Adolescents and Cannabis Use: The Prescription for Addiction Webinar Series

[music playing- Signal Hill: The Dead Vineyard] Jordan Friend: Good morning everyone, or afternoon I guess it is I just wanted to welcome you all to our webinar today

My name is Jordan Friend, I'm with Office of Continuing Medical Education at the School of Medicine at the University of Nevada, Reno We've put together this program today with Join Together Northern Nevada and Nevada Statewide Coalition Partnership and Hazelden Betty Ford Foundation I wanted to show you today our CME accreditation and designation, and our continuing education credit policy today; so these are on this screen Our accreditation and designation information is here, as well as our disclosure information And I want to welcome our amazing speaker today, Paul Snyder who's going to be talking with us, we so appreciate your time, Paul

And I'm excited to hear what you have to say So, let's just get 'em started today Paul Snyder: Oh, thank you very much Jordan It's a pleasure to be back here with the medical school I want to thank a lot of people, Jeanne, her team, again, Jordan and Jennifer, Join Together Northern Nevada who's worked with Hazelden Betty Ford

Hazelden Betty Ford's my Alma Mater University of Nevada, School of Medicine and Sharon Levy from Harvard who put together the vignette We have a lot of information to cover here, there's a couple of poll questions to get started with And hopefully we can cover those through the presentation, if we can't then please feel free to contact me afterwards My information will be up there but hopefully there will be enough time so that we can get through some question and answers towards the end of this

We have a couple of things going on here, we have the vignette set up by Sharon Levy from Harvard And then we also have some, what I found was the need-to-knows that are most prevalent or the best, the most impactful information for a physician dealing with this subject, especially when we're working with adolescents The idea is, especially with an hour, not to tell you how to build the watch but just tell you what time it is and give you some snippets that you may be able to use in your practice So without further ado, [loud bell sound] we're going to start off with the vignette And it starts off with working with Doctor Kotay in his afternoon adolescent health clinic

He says 'Come with me to see my next patient, Jesse, looks like he's here for refills on his asthma and Attention Deficit Hyperactivity Disorder medication So, you look over Jesse's medical record He's 16 years old; he has asthma, exacerbated by exercise and seasonal allergies No prior hospitalization, no prior ER visits for exacerbation And ADHD, he was diagnosed in first grade and his intital medication was amphetamine salts

So, you see he's on Flovent, Albuterol, and Adderall and he's been on stable doses of these medications for the past three years, since he was first followed at this clinic He notes that no changes were made in the last clinic visits six months ago So, let's go to the next slide, we're meeting Jesse Jesse's sitting on the exam table and his mother's in the other chair You introduce yourself and you say 'You must be Jesse, and this must be your mother

' Here's Patricia She's upset because he knows that she's going to tell you that he got caught with marijuana at school again So, the doctor says something really good here, he says 'It sounds like things have been pretty complicated And he says it to Jesse, so he's already starting to build that alliance Turning to Patricia, Dr

Kotay says 'I'd like to talk to Jesse alone' Now, here he's building the ground rules Before I ask you to step out, I want to explain to the two of you, how I manage confidentiality So he's keeping everything transparent with both of these people 'Jesse, what you tell me will remain confidential, now here's the caveat, the limit is safety

So if i'm worried that you or someone else is in danger, I would need to share that with your mom Your mom already knows and is concerned about your marijuana use So we'll want to let her know, what the plan that we agree on, but I'm not going to share the details we discuss Do either of you have any questions?' Neither Jesse or his mother have any questions Now, we go into confidentiality and the rationale in building this alliance real quickly with the teen

So you give the teen the opportunity to speak confidentially And let him know that it's not absolute, that if there's going to be danger or hurt involved with somebody older or themselves or somebody younger you are a mandated reporter, you have to explain that And again, this is all your clinical judgment When you see the spectrum, generally speaking, Dr Levy is saying occasional alcohol or marijuana use in an older adolescent does not need to be reported to parents

That's up to you, that's clinical judgment The idea though is to gain the confidence of the young person and if you're going to disclose it, it's a good idea to be transparent with that In this case, Jesse's mother is already aware of his marijuana use and so confidentiality is easier to manage Dr Kotay assures Jessie that he will not discuss details with his mother so he will be more comfortable answering honestly

At the same time, he lets Jesse's mother know that she will be told the plan Now, we go into the history 'So, how are you holding up?' This is Dr Kotay and that can be a closed question or an open answer question Jesse chooses to look at it as closed and says 'Fine

' So here's where the good doctor continues to dive in 'She's really mad at me because I smoke marijuana, she doesn't understand it's the one thing that keeps me calm' So then, he asks 'Why do you think she's concerned about your marijuana use?' 'She thinks it's bad for me, I think she's overreacting I can control my use and it's really not a big deal for me Plus, it's the only thing that makes my ADHD better

' 'So why does your mom think marijuana is so unhealthy?' So the doctor's, right now, using the mother to deflect, to get the mother's view which is really the son's view 'She says it's bad for my brain, I've read a lot about it and I don't think it's a big deal My mom thinks I smoke a lot, more than I actually do It's not like I can get addicted to marijuana, right?' When we're going down to Who's Concern Is It? For many reasons, it's important to further explore the problems in adolescent reports Asking the adolescent what he or she believes the parent perceives as the problem is a good opportunity to learn more about what the adolescent himself is thinking

As children, we often project their own concerns onto a parent So, here's the question Jesse thinks that marijuana is helping him with his concentration So, marijuana helping with his concentration Which of the following have been associated with marijuana during adolescence? Choose all that apply

So, we have mental health disorders, loss of IQ points over time, improved concentration, and higher risk of addiction So what are your answers? So which of the following is associated with marijuana use during adolescent? Oh good! Nobody is saying improved concentration [inaudible] Okay Let's go down, see what the expert has to say

We're talking about the endocannabinoid system The endocannabinoid system's the largest system in the body It's the active ingredient in marijuana is tetrahydrocannabinol, that's THC, it's actually delta-9-tetrahydrocannabinol That's more important than the body's endogenous more potent, not important, it's potent than the body's endogenous ligands Over the past few decades marijuana has been selectively bred to increase the THC concentration When people use marijuana, they expose themself to a large amount to potent cannabinoids The endocannabinoid system is involved in many homeostatic processes including the regulation of anxiety, hunger, memory, and learning and others

Use of marijuana during adolescence has been associated with increase rates of mental health disorder, including anxiety, depression, and schizophrenia As well as a detriment in neurocognitive functioning as measured by declines in IQ score over time So, I'll just give you a little bit about that Right now, about the largest study that we have is from the New Zealand study And that tracked 1,000 people who smoked pot for 25 years

This is a big deal Tracking 25 years, 1,000 people and their ages were 13-38 and then they had a group that was their base line that didn't smoke pot And at the end of the day, they did IQ tests, they did all kinds of tests all the way through, but the IQ test showed that the pot smokers, or the people who are using marijuana had an 8-point less IQ score So, we know that IQ average is 100 And then there's a growth margin there of about 16 on either side

So, what we're looking with that 100, is can that person afford to lose 8 points That puts them in to 92-points for their IQ Which is still functional, however it's definitely not reaching their potential And when somebody comes to see me as an adolescent there's two things that they want to know 1) Am I in trouble?, and if they are then 2) Can you get me out? And then 2) Is have I done anything that will negatively impact me over time? Well, this test says that 'yes, it will impact you negatively especially with your cognitive functioning'

Of all these problems, going back to the vignette, all of these problems are more to likely to occur in individuals who use marijuana during their adolescence Use of psychoactive substances including marijuana can also cause the symptoms of ADHD Okay, so we're going to go into some slides I'm going to show you the endocanabanoid system, I'm going to show you the acts of the brain But I want you to think too about the risks with the PTSD guy, or people who say that they have ADHD or ADD

Can this possibly impact them more negatively than positively? Because their perception when they're high is not necessarily reality I'll give you an example I was doing a treatment group and I happened to have one of the managers and one of his employees in the group with me And the employee would say 'I was just an incredible worker while I was high I bet you didn't know when I was high and when I wasn't

And the manager said, 'Yeah, I knew you were high the majority of the time Because it took you so long to do the menial task, it was incredible how much time you wasted when you were concentrating on just putting the lettuce on the bun Now when you weren't high, you were lickety-split, you were really fast; however when you were high there was definitely a difference there' So, perception and reality can be two completely different things Okay, going back to the vignette

Some individuals will report that they feel that they can concentrate better after using marijuana This is likely related to changes in perception of the passage of time and impairment in ability to self-monitor While this may make an individual feel as if they improve concentration, in reality THC has been shown to cause performance deficits, not improvements, in tasks involving attention and impulse control Chronic cannabis use can result in loss of motivation, there's no evidence that cannabis or THC has a beneficial effect in the treatment of ADHD And then we're going back to addiction

Addiction refers to a loss of control over substance use and is a neurological condition resulting from changes in the brain's reward center known as the nucleus accumbens Marijuana effects the nucleus accumbens in the same way as other addictive substances So when we're looking at the release of dopamine from the nucleus accumbens we look at the ventral tegmental area, which tells the nucleus accumbens 'hey, this is important to me, this is good for my survival, this will make my life better' The nucleus accumbens then releases dopamine into the prefrontal cortex which says, 'I'm going to move forward with this activity' When we're talking about [inaudible] just to give you a baseline what we're talking about here with dopamine release

If you're looking at food you probably get a dopamine release around 50 When you're talking about sex it's around two and a quarter, that's the highest internal dopamine release we can receive; that's because of procreation, that's how we're set up biologically Marijuana can get into the 3-400s and other drugs can get in high than marijuana The deal is, the things that release dopamine in adolescents like playing basketball or getting a good grade or having friends or playing games or eating good food or hanging out with Mom and Dad That all takes energy and effort and so when we're talking about drugs that goes into a younger person's system, they're training their body that you don't really need any energy or effort to be involved to get this dopamine release

So, a lot of the time we're looking at with motivation or lack of motivation So back to the vignette, just as with alcohol, not every individual who uses marijuana will become addicted But the developing adolescent brain is particularly vulnerable to addiction The earlier the individual begins to use marijuana the more likely he or she is to develop an addiction So that was 'C'

The studies are showing that people who are young, adolescent one in six who started at a young age will become addicted Some individuals believe that marijuana is not addictive, because for many marijuana users the station is not associated with withdrawal This is because marijuana is liquid soluble and therefore remains in the body and it is slowly released from adipose tissue for a period of time after use has stopped Okay, so when we're looking at DSM 5, cannabis withdrawal what that looks like looks like irritability, anger or aggression I'm sorry, let me go back to this, I'll read the whole thing

Withdrawal sensation of cannabis use that has been heavy and prolonged Usually daily or almost daily over a period of at least a few months So then three or more of the following signs and symptoms developed within approximately one week after the use had stopped So irritability, anger or aggression, nervousness or anxiety, sleep difficulty decreased appetite or weight loss, restlessness, depressed mood and at least one of the following physical symptoms causing significant discomfort: abdominal pain, shakiness, tremors, sweating, fever, chills or headache, So, that's page 518 of the DSM 5, which 'withdrawal' is now a new component for the DSM 5 from the 4 Addiction is also called 'severe substance-use disorder', well, mild, moderate, or severe substance-use disorder

And it's defined by the diagnostic and statistical manual, there we go, DSM 5 The diagnosis of severe substance-use disorder is made when an individual meets six or more of the 11 criteria for substance-use disorder We'll go through those a little bit later Right now though we're going to go over to the slide show See if we can pop that up here

[whispers: There we go] Ha! Right on Jennifer, thank you, thank you Okay, so here we have anandamide, this is a brain's chemical Ananda means bliss or joy Here's THC and you can see the similarity in structure which allows the drug to be recognized by the body and to alter brain communication

Now here's the thing about anandamide, it's made to be resilient, it's made to be recycled, it's made to be very delicate, gentle, and fast THC, on the other hand, is kind of clunky, it's big and it attaches to those receptors and just has it's way with the receptors When we're looking at the receptor system, we have to look at the endocannabinoid system is the largest receptor system that we have in our body See all these light blue dots that are clusted in the brain, it's tough to see where one ends and where one begins? Those are all cannabinoid receptors, that's why marijuana has such a big impact on a person when they smoke Now, how do you know what a person's going to get? I give the example when I'm talking to students or people about

Okay, take an example You have three kids sitting on a bench and they're all smoking the same joint One's got the munchies, kind of giggly; the other one is just completely zoning out, slow reaction time, maybe dozing off and then the other one is really paranoid

Why do you have three completely different behaviors from smoking the same exact joint? Well, the idea is marijuana is a plant It has over 480 compounds, when those compounds are combusted that 480 becomes over 2,000 compounds So, now we have 2,000 compounds and they're impacting this system So you give a monkey 2,000 darts and you tell him to throw up against this wall and see where the darts going to land in the brain area And we're going to see what we get, so we'll take a little tour of the brain here

This is going back to one of the comments about 'does it impact adolescents for future days?' Well, if we're introducing a new chemical to the brain when someone is going through adolescences which is the developmental stage, we have to recognize where they are in development Now, we know that the brain grows and is built from the bottom to the top and from the back to the front So, the pre-frontal cortex, that executive functioning begins to mature around the age of 25 So, when we're looking at this neocortex level, all this gray matter, that's relatively new to the human experience Everything was set up for us in this limbic system, all the emotion, all the anx, all the drive that we have

This executive functioning came in a little later during our, during our development So when we're thinking about somebody who's young, an adolescent, and we wonder why do they act the way that they do? We have to think about where are they in their development? Now, a young male has a chemical that's surging through his veins and being produced at an incredible amount, that's called testosterone So, why does he get on top of a car and surf, why does he do the things that he does? He looks like an adult sometimes, but he certainly isn't acting like one And then we look at females and they have estrogen and progestogen, so they have their own kind of crazy So, they're trying to figure out how they can operate with all these chemicals that are being introduced to their body and this new growing body and that's a challenge in itself

And now, we're adding a drug to it which is actually impeding the executive functioning So, when we're looking at the brain, this is one of the slides that the younger people get most out of Because I can show them what's happening and if their friends are smoking pot, they can distinguish and they can see what area of the brain is being impacted For example, up here at the top, we'll just go from the top and then go around We already did the neocortex, now we'll look at the basal ganglia

Basal ganglia, my athletes are really interested in this area 'cause that's reaction time So, especially if they're on scholarship or they want to advance to the next level This is an important part of their future, so they want to protect this and not expose this to something that's going to slow down that reaction time Does it do it permanently? We don't know But do they want to take a chance with it even though it's temporary? Generally they say 'no'

Nucleus accumbens is next, this is a trouble-maker, this is the one that releases the dopamine and tells us that things are good or bad This is the stuff that can be fooled by THC The ventral tegmental area, that's way down in here And that's what goes into that nucleus accumbens But what if the prefrontal cortex is under construction? *gasp* Now we don't have a break

We don't have executive functioning to tell us 'Hey, this isn't a good idea I'm not going to go forward with this because I don't have an experience or I would rather go with the impulse that feels good right now and see what the consequences are And so we get adrenaline release, we get all kinds of good stuff going So, when we're looking at kids and we're looking at how they are impacted and we're adults or we're put in the 'helper' role, we have to recognize we're their surrogate prefrontal cortex We're the ones who they're coming for, not to be friends, but to give them good, honest advise about what damage they possibly are doing

And through the results of these tests, definitely are doing in their life and their potential Hypothalamus, when we look at the hypothalamus, that's eating and sexual behaviors So, this is our guy who has the munchies And don't forget if they have a choice between getting high or having something else, dopamine you can usually go that route; however, they're always willing to add something to get that high even higher So, when we're looking at these different appetites and different behaviors we have to recognize that in an adolescent's mind a lot of times the packaged deal is the way to go

We have amygdala, down deep in here This is for our friend who was paranoid Hippocampus, and when we overly sensitize the amygdala then we could have somebody who has consistent issues with panic and paranoia Now let's go back to the PTSD guy; his brain still operates too Let's say we inner pack that amygdala with THC and we're shutting down the prefrontal cortex so he doesn't have the executive functioning to slow down whatever impulse he has

And he's now manic or scared and he's going into his trauma survival mode Now we have a different problem, so we've just exposed someone with PTSD to an even more challenging life Hippocampus, this is for the person they say they can study or concentrate better That's from my artists and musicians, they like to talk about this As we know the hippocampus, is more of a filter

It tells us what not to remember as opposed to what to remember And so when they say it keeps them in the moment and it helps them be present; it does, however, they forget that moment If you have a question about that ask someone who's high to read a couple pages and recite what they just read back to you That's why TV is such an incredible babysitter for somebody who's high We have brain stem, spinal cord; this is the anti-nausea effect

And anti-nausea that's important for people who have AIDS/HIV Spinal cord, that's really important for pain This is being impacted as well and cerebellum, this is our emotions this is also our balance If you like you can have this slide and if you give them a quick tour of the brain, have them recognize what's being impacted negatively, tends to resonate with a lot of my patients Oh, here we go

FDA approved medical marijuana It's already out there, hold on a second, 'Marinol' that's been out for over 20 years But, why aren't we pushing Marinol? That's synthetic delta-9-tetrahydrocannabinol Here's a little aside, with the edible The delta-9-tetrahydrocannabinol is usually picked up in the screening tool by a by-product called 11-hydroxy 11-hydroxy is attached to this compound when it is being metabolized

This can be detected up to five weeks after the person's had it Usually, young people are interested in where their clearance time is Okay, so Marinol, indicated for the treatment of anorexia associated with weight loss in patients with AIDS Nausea and vomiting associated with cancer chemotherapy in patients who have failed to respond adequately to conventional antiemetic treatments So, this has been out for quite some time

But the message is that young Jesse's getting, and the message that society is giving is that, it's usually sales message and it's from somebody who wants to sell you something And the people who are really enjoying this are the people who want to get high So if we take out getting high or making money then marijuana tends to lose all of its appeal Here's a couple more, Sativex, this is in stage 3 trials Epidiolex, look up GW Pharmaceuticals, their stock has just gone crazy

Because they have a CBD-based drug recently created to treat certain forms of childhood epilepsy See, nobody wants to see a kid suffer, nobody wants to see a veteran with PTSD suffer These product are already out here and when people are saying [chuckles] here's a little something for you too Part of the marijuana campaign marketing techniques, because they can't do billboards, they can't advertise on TV, but they can get to be friends with newscasters and people who have their nightly TV shows So, they make friends with these people and then they do a nice, happy story, only giving basic biased reports that aren't scientifically researched And for example, I saw one where this guy in a white coat, I don't think he's a doctor But then, do you have to be a doctor to wear a white coat? They've kind of taken all of the respect and knowledge away from the doctor-physician profession and kind of making fun of it, which is insulting to me

I'll get you another story there, but the person is separating, he's working at this pot plant, and he's separating THC from CBD and they're making it sound like the CBD is going to be used for therapeutic effects But what they're doing is they're really interested in that THC because the more potent you can make that THC, the more valuable it becomes, and the more potent it becomes in any of those receptors that we just talked about So, we're talking about 75-90% more potent Now, this is completely different than the THC or pot that we used to smoke 30 years ago 30 years ago, the Mexican ragreed was nowhere near the drug that it is now

It was still a Schedule 1 controlled substance, but now, it's so potent that Mexico is not importing any more of their pot We have arguably the best pot in the world in Colorado [loud bell sound] We are now getting a new product from Mexico They've taken out their old pot plants and replaced them with poppies, so now we're getting a lot more black tar heroine So, the marijuana is already available if you want to go with CBD, THC to help those medical issues

Before recommending marijuana to a patient a physician should ask him or herself the following: has the patient had failure on all other conventional medications? has the patient misused marijuana or other psychoactive and addictive drugs? do you periodically provide drug testing of the patient who has been recommended marijuana and have patients been excluded from being recommended marijuana who are found to be using other illicit drugs? So, why are we doing drug testing? We're already recommending it; by the way, doctors can't prescribe, they can only recommend Just like banks can't take in the money, just like Walgreen's can't stock it in the pharmacy The idea of drug testing is to find out is the person kind of taking it? Because what if you give them a drug test and they're not taking it, however they got a new car In other words, they're selling it Have you carefully reviewed exactly which patients should be allowed to use this drug medicinally and for how long? That's the question and go over this with opioids

Two questions, what does success look like and what's our exit strategy? So, how long are we going to use this and, when do we get out and how do we get out? To experiment and try other healthful, therapeutic ways of helping that person If something is not working, let's try something else So, we got to examine and consistently follow up with the patients, exercise due care in assuring the standardization of the tetrahydrocannabinol potency content of the marijuana to be considered for medical use and whether it's free of microbial contaminants Oh yeah, how's this stuff being fertilized? We have no idea really what the strain is, what the fertilization is, how it's being packaged We don't know what's going into this and then people are ingesting it into their lungs

Here's a quick one, I go into a pot shop and I tell the guy, I just really want to get high, but I have a little bit of back pain And he says 'Oh, okay' and so he takes me over to this area and says this will take care of you 'Okay, well, my family also wants to get high with me and it's kind of a family thing We're going to go camping, what do you suggest?' Takes me over to this other area 'Here ya go' Then I say, 'Well, my dog's part of the family

What do you think over there?' 'Well, we really don't recommend for animals, however' and he starts showing me some edibles Here's somebody who is a sales person who just wants to move the product in the pot shop

He's diagnosed me, he's prescribed something for me he didn't do an examination, he doesn't have a medical degree, he didn't ask me how old my kids were, and when you involve the animals that's where a lot of complications happen We're giving a lot of these talks to veterinarians because they're seeing a spike in all the animals who are coming in due to ingesting marijuana Here's one of the problems, the availability In Colorado, there's more pot shops than there are McDonald's and Starbucks combined And that's in the future for us, if this continues to go and grow

And if a dog is eating it it's just like a person eating it If your smoking and you get too high, you can always put that out If you are ingesting it you got to let that metabolism go and you have no idea how long it's going to last or the impact that it's going to have So, playing Russian roulette Because marijuana is a federally controlled substance, has a system been established in the state to track all patients? Have you shown knowledge, training, or certification in addiction medicine? Do you have demonstrable knowledge of the psychological effects of marijuana, it's side effects and its interaction with other drugs before prescribing it? Here's what I thought was interesting

Now, this is from 2012, but this will show you the prevalence of this This is a Ted Said Treatment Episode Data Set and when we're looking at marijuana, you're seeing a large population here, 12-17 years old that's 429% of the 1,735 people who are coming in, the young guys, the adolescents Then we have 18-20 year-olds, that's 131% and 21-25 year-olds are that's 17

1% So we have over 70% of the adolescents coming in for treatment for marijuana Talking to Darryl Inaba, he wrote Uppers, Downers, All Arounders, he was a clinician over at Haight Ashbury back in the '70s He says there wasn't treatment available for marijuana, it just wasn't needed back then Now, it's the number 1 reason right here for treatment And treatment's when you go in and you take the person out of their life and start working with them in a cocoon, detox residential and monitor them

Now, here's what's interesting too, you look at 51-55 years old, it's less than one percent and it continues to go down after that And you think about who's making money off of this stuff and that's the age group that people are making money That's a 55-year-old, it takes about $250,000 to get into this marijuana business So, let's go back to the vignette Remember the vignette, [chuckles] took you on a little excursion there [chuckles]

So now we have more history So the good doctor's asking 'How long have you been smoking marijuana?' Jesse says 'I first tried it when I was 13, but I didn't really start using it regularly until last summer when the school year started, I really noticed it helped me with my ADHD much better than my prescribed medication' 'How much do you smoke now?' 'Not a lot, once a day after school' 'Have you ever had problems because of your marijuana use?' 'No' Interesting what his mom would think about that Okay, then the good doctor asks 'Tell me about the incident your mom was talking about

' So he said that very nicely 'The problem was the school and my mom The vice principle said he could smell marijuana so he searched my bag and found my pipe and bag of weed And he called my mom and she went nuts She didn't understand that marijuana is the only thing that helps me with school

' 'I don't know your mom very well, but it sounds like she really loves you and is very worried about you' 'Yeah, I know she's doing this because she loves me' There it is It's not uncommon for parents and children to become polarized regarding the use of marijuana Parents may feel angry and frustrated while kids feel parents are exaggerating and nagging

So, this is where the relationship changes between a parent and an adolescent Parents become more of a policeman or a punitive person and the kid starts to not only rebel but then also starts to avoid and hide from the parent It's often helpful to reframe the conversation and remind kids that their parents are acting out of love and concern So breakdown those barriers, let the kid know and let the kid verbalize that the parents are there for them And doing their job, just like kid's doing their job growing and being kind of crazy

Parents are doing their job being that surrogate prefrontal cortex and occasionally saying 'No, you can't do that' So, Dr Kotay [inaudible], slide 5 Dr Kotay asks Jesse, 'I see you need a refill on your asthma meds, how's your breathing lately?' He's saying it's a little bit worse, he's blaming it on the stress with his mom

'Have you noticed whether smoking has impacted your breathing?' 'Yeah I know smoking isn't great for my asthma, but it really helps with my concentration It's fine though I just use my inhaler more' So, multiple choice question: What can the good doctor tell Jesse about the relationship between smoking marijuana and asthma? Select all that apply

A) Marijuana smoking is associated with airway mucosal injury and inflammation that can trigger asthma symptoms B) At low levels of exposure smoking marijuana is not associated with decreased lung function C) Marijuana exposure is associated with short-term bronchodilation A, B, and C have been selected by the expert Looks like we all got 'A' correctly

I didn't put down 'B' simply because I didn't know what 'low-levels of exposure' meant If I see somebody smoking a cigarette, it's completely different than somebody who's smoking marijuana So, 'low-level of exposure', if you're smoking a cigarette it's usually a drag If they're smoking pot, I've seen them look like they don't have any more capacity in their lungs [chuckles-inaudible speech] And they hold that for a very long time So that didn't really make a lot of sense to me But smoking marijuana, goes on to say that the short-term effects of bronchodilation because marijuana is a dilator are long-term detrimental

C) Marijuana exposure is associated with short-term bronchodilation Now they go into a couple of different things when they're looking at smoking on asthma symptoms and effects on pulmonary function What I'm going to do, is I'm gonna go through this to the next slide, let you read through this It's pretty good information It might help you with your practice

So, diagnosis The doctor continues to talk with Jesse about his cannabis use eventually gathering the following descriptions So, when we're looking at DSM 5, you're looking at 11 different criteria If the person has met two to three of these criteria, he, at that point, has what's known as 'mild substance use disorder' If it's four or five of the criteria, it's 'moderate substance use disorder'

And if it's six or more he has 'severe substance use disorder' And remember, can't really label somebody after meeting the criteria there's a lot of things that go into getting this information One, we're looking at a snapshot of that person's life, we're looking at how safe is the environment where the person feels that they can trust the person We're looking at the skill of the clinician to gather this information We're looking at the honesty or the ability of the patient to relay this information

All of this under a snapshot of time that hopefully will give us a guide as to where we can begin so that we can change this diagnosis over time So the idea is that if they're hitting six or more of the criteria to bring them down to moderate and then to mild So, when we're looking at characteristics at Jesse's cannabis use, he deny's using more than he intends to He says he takes a hit or two and saves the rest to that it will last longer I remember him using everyday

Says he didn't use cannabis for three weeks while at camp over summer and did not have any cravings Cravings are a fun thing, very interesting, you don't know if they're gonna hit When I'm talking to people, if they're not craving at that moment, that's one thing However, had they had cravings in the last week, what do the cravings look like? Because the cravings will lead to a thought-process, the thought-process will lead to actual use And the cravings come from triggers, so if he was at camp while he was doing this geographic; he was away from maybe a lot of the triggers that he has at home which would change his though-process

Denies marijuana is problematic and has never thought about cutting down or quitting 'Yeah, I have a problem, it's you Mom' [chuckles] Has never driven under the influence or used when being impaired could result in danger Has one of his buddies driven while under the influence, and just because they haven't just smoked are they still under the influence even hours after they've [inaudible] He reports he has tolerance and no longer gets as high as when he first started using

Says that he spends a lot of time under the influence of cannabis for self-medication Acknowledges that smoking exacerbates his asthma which has lead him to quit both skateboarding and his school's ultimate Frisbee team Use of cannabis has clearly created recurrent problems with his mother and his school's administration So the good doctor sees him hitting five of the 11 criteria Puts him in moderate substance use disorder

Here they are, this is what an alcohol and drug counselor does This is one of the tests that they use and it kind of gives you the guidelines This could be good for you I don't really go with these formal, rigid verbiage I have more of a conversational way to get this information; so that I can get as clear and as true a picture as I possibly can

And again, the idea is to help the person not to be punitive and to hurt them Here's our summary, the good doctor summarizes what he heard from Jesse 'Jesse, it sounds like you really feel that marijuana is helping you pay attention better and you cannot image how you can concentrate without it You've heard that marijuana is bad for your brain development Clearly, there is tension between you and your mom and you feel that your asthma's getting worse

As your physician, I would recommend that you quit smoking for the sake of your health and your relationship with your mother' There you go, 'As your physician', as a person who's earned that white coat, going to medical school, has empirical knowledge that he is passing on, that he can give reliable information for this patient It might not be the most comfortable message, however that's the good physician's responsibility and Jesse will remember that as a young person Sometimes they push people just to get away with something or try to get away with something But, they'll remember the doctor who told them 'No, this isn't a good idea

' Now, Jesse is putting it in his own words, 'I know my mom wants me to quit, but marijuana really helps me concentrate' Oh, by the way a majority of people aren't going to their family practitioner to get marijuana they'll get it somewhere else, usually from somebody who will rubber stamp and get as many prescriptions as possible Or, in talking to a physician, what they do is they go over to a physician and say 'Hey, remember when I broke my arm three years ago? Can you dig up one of those x-rays for me? I just need it' [laughs] So they're having you do the work so that they can provide to somebody else who can prescribe that to them Er, recommend, they can't prescribe

'Okay, I agree with you that we need to figure out some way to help you with your ADHD I also think we need a better plan for managing your asthma I'd like to make some medication changes today What would you think about taking a break from marijuana for the next month so we can see if these medications are effective?' So there it is, that's the closer; and, he's having Jesse be accountable 'I guess

I've been thinking about taking a tolerance break anyway' So, a 'tolerance break' is so that he can get high faster if he goes back to smoking marijuana Doesn't really matter what real reason he's giving, he's just saying 'Yeah, I hear you and I'm willing to take your advice And I'm willing to do this' 'I'm glad that you're willing to try not smoking for a while, I'd like to share this plan with your mom and let her know that you've agreed to stop smoking for a while

What do you think?' And Jesse agrees So this goes on to talk about a 'tolerance break' and what a 'tolerance break means' 'Okay, Jesse did a really good job talking about his history and we've had a good conversation' The good doctor tells Patricia 'We agreed that we need to re-evaluate, so we're holding him accountable, his ADHD and asthma medications to see if we can control his symptoms better I asked Jesse if he would quit smoking for the next month and he agreed

I'd like to see him back in a month to see how everything is going' So, successful vignette by the good doctor Now I left out a couple moments here for some questions Hopefully we can get some in [silence] Friend: If you have any questions go ahead and write them in this general chatpod here at the bottom and Paul will read them and answer them for you

[silence] [continued silence] [continued silence] Snyder: Abstinence versus harm reduction? Harm reduction is an older term and that's a term that's used to keep the person high it's like a methadone clinic or make things more available for the person so that they continue to be high Abstinence would be after withdrawal Withdrawals are uncomfortable to witness If you've seen a heroine withdrawal, it's pretty nasty They're leaking from every pore in their body and they think they're going to die

However, they're not going to die, but you do want it medically monitored And one of the things that you could do is, you can introduce the medical procedures and some pharmaceuticals that will actually help them titrate down and avoid those real harsh symptoms, they're still going to feel nasty, but abstinence comes after the person withdrawals Harm reduction is usually to make things easier like a methadone clinic It's kind of harm reduction Here's the thing when I work with somebody, I want to work with them, I want to get them off the junk as soon as possible

That's what detox is for, that can take three days to a couple of weeks The idea though is that they're off of it and now we give them the coping skills that they need to deal with a life that hasn't changed at all 'Cause when we're looking at ways that addiction strikes, it first strikes spiritually, then hits emotionally, then mentally, then physically The healing process is exactly the opposite: it goes physical, mental, emotional, and then spiritual And then, the physical is the withdrawal, the mental comes back in a very short amount of time

The emotional is where we spend a lot of time working and we have to be able to get to that emotional level from those first two stages, mental and physical, before we can actually do some real work In a methadone clinic, I'm asking somebody about what does success look like and what's your exit strategy? And they said they were on a maintenance plan for five years Five years You could be an expert in any area after five years The way we calculate that is say there's 2,000 hours in a work week, takes 50 weeks a year, two for vacation

40 hours a week that's 2,000 hours multiply that by five that's five years and then, that's 10,000 hours That's one of the things that I ask my people to do when I ask them and they're having a difficult time rather deciding what they want to do with their life I asked them to project themselves out five years and then give themselves advice What do they need to do, where do they need to go, so that they can reap their rewards of their potential as opposed to stifling it And then, they have some motivation to go through those withdrawals which are uncomfortable

So, difference between abstinence and harm reduction One isn't using, one's continuing to use and is being enabled to be continued to use [silence] Friend: That is such good stuff you're offering today I'm gonna move us to this last slide 'cause we're about out of time today If you have any questions that you want to continue to talk with Paul about, just go ahead and write in the chatpod or send me an email and we'll make sure you get hooked up with him to get some answers

So, on this last page I want to direct you to our evaluation So that you can get your CME credit so go ahead and just browse to the evaluation link or copy and paste it in the pink over here You're just gonna fill out a quick evaluation online and then you will be taken to a page to get your certificate Again, thank you so much for being with us today and thank you Paul for that amazing lecture Snyder: Thank you

[silence] [continued silence] [continued silence] [low bell sound] [low bell sound]

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