing marijuana and cannabis. The most important thing you could have done, and some states already have done, is decriminalize it because the criminalization of cannabis has, to a certain extent, ravaged already very, let's say, the minority groups who have already a very difficult life without criminalizing marijuana. So that would be step one. And I think that's very important because that will help and that will prevent all these difficult programs you try to make to have some advantages from selling marijuana legally. And that's the second point I would like to make. About four years ago, I went to this APA and I visited some introductions about legalization. And I'm actually a bit stunned because four years ago, the general tendency of especially psychiatrists was it's a very tricky business. And it can only have, I think, in my opinion, and I'm talking about a couple of decades of practice. In Holland, we haven't legalized marijuana and cannabis, but we have decriminalized possession of small quantities. At the same time, the production is illegal. Well, that's a paradox. So right now, they're trying to make a government-regulated production system which can, for instance, have an exact number of the quality of the product and which has the possibility of regulating it in production and in buying and selling it. So that gives at least a very strict and legalized system of production as an economic value. And I think that one should try to do it as strict as possible because otherwise, and that was something that was four years ago also a problem, is that, for instance, the tobacco industry will grab their chance of getting into the legalized marijuana and cannabis production, which they already have done in Oregon and in California, and they will have so much power to get regulations the way they like it because they can spend so much more money on lobbying, etc. So decriminalization is, I think, the main point in this whole situation and strict, very strict regulation the second. And then it is possible to have it. And by the way, we have all these programs about alcohol. Most of them don't work. The same will happen with the programs about marijuana and cannabis. So don't have that illusion, but regulate it and regulate it strictly. Thank you. Thank you for sharing those points. It's great to hear another country's perspective. Yes, sir. So I know that on the slide where you guys were talking about the levels of evidence for certain harm reduction strategies, the one with the most substantial evidence was decreasing regular intensive use. And I'm just curious, the level to which people have to decrease to see that benefit. Is it decreasing from daily use to once a week, or along those lines, if you guys could speak to that. So, yes, I didn't see any articles or research about what use would be critical. So I think there's still research needed to be done on that. So, yeah. I can just say a little bit more about that. So in clinical practice, oftentimes when you have, for example, a patient that uses daily, you know, I recently had a patient that uses daily for two years, and then said, oh, I'm going to take two weeks off so that I can do my work, and then I'm going to go back to it. And, you know, the advice was, you know, if you really do want to quit it or at least reduce the amount, we can, you know, make a plan, a long-term plan, and then just gradually reduce the frequency of use over time. That way, you know, you're not so dependent that you're not functional at work, and you have to take a, you know, sudden break, or cold turkey is the word, and just try to work and then go back to it. So, you know, I think the best thing is just encouraging them to, you know, reduce frequency. Okay. Could you say something about the latest evidence about the effects of using marijuana on the risks of using opiates and other drugs of abuse? I know it's a very complicated thing, but in terms of the effects and the associations of using marijuana on that. I know in the past there was a lot of discussion that cannabis is the gateway drug to a lot of opioid use, but what they have found, research is showing, that cannabis and opioids both tend to work in the same system pathways, like the prize reward, the dopamine pathway, and the cannabinoid system, so they're all intertwined. But as in to say specifically cannabis will contribute to you having an opiate use disorder, I have not seen any evidence of that during my research. But if anybody else has additional information and throwing it out to the crowd, we're all willing to listen. Okay. What about in terms of like cocaine use, stimulant use? Yeah, no other substances I've seen have been directly related to just using cannabis alone. But like I said before, the reward pathway is intertwined with a number of other substances depending on the receptors that they touch. So if you're using cannabis and you're also using opioids, persons are getting similar benefits from taking that. I did see one study that said that when you talk about withdrawal from those substances, cocaine and opioid use, that using cannabis in that instance was beneficial. Okay, thank you. All right. So we just have maybe about one more, two more questions from our online listeners. What would be considered heavy and frequent use and what would be considered moderate or minimal use? Are there any clear values? So this is pretty much the crux also of our presentation in terms of the various routes of administration and their bioavailability, whether it's smoking or edibles or just sublinguals. So it depends on what that person is using and how much. There are a number of other factors that go into play in determining what is considered appropriate use. So there haven't been any clear-cut guidelines or values, and that's what we're trying to aim towards with more research, what would be considered, if anything, safe use, depending on the route you're using to ingest it. And that basically is all the questions I have. Okay. All right, well, thank you all for participating and listening.

cannabis

marijuana

mental health

harm reduction

THC concentration

public perception

legalization

psychiatry

treatment plan

social justice

evidence-based