November 28, 2019

Quick Takes

Episode #7 – What all physicians need to know about cannabis use and how to talk to our patients about it

[Musical intro]

David Gratzer: Welcome to Quick Takes. I'm Dr. David Gratzer and I'm talking today with Dr. Leslie Buckley, who is Chief of the Addiction's Division here at CAMH and also an Assistant Professor at the University of Toronto. Welcome, Dr. Buckley.

 

Leslie Buckley: Thank you for having me, David.

David Gratzer: So, we're at the one-year anniversary, roughly, of the legalization of recreational cannabis. And of course, recently there's been the legalization of edibles. What are your thoughts?

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Leslie Buckley: So, it has been one year of this, somewhat of an experiment. And now edibles are legal, but they're not quite on the market because there will be a lag of a couple of months while people are actually proposing what their product will be and actually getting them on the shelves.

David Gratzer: Bit of an experiment. Dr. Buckley, do you think this is a game changer?

Leslie Buckley: I think that it will have an impact. And, of course, we'll be able to use statistics to see what that impact will be. I think there've been a few game changers. I think the medicalization of marijuana will have a significant impact as well.

David Gratzer: Well, let's pick up on that point. You know, I was in the emergency department the other day seeing a patient, and he spoke pretty frankly. He said that the only thing that seems to help him out is medical cannabis. And he emphasized that it's medical. He suggested it helped him with his mood and his anxiety and suggested that, in fact, more conventional treatments like Sertraline and other drugs weren't that helpful.

Leslie Buckley: I think that's a common response. And there was a recent Lancet article in the past month that was looking at the effectiveness of cannabis or cannabis products on mood, anxiety, and PTSD. Now that Venn analysis came out negative for all of those different areas. But actually, the second most common reason that people use medical cannabis is for psychiatric diagnoses. So even though there isn't a lot of evidence for it, it's very common for people to be prescribed medicinal cannabis for their mood disorder or their anxiety disorder.

David Gratzer: So there's not much evidence. Is there evidence that it might, in fact, be harmful over a long term?

Leslie Buckley: Definitely we have concerns about that. We know that there's a high correlation between substance use with all of our major psychiatric diagnoses and, generally, it has negative impact on mood almost across the substances.

David Gratzer: We as clinicians face this all the time where we've somebody in front of us saying that, in fact, it is helpful. This gentleman insisted it was the only thing that worked with his panic. On the other hand, there's perilously little evidence. What would you say to a patient like this?

Leslie Buckley: I think this is such a common situation. And sometimes it's someone that you've known well for a long time, and sometimes someone new that you've seen in the emergency room. And usually you get a bit of an idea right away where this person sits – if they're really, really strongly tied to their cannabis or not – as soon as you start talking to them about it. And, of course, in the realm of addictions, when we're trying to think about changing behaviour, we always think about motivational interviewing. So, that's something you could consider even in the emergency room, having an intervention that might really push a little further to see if you can move this person at all, in terms of their use or even their perception of their use.

David Gratzer: What are some core principles of motivational interviewing?

Leslie Buckley: One of the most important things to think about when you are doing motivational interviewing is autonomy. That was probably the biggest change when motivational interviewing came out in the ‘80s. And the principle is that somebody likes to feel part of the team, not really told what to do. So as a person who's working with somebody in motivational interviewing, you're thinking about their autonomy, you're thinking about their reasons for use. Somebody is going to change because of the reasons that they think they should change, not the reasons that their physician thinks. So, it's really you trying to pull out of somebody the reasons that they might want to change – and trying to build discrepancy. The discrepancy is between the way things are now, and the way things could be.

David Gratzer: Let's go back to this gentleman sitting in front of me in the E.D. a couple of weeks ago. How could one apply that principle?

Leslie Buckley: I think you've just hit on what's so difficult for us in addictions. We have a lot of people who might be coming to speak to us about a different substance and don't want to touch their cannabis. And we're thinking that we want to talk to them about their cannabis. But certainly, there are a lot of people who just are not ready to entertain the thought of stopping their cannabis. So, it makes it difficult to do motivational interviewing with somebody when you might have two completely different ideas about what a substance is doing to them. It could be if, David, if I said to you: “I think you should do your outpatient afternoon clinic (even if you don't do one) tomorrow.” And I forget to mention that there's going to be a snowstorm of the decade tomorrow. If we're not sharing the same information, then we might not really be able to move forward with motivational interviewing as sort of a collaborative pair. So maybe before we get to motivational interviewing, we have to do some psycho education. So, really, cannabis is different than all the other substances because when somebody is talking about their alcohol, usually it's fairly clear what the consequences are. Maybe it gets clearer as you talk with someone longer and you might even provide some thoughts about what could be going wrong or what could be a consequence. Opioids, cocaine – usually people really can see their consequences. But with cannabis, it's much harder.

David Gratzer: Why is that?

Leslie Buckley: I think it's partly because of the way media has picked up. I think it's because of the medicalization. A lot of people, I think, really do believe and hear there's printed material out there that cannabis helps. So, I think that it's not surprising that people think that cannabis is helping them.

David Gratzer: What might you say in terms of psycho education? What might be some quick things you might say in an E.D. or an outpatient clinic?

Leslie Buckley: One of the first things I talk about is that sometimes substances can be tricky. When you start out with a substance, especially if you're just using it occasionally, you might actually feel like your mood gets better (at least when you're intoxicated), or maybe it takes away some of your worries. And that's really part of the trap of substance use disorders: first you don't really have any consequences, but as time goes by things change. So somebody who you're working with might have felt really differently, or might have had a different impact from their substances, when they were younger. I'll tell somebody that it may have changed without you realizing it. There's a certain point where the substance doesn't give you as much. And, without knowing it, it might be taking more away from your mood, from your motivation, and you might be much more negatively impacted than you realize.

David Gratzer: So, we're doing some psycho education. You're emphasizing more medium-term, long-term consequences. Say we do get that discrepancy. How might you apply motivational interviewing then?

Leslie Buckley: It's also very important to talk about self-efficacy when you're doing motivational interviewing. Helping somebody to believe and have the confidence that they can make a change. Sometimes I'll bring up a real case that I've seen (of course without a lot of information) so the person isn't identifiable. But I might say, “I had somebody recently in here last month who was really unsure about making a change and then decided to try to stop and it had a really big impact.” And I'll say this person really did not think that cannabis was harming them, but it can make a huge difference.

David Gratzer: What sort of goals are you looking for in that first contact?

Leslie Buckley: You want to open the person up to the idea that maybe their perceptions of cannabis may not be correct, that maybe it's not helping their mood – which may be a significant change. That might happen in one day. That could happen, over a few appointments. You can also provide information or encourage someone to read some web pages that provide accurate information. And then you might want to introduce the idea of an experiment. So, when you're thinking of making a change, it's really, really hard to imagine changing, especially when things are hard. That's another major point of motivational interviewing: that it's not easy to change. And people have a lot of hesitancy for change. Part of the work that you're doing with somebody is trying to help them move past that and feel more comfortable with even just the thought of change. Sometimes if you package a change as an experiment, it might seem a lot less overwhelming.

David Gratzer: Breaking it down to something much more manageable.

Leslie Buckley: Yes.

Leslie Buckley: It's also helpful to think about empathy and summarizing somebody's experience. So, you could say something like: "You know, you've worked really hard in a lot of ways." You could talk a little bit about their life and some of the things that have happened in their life that [show that] they have been resilient. You can talk about their strengths, you can say: "[You have] wonderful interpersonal abilities, you have supports. You may not be where you want to be in your career, but you're working now." You're just pulling things out from their life and saying it's probably very important for you to know if cannabis is bringing you down – or not.

David Gratzer: Right.

Leslie Buckley: And, really, there's only one way to know. And that's to try a period of two weeks or so where you're abstinent. You can pick the two weeks that you want, try to make it a doable time when there might not be a special event or something that might be difficult to get around, and just see how you are. Usually after two weeks, somebody is starting to feel much better. And then you can make a decision based on real knowledge about what's best for you.

David Gratzer: Sure. And just to shift back then to real-world examples. Can you think of somebody you've been successful working with, and what might have made it successful?

Leslie Buckley: I'm thinking about an emerg. shift I had, maybe a year and half ago. I had two patients who were young and who were using cannabis on a regular basis. One was in for mood and having had a suicide attempt. And, you know, I probably spent two hours with him. His partner was there. We talked a lot. He really, really walked through the consequences. He was very realistic. And his girlfriend was very supportive about him not smoking. And I could really see a transformation and a big shift.

Leslie Buckley: Now that same shift I saw another young male who was about the same age who was having psychotic symptoms. And he also was very willing to talk about consequences and about his use. He did not have a supportive partner. And you know, when we when we talked about a plan, and we talked about his motivation, he seemed motivated. But I could just see that it was different. When we talked about how he was going to cut down he said, “You know, I think I'll only use cannabis socially and when I'm playing video games.” But he played video games every day. So, I knew that it had not worked. I knew it had not really worked the same way with the second person. I think it could be partly because of that psychotic phenomenon and differences in cognition.

David Gratzer: To shift gears for a moment, we've emphasized motivational interviewing in our conversation. Is there any evidence for prescription drugs to help with cannabis use disorder?

Leslie Buckley: So, there's nothing approved at this time. There is research that's happening, looking at whether Gabapentin works. There's a dietary supplement.

David Gratzer: Do you prescribe anything?

Leslie Buckley: No.

David Gratzer: Though, obviously, there's evidence for treating co-morbid conditions so if somebody has a panic disorder.

Leslie Buckley: Absolutely. And never forget insomnia. One of the toughest things during withdrawal from cannabis is insomnia. So, if you can provide sleep medication for that time, and maybe carrying on, depending on if it resolves or not, that can be a really big help.

David Gratzer: You've spoken about cannabis and you're not really distinguishing, I gather, between THC and CBD.

Leslie Buckley: Yes. I'm glad you asked that because that is really important. And I know it's hard for a lot of people to know the difference. So, they're very, very different. THC is the component of cannabis that is psychoactive and it's the part that is the cause of dependence and use disorders. It has increased in recreational cannabis from 4 percent over the last couple of decades to 15 percent. THC is very high in recreational cannabis and any cannabis that you would also buy in a store. It is the substance that we're most concerned about versus CBD. CBD actually may counteract the THC. And there are no significant findings in terms of it being psychoactive in a way that is rewarding – so it doesn't really create addiction.

David Gratzer: So, they're different. Is CBD helpful? I mean, one sees it now in dog treats, there's a hamburger Martha Stewart endorses that has CBD oil in it. I mean, it seems to be something of a panacea for all problems in all circumstance.

Leslie Buckley: So, it might be helpful. Again, we're waiting for research to really identify whether it is. I'm not worried about my patients taking CBD at this time.

David Gratzer: Though a lot of supplements and so on, actually have a mixture. So it will say that it has CBD oil, but in fact, may have some THC. And that might be more concerning because that THC component at least is established to be addictive.

Leslie Buckley: That's right. And bringing this topic up, it leads us to the conversation about THC in edibles and THC in beverages, and how it’s important for us to think about it, and talk about it, with our patients. Edibles are becoming more popular over time, and then, obviously, when they're legalized and products are out that are legalized, it will probably increase even more. A lot of people want to avoid the smoking of cannabis because of the smoking-related harms. But there are some concerns about edibles as well.

David Gratzer: Such as?

Leslie Buckley: So, when you're taking an edible, it takes one-and-a-half to two hours to get the impact, to feel different. Versus smoking, which is about 10 minutes. So, the worry that we have is that people will be waiting for that response, and that feeling, and it doesn't come. So – they take more. You're really not getting the peak effect for four hours with an edible so people might be loading up to some degree. Edibles come as gummy bears and chocolates. And sometimes the appropriate dose, which is the amount that somebody might want to take, could be just a tiny corner of a piece of chocolate, like a chocolate square. And people have to be really aware that they might just feel like eating more ‘sweet.’ So, it's really worrisome in that way that people might overdo it. And while they're waiting for the substance to sort of have its impact. It also means that driving is more complicated for someone using edibles. So really eight to 12 hours until that edible is really reduced in in someone's system versus smoking, which would be more like four hours.

 

David Gratzer: Dr. Buckley, it's something of a Quick Takes tradition that we close with a minute's worth of questions. Our rapid-fire minute.

Leslie Buckley: Great.

David Gratzer: Are you ready?

Leslie Buckley: Yes.

David Gratzer: OK. We'll put a minute on the clock. Here we go. First things first: legalization. Was this a mistake?

Leslie Buckley: I think it's about how we do it. I think we need to increase the age of use to 21. And I think we should be careful with edibles.

David Gratzer: And you think there's more use today?

Leslie Buckley: Yes.

David Gratzer: Can you give us stats?

Leslie Buckley: So, the high school survey that CAMH does [OSDUHS] shows that 37 percent of grade 12's are using cannabis. StatsCan says that 34 percent of 20–24 year-olds are using cannabis. Those numbers seem high.

David Gratzer: Does that keep you up late at night?

Leslie Buckley: It does.

David Gratzer: What one piece of advice would you give to all clinicians about cannabis use?

Leslie Buckley: I would suggest that people try to have that long conversation with them about their use and make sure that they know the harms. Because I feel like most people don't.

David Gratzer: One tip on motivational interviewing.

Leslie Buckley: Understand why it's so difficult for someone to change.

David Gratzer: And that's our time. Thank you, Dr. Buckley.

Leslie Buckley: Thank you very much for having me.

David Gratzer: And that concludes our podcast. If you're interested in more information on cannabis, in particularly a role-play and practical tips on motivational interviewing, check-out our Double Takes, which is a further conversation with Dr. Buckley.

Thanks for joining us.

Outro: Quick Takes is a production of the Center for Addiction and Mental Health. You can find links to the relevant content mentioned in the show and accessible transcripts of all the episodes we produce online at porticonetwork.ca/web/podcasts. If you like what we're doing here, please subscribe. Until next time.

November 28, 2019

Double Take: Motivational interviewing for anxiety-related cannabis use (A role-play)

[Musical intro]

David Gratzer: Welcome to Double Take where we’re going to talk further with Dr. Buckley about cannabis, cannabis legalization and the implications for your clinical work.
Dr. Buckley, let's talk about motivational interviewing and, maybe for a few moments, let's do some role-play. I can play the role of a patient. Perhaps you can walk us through some things you might do in terms of incorporating motivational interviewing principles into practice. Fair?

Leslie Buckley: Sounds great.

David Gratzer: Sure. So, let's talk about a 25-year-old gentleman seen, again, in the emergency department. History of panic disorder. Presents, maybe, a little bit unsure if this is the best treatment, but also unsure that he wants to go off of cannabis because it's proven helpful.

Leslie Buckley: Right. So, it's great that he's already a little bit ambivalent. He may as I said, he may not know all of the harms of use. So, you would want to go over that with him.

David Gratzer: So let's role-play. Why don't you give us some questions?

Leslie Buckley: So, you're him?

David Gratzer: I'm him, for now.

Leslie Buckley: So, David, how long have you been using cannabis?

David Gratzer: Well, you know, probably a few years now. I mean, if I think back, I started smoking a bit behind the arena back in high school and I'm probably using it more now. Well, truthfully, I am using it more now.

Leslie Buckley: And what was your anxiety like when you were in high school before use came in into the picture?

David Gratzer: It was bad. You know, I was the sort of kid who liked to do things with others, but hesitated. I always wanted to go to socials and parties, but it was really anxiety provoking. I remember before I started regularly using pot, I remember sitting in a car, having driven over to a party and just sitting there for two hours working up the courage. It's weird because everyone I knew in the party was my friend and there was no pressure on me. Yet, I just I just felt so judged when I'd walk into those parties and I'd smoke a joint or two and suddenly I could be me.

Leslie Buckley: That sounds so tough. Did anybody ever help you with that? Did you ever reach out to anyone to get some help with the anxiety?

David Gratzer: I was too embarrassed to talk about this. I mean, the one thing I discovered was if I went into a party and had a couple of drinks, I felt better. But then I'd be hung over the next day. And the pot I'd heard was medicinal, and I'd heard was helpful, and I tried it and it was. I never got a hangover and never threw up when I did a lot of pot (sometimes I ate too many Doritos) but that was about it. So, what do you think?

Leslie Buckley: And what about people in your social circle? Do you feel like a lot of other people around you are smoking as well?

David Gratzer: Well, now that I'm in university, I think a lot of people use pot. Not everyone, but certainly around parties. It's not uncommon for me to go.

Leslie Buckley: And are you ever using it when you're alone?

David Gratzer: Sometimes.

Leslie Buckley: And do you ever feel like if you don't use it and you feel badly? Like if you feel withdrawal symptoms or just not yourself?

David Gratzer: I've never gotten any withdrawal symptoms, but I do get some more anxiety. So, again, I feel pretty good when I use the pot. I can go to parties; I can give presentations in class. Maybe I'm not as sharp as I usually am, but boy, if I don't use it, I've got the panic.

Leslie Buckley: And what's the most amount of time you've had away from it? If you think about it from when you've been using regularly? Have you ever had a couple of weeks when you haven't had any pot on board?

David Gratzer: Boy, at this point in time, I think I'm just always using it. I mean, it's part of my life. I use it to help me with sleep – now that you mention it. I use it before class presentations. I use it before parties. At this point, I'm probably using it at least daily.

Leslie Buckley: And what's the downside? Is there anything?

David Gratzer: It's costing me a lot of money. I think sometimes I smell because I'm smoking. It can't possibly be healthy long-term to be smoking something – though it's not cigarettes.

Leslie Buckley: How's your function? Do you feel like you're functioning as highly as you could?

David Gratzer: No. I mean, when I smoke before a presentation I'm not as sharp. I know I messed up recently at an English presentation. I was kind of off. I was kind of, frankly, giggly. People thought I'd done something.

Leslie Buckley: And how about irritability? Do you feel like you are lashing out at people? That you're not yourself?

David Gratzer: I've had friends who've had that problem, but personally, I've not.

Leslie Buckley: That's not you. Ok. And would you ever consider, you know, actually having treatment from a psychiatrist for anxiety and maybe considering a medication or some of our therapeutic tools?

David Gratzer: So, my partner told me I should seek out care. Truthfully, I had briefly seen a family doctor. I tried an antidepressant. I thought it actually made my anxiety worse. And I also thought they'd prescribed a drug real fast. I would have liked to maybe explore other things.

Leslie Buckley: Right, because, you know, things have changed. Years have passed since you first started using. And it would be really interesting to see what your baseline anxiety is now because it could have changed over this time. It could be better. It could be just the same as it was.

David Gratzer: So, I worry about that. Though, like if I go cold turkey or something, am I going to have more panic? And I'm coming up on midterms.

Leslie Buckley: Well, this might not be the best time to do it. What we might want to do is set up a follow-up appointment when your midterms are over, when you feel like it's the right time for you. So, let's say in three weeks or so and maybe talk about making a change at that time. Maybe even trying to try an experiment of two weeks or so without any use at all and see how you are. And maybe try some medications, try to help you sleep better. We could even introduce some medications during your withdrawal if you feel like the anxiety really is creeping up.

David Gratzer: I like this idea of two weeks because I'm pretty hesitant on making a big long-term commitment, especially if I don't know about the anxiety.

Leslie Buckley: Well, I think that's great! There's been a lot of things that you've been able to do. If you look back right, you've been able to push through a lot of anxiety in your life, you've achieved, you're in school, you're doing well. You have supports around you. So, you've been able to accomplish a lot. I think it would be really worthwhile for you to find out whether the cannabis is helping you or hurting you. And if you take these two weeks, and you do feel better, then it's maybe something that you might want to continue.

David Gratzer: Let's pause right here. Let me step out of my role as a 25-year-old cannabis user with a full head of hair. What principles are you using right now in terms of engagement?

Leslie Buckley: So, certainly autonomy. I'm really thinking about you and I'm trying to see everything from your perspective, and I want to know what's important to you, why you want to change. I'm thinking about discrepancy. And, also, your hesitancy. You are not sure how things are going to get better. Sometimes with alcohol or cannabis or, sorry, or cocaine, people really believe that things will be better, and they can imagine that future. But with cannabis, and your character, you weren't sure, so I was trying to create that possibility for you. to think that it could be better. And if it's not, that's okay. At least, you know, there's still a reward, there's still a gain. And you would leave that experiment knowing more than you did before.

David Gratzer: And what's a pitfall here? With clinicians trying to do this motivational interviewing, exploring this discrepancy. What's a rookie error?

Leslie Buckley: Probably the biggest rookie error is feeling too strongly about it. And with all the knowledge someone might have gained about substance use and harms, and maybe even a strong opinion about cannabis, we could come on too strong and push too much and maybe turn somebody off. Maybe he wouldn't come back in three weeks. So, it could've been a mistake that I told you to come back in three weeks. Maybe I should have taken this opportunity while you're motivated and you're here with me to try that experiment.

David Gratzer: And just to jump ahead, if we were to keep going with a role-play, what are some things that you'd want to do before the end of the session?

Leslie Buckley: I would want to talk about withdrawal. I would want to give a lot of information about how someone might feel. So, nausea, vomiting, could have irritability, sleep problems, and maybe talk about sleep meds if needed. And I would want to talk about concerns and triggers that this person is worried about in that two weeks. I'd want to talk about structuring the two weeks and really thinking about things to do and planning events to keep, you know, sort of some distractions there. And I'd want to talk about safe things to do when there might be a craving. So if we had time, we would walk through what it's like to have a craving, how to ride through a craving, an alternative or soothing things that work for that young man, because things that work for me might not work for him.

David Gratzer: So, it's a personalized plan.

Leslie Buckley: Yes.

David Gratzer: Sleep medications. What are some medications you may choose?

Leslie Buckley: So, in addictions, we almost always use Trazodone because it's just the least addictive of the sleep meds.

David Gratzer: That's right. So, that's an old antidepressant. You're using it at a low dosing like 29, (Leslie Buckley: 50 mg) 50. And if the patient suggests that Trazodone isn't hopeful, what might one consider otherwise?

Leslie Buckley: You know, I probably wouldn't use a benzo because I actually never prescribe them unless somebody is already on them and I need to. Maybe I would consider Zopiclone, but I would much prefer Trazodone unless somebody really strongly feels like they don't want to use that.

David Gratzer: Gabapentin if the renal function's good?

Leslie Buckley: Sure.

David Gratzer: And where do you stand on Melatonin?

Leslie Buckley: I don't know enough. I don't really suggest it.

David Gratzer: Fair enough. And then thinking bigger picture for a moment, if you were to talk to a colleague who wasn't so familiar with motivational interviewing. What's a nice workbook or book one could recommend?

Leslie Buckley: Miller and Rollnick have books with new editions coming out, if you wanted to read a lot. But even if you just wanted a brief update, a reminder, you could just Google it, and even on Wikipedia, it will give you the important reminders of the main tenets of motivation interviewing.

David Gratzer: Excellent. Thank you very much Dr. Buckley.

Thanks for joining Double Take. For more information on cannabis, please be sure to check out our web page, including some web resources.