October 17, 2018

Quick Takes

Episode 1: What all physicians need to know about cannabis legalization

[Musical intro]

Dr. Gratzer: My name is Dr. David Gratzer. Welcome to our series. Today we're joined by Dr. Jonathan Bertram who is a physician affiliated with CAMH in the addiction division. And he's also somebody with great expertise in the field. He serves as the co-chair of the working group on cannabis use disorder guidelines for older adults. It's part of a Canadian Coalition for Seniors Mental Health efforts. He's also a board member of the Ontario College of Family Physicians. He's also in clinical practice like me. Welcome Dr. Bertram.

Dr. Bertram: Hi David. How are you?

Dr. Gratzer: Good. There is lots going on with legalization and there's a policy aspect to this, and there's an economic aspect to this, and there's a larger societal fate. This is a podcast series for physicians by physicians. So let me ask you, as a clinician what should we be thinking about?

Dr. Bertram: Well I think probably the most important thing is what we might come across immediately. Acute intoxication is probably the most straight-forward and also perhaps the most prominent when it comes to headlines and presentations in the emergency.

Dr. Gratzer: And tell us what an acute presentation might look like.

Dr. Bertram: Sure. So acute intoxication with cannabis can happen either because a person is naive to cannabis, naive to the potency of cannabis that they're using, or maybe using more than they normally do — which is basically a variation of potency. And similar to what's happened in the States, what we anticipate potentially happening here, especially with retail cannabis, is that potency will increase and people will be using far more of the strong stuff relative to what they're used to, or as a first time, far more than what they expected. And so they may come in with acute nausea, vomiting, increased paranoia, anxiety some of what you see with hyperemesis that I'll try to highlight a bit later. And you know very much either very aware of the fact that it's associated with their cannabis use or maybe thinking that it's for some other reason.

Dr. Gratzer: I'm a CAMH doctor doing a shift in the ED. Or perhaps, like you, I'm working in an out-patient clinic. Describe to me a patient who walks through the door with acute intoxication.

Dr. Bertram: Sure it's you know it's probably someone who's vitals are not entirely stable either with really, really high blood pressure or, in some cases, actually telling you that they feel real faint when they are about to get up so that sort of postural hypertension picture. Somebody who's probably diaphoretic, so sweating quite a bit, and confused by the fact that they're really nauseous and vomiting quite a bit just because they probably expect that the cannabis is going to be doing something different about that or sort of dealing with that. They might tell you that they just tried cannabis for the first time or they try something from the store because they wanted to see what it was like or that they've been using cannabis for a while and they decided to go with something that seemed a little bit like what they normally get from whomever it is that they get from. And they just can't understand why it is that they're feeling this way.

Dr. Gratzer: Any in terms of history one might take from a patient, what sort of questions one might ask?

Dr. Bertram: Well the most important thing is getting just you know your typical sort of substance use history – which of course in this case would be cannabis use history – and identifying: if this is the first time they used cannabis, or if they used cannabis before; how long they've been using cannabis for; and the means by which they were getting it; and also the means by which they were using it. While legalized cannabis is going to be available inhaled, and we're really only looking to see different formulations maybe a year from now, it's quite possible that they're mixing what it is that they get illicitly with what they were getting the legalized store. So that means they were using will be important.

Dr. Gratzer: In terms of treating the acute intoxicated state.

Dr. Bertram: So most of that is really symptomatic. So managing symptomatic presentations along the lines of nausea, vomiting. Some of the intersection between acute intoxication with cannabis and cannabis hyperemesis is that you know we often use Haloperidol and that would still be reasonable in this type of a setting, but especially when we're talking about someone who's naive to cannabis use. You know really addressing if they're sweating – going with Clonidine. If they're nauseous, vomiting, something as simple as ginger. And that's available even as a formula you order in our emerg in our hospital. And in cases where they are acutely anxious, especially if they've got a historical sort of issue with anxiety, then what's used normally just as far as short-acting Benzodiazepines might be useful, again in that very sort of acute presentation, short-period stay in emerg or in an out-patient setting.

Dr. Gratzer: Do you think we're likely to see more cannabis use disorders?

Dr. Bertram: I think that that is both a concern for the short term in ways that I don't think everyone anticipates and certainly in the long term although there are lots of biases around that. I think in the short term it may be that people having availability or access to cannabis through different streams are now increasing their use of cannabis. The socialization of cannabis use is not a new phenomenon so it's not like it's suddenly become a cultural norm. But the access of it in more frequent ways may become a new phenomenon or certainly a more developed phenomenon. So there might be more normalization in terms of where you get it from. And so in that respect, people who maybe previously were using cannabis on and off, maybe using it problematically but not and they use disorder sort of way, might begin to increase their use and by virtue of that develop a use disorder.

Dr. Gratzer: You see somebody in an outpatient clinic and they're not acutely intoxicated. What are some things you think should be highlighted on a history?

Dr. Bertram: The most important is what is very much I think in line with what was out there with the College of Family Physicians of Canada's 2014 position document, which is people with mental health disorders are the people with whom we need to raise the most caution around cannabis use. And so establishing what their previous mental health history is, is quite important. Especially because in many cases people may be thinking that that's in fact an indication for the use of cannabis. Post-traumatic stress disorder, established anxiety disorders across the spectrum, established depressive disorders, but also poly-substance. And in many cases people are feeling as if they are using cannabis in ways that are productive as a means of mitigating their cravings, urges, anxiety, related to other substance use. So getting a good idea of what their substance usage history is, is also important.

Dr. Gratzer: Thinking about a patient I saw recently. She is panic disorder. She's really struggling. The sort of person who has difficulty going to work even though historically she's highly functional. She comes to my office and explains that cannabis helps. It's a difficult conversation because, on the one hand it does help at least short term, on the other hand we see it as part of the problem. What are some phrases or observations you've made in such patients that we can find helpful?

Dr. Bertram: I get this question asked a lot by patients in part because my practice is mixed. I work in Bowmanville two days a week in a community practice looking at chronic pain and addiction. So the question often is whether it's anxiety or whether it's pain – proofs in the pudding – I'm using marijuana and I'm feeling better. Or someone else used it and they clearly are showing better. And I usually tell them what works, and what you feel works, is not the same thing as what's going to work long term. And so sustainability versus effect are two very, very different courses and they very much define or influence what a person is going to decide to take. The other piece is that when a person is using something therapeutically they are actually far more likely to use more frequently and a greater intensity than they were recreationally. And so what they are at risk for actually starts to elevate because they're exposing their system in ways that they normally wouldn't.

Dr. Gratzer: What are some comments you've made to patients about reducing marijuana use? Say with an anxiety disorder or comorbid PTSD disorder.

Dr. Bertram: The main thing I try to emphasize is that tapering is not just a therapeutic exercise it's a learning exercise. Which is, in and of itself, therapeutic of course. Doesn't always feel therapeutic though when a person is feeling really anxious as they come down off of their dose. So what we try to look at is just general principle. And the general principle I tend to employ with decreasing is 10 percent. So let's talk about how much you use, how much you pay, or what you think an ounce looks like for you, how many joints it is that you're using. And let's look at how you can decrease that, either by 10 percent in terms of the amounts that you're using, or 10 percent in terms of its frequency throughout the week. So if you're using two joints three times a day seven days a week. Well, you know, if you do the math on that quickly that's more than 40 joints a week. So if we're at least coming down by 4 joints sum total per week we can manipulate the different times of the week that you're using, in a decreased manner, and let's use that as an opportunity to see whether or not if that's closer to night – you're having trouble sleeping or difficulty with anxiety – or that's a pain related issue an intersection with pain, increased pain. And then let's do a quick follow up to identify what it is that we can do. Let's also establish a way of addressing that so that you're coming to see me, or you're seeking safe supports, rather than going back to cannabis in order to deal with that sudden deficit.

Rapid Fire

Dr. Gratzer: What I thought we might do is, again, try and cram a lot into one minute. It's meant to be a little bit of fun. So let's try one minute of rapid fire questions and continue the conversation. Are we ready? Let's go.

Dr. Gratzer: Is this a big deal?

Dr. Bertram: It's a huge deal.

Dr. Gratzer: This is a game changer?

Dr. Bertram: Yes absolutely.

Dr. Gratzer: What do you think we're going to see in the emergency department: more cannabis use? less cannabis use? neither?

Dr. Bertram: I think we'll see more cannabis use.

Dr. Gratzer: Are we going to see more cannabis use disorders as well?

Dr. Bertram: Most likely.

Dr. Gratzer: Are going to see other substances increase in terms of use disorder?

Dr. Bertram: Absolutely, and I think we might even see more substance histories being discussed as a result of this.

Dr. Gratzer: What is the biggest change do you think we're going to notice in terms of a society that has legalized pot?

Dr. Bertram: I think that we're probably going to see less stigma. That's a positive. But with that we might sometimes see some misplaced confidence.

Dr. Gratzer: What's the biggest piece of advice you give to doctors with legalization?

Dr. Bertram: Get the information. Be willing to talk about cannabis. Cannabis is not the same as cannabis use disorder, but cannabis does come with both consequences and obviously patients receive benefits.

Dr. Gratzer: What are you worried most about?

Dr. Bertram: Mainly the impact it's going to have on cannabis use disorders.

Dr. Gratzer: Just one last question at the buzzer. Do you favour legalization doctor?

Dr. Bertram: I favour legalization with regulated distribution.

[Outro]

Quick Takes is a collaboration between David Gratzer and CAMH Education. You can find links to the relevant content mentioned in this show, a video version of the episode, and accessible transcripts of all the episodes we produce, online at porticonetwork.ca/podcasts. If you like what we’re doing here, please subscribe.

Until next time.

October 17, 2018

Episode 1 Bonus Content: In this clip you’ll hear a more in-depth discussion on hyperemesis syndrome, dealing with sub-populations and the benefits of ginger – stat!

[Musical intro]

Dr. Gratzer: With regard to evidence. Something that's become popular amongst patients to talk about is opioid use disorder and then using cannabis. What are your thoughts?

Dr. Bertram: The interesting thing with the use of cannabis in the setting of opiate withdrawal – which is where you're often going to be seeing people with opiate use disorder speak to its effectiveness – its use in opiate withdrawal has been steady to an extent. There are studies that speak to some promise, but don't actually have established evidence of its use for opioid withdrawal. With that said, there are I think increasingly more voices lending themselves to discussion around using cannabis, and in some cases using synthetic THC analogues like Nabilone, for the sake of easing opiate withdrawal symptoms in a two to four-week period where you can sort of abruptly discontinue. Again, that's easier to look at when we talk about Nabilone because of measurements pharmaceutical, much harder to sort of measure what we're talking about medical marijuana dispensed out of marijuana clinics. That is not the same thing, though, as treating opiate use disorder. Which is an entirely different process.

Dr. Gratzer: To pivot for a moment. So we've talked about out-patient management, relevant also to docs who are doing shifts in their ED. In-patient wards – people who have been admitted and have been in the hospital for a few days, whether it's in the forensics department or in general division where I work. What might the patient present with?

Dr. Bertram: You know a patient could present with increased paranoia, psychosis. It could be an episode that led to them actually being admitted for that very reason or in some cases it could be a late presentation by virtue of them being an inpatient. Something I actually see far more often, because I wouldn't be, especially in a forensic setting, as experienced, but it's got some interesting parallels is long term care. Where you're seeing older adults who are transitioning, people who are really not all that old but for cognitive reasons are actually going into long term care. And they are often presenting in the same way but increased irritability, increased anxiety, more of a flight risk – which again I think is different depending on the care circumstances under which they're being seen. But those are situations where there's perhaps an opportunity to have a conversation about cannabis if that's showing up in their drug screen. If that's in any way a part of their admission profile or if they're actually sort of openly speaking about it as the reason for why they're feeling the way that they are.

Dr. Gratzer: And for docs who are listening, what do you recommend in terms of resources outside of CAMH?

Dr. Bertram: You know, there are a few different projects that I'm involved in that we're hoping can provide some sort of clinical support to clinicians. One that we're looking to make available with legalization, in fact the ask for the ministry is that it's available before the 19th [17th], is a clinical working tool for non-medical cannabis. And we've aptly named it “non-medical cannabis” for a few different reasons. The first is we're trying to make sure that people are aware that this is not advice on medical cannabis. And the second is we didn't want to make it the cannabis use disorder tool because I think, case in point with our conversation, the legalization of cannabis is not just a cannabis use disorders discussion, in fact, it's mostly a cannabis use discussion. And so we're trying to speak to non-medical cannabis and not just recreational cannabis use. So that's coming out of the Centre for Effective Practice which is CEP.CA [https://effectivepractice.org]. And then I'm also working with the group who are putting out guidelines for older adults – and the older and older adults present a very interesting intersection because a lot of their asks around recreational cannabis are really how it can help them therapeutically as opposed to trying something purely for the sake of enjoying cannabis on its own. And so we are putting out a guideline, hopefully before Christmas, that'll be coming out on the Canadian Coalition for Seniors Mental Health website CCSMH.ca.

Dr. Gratzer: You've made mention of hyperemesis. Tell us what that means.

Dr. Bertram: So cannabis hyperemesis syndrome is a presentation where a person is, understandably, going to be present with nausea, vomiting, but also a number of other symptomatic features like diaphoresis, but also things like abdominal discomfort. In some cases diarrhea but that's not required for the diagnosis of the syndrome. In a setting where there's usually prolonged and usually problematic cannabis use. It's hard to quantify problematic use when it comes to cannabis, so we don't apply the same parameters as we do with say opiates or alcohol. But when it comes to frequency and obviously its impact on a person's activity, behaviour, connection, that all constitutes problematic. In most of those situations a person is presenting that way and, again, cannabis is in the background. And so their own insight into why they're coming to you and what they think is causing the problem usually doesn't account for cannabis.

Dr. Gratzer: A careful history is critically thus important. What you do in terms of treatment?

Dr. Bertram: So usually Haloperidol is kind of the mainstay.

Dr. Gratzer: And what sort of a dose are you looking at?

Dr. Bertram: That's a good question. It really depends. I would say whatever is used in your ED is the norm. I try not to be too prescriptive with doses.

Dr. Gratzer: And ginger?

Dr. Bertram: Ginger is fine. And in fact any of what we talked about with regard to acute intoxication with cannabis is probably appropriate when it comes to symptomatic management.

Dr. Gratzer: So how does one prescribe ginger?

Dr. Bertram: You actually can just through the formula you can say a ginger tablet. And it's available – I'm not even sure what the dose range is for it. If a person is worried about nausea, vomiting, kind of going forward I usually tell them if you go to the pharmacy and you seek some counsel from the pharmacist in terms of over-the-counter ginger tablets, they'll probably recommend Life Brand and they'll be able to tell you one to two ginger tablets every four to six hours.

Dr. Gratzer: Ginger stat.

Dr. Bertram: Ginger continuous!

[laughter]

Dr. Gratzer: You've made mention a couple of times of older adults. And we recognize that presentation and treatment might be a little bit different in this population because often management is a little bit different in this population. Let's turn it over to you.

Dr. Bertram: So older adults are an emerging issue from a population standpoint, presentation standpoint. We sometimes 1) don't expect that to be an issue in that population, but, more importantly we sometimes think that the considerations for different substances and older adults will apply the same as they do with mainstream. Cannabis hyperemesis, cannabis withdrawal – in both of these situations you're seeing a change in the vitals. You're seeing a change when it comes to nausea, vomiting, so some hypovolemia issues. You're also concerned again with how destabilizing that could be as far as hypotension. Those can actually be morbid in older adults. So medical clearance is usually something to consider in an out-patient setting, in a mental health setting, where we otherwise might not think we would need to because its cannabis.

Dr. Gratzer: This could be an emergency.

Dr. Bertram: That's right. And especially at CCSMH we've published on really thinking about medical supervision of withdrawal management in the setting of withdrawal from substances we normally wouldn't consider to be morbid or mortal like opiates and cannabis.