- [Jeff] Welcome to “Healthy Minds.” I'm Dr.

Jeff Borenstein.

Everyone is touched by psychiatric conditions, either themselves or a loved one.

Do not suffer in silence.

With help, there is hope.

Today on "Healthy Minds."

- Cannabis use is on the rise, and public perceptions are changing of cannabis use.

Basically, more and more people are using it.

From a mental health perspective and an addictions perspective, it becomes a problem when there are psychological and behavioral issues associated with the use.

- That's today on "Healthy Minds."

This program is brought to you in part by the American Psychiatric Association Foundation, the John and Polly Sparks Foundation, and the WoodNext Foundation.

(gentle music continues) Welcome to "Healthy Minds."

I'm Dr.

Jeff Borenstein.

Cannabis.

It's more available than ever before with an increase in use and addiction.

Today I speak with leading expert Dr.

Victor Tang about cannabis addiction and treatment.

Victor, thank you for joining us today.

- Thank you for having me.

It's a pleasure to be here.

- I wanna jump right in and ask you about cannabis misuse and addiction.

Tell us about the scope, and what are the current issues in terms of cannabis?

- Cannabis use is on the rise, and public perceptions are changing of cannabis use.

And basically, more and more people are using it.

And so when you have a substance that's commonly used and can be both for recreational and medical purposes, there becomes this kind of spectrum of use.

And the spectrum of use, as you might imagine, relates to frequency, like using it more and more often or less or less often, and quantities, using more and more amounts of cannabis or certain cannabinoids like THC or CBD, and I can talk a bit more about that.

But with that range comes increasing risk of misuse.

So cannabis is not like any other drug that you can get addicted to.

So most people are familiar with alcohol use disorder.

Most people know that things like heroin, and opioids, and cocaine, things like that, you can become addicted to.

And same thing for nicotine and cigarettes.

Like a lot of those substances, especially the legalized and recreational ones, there's a range, right?

There's a range of the types that you can use.

The trick, and it becomes clinical too and often requires a clinical assessment, is when that becomes a problem and when it becomes too much.

From a mental health perspective and an addictions perspective, it becomes a problem when there are psychological and behavioral issues associated with the use.

And so while it's related to the amount of cannabis you use, it's not completely tied to that.

So, so what I mean by that is that typically, you have clusters of symptoms.

One of the big clusters is loss of control.

So basically, people are using cannabis in ways that they didn't intend to for longer than they thought they would, and they have difficulty stopping or controlling their use when they're otherwise trying to reduce or stop.

And then cannabis misuse becomes a big problem when it starts to essentially interfere with any sphere of your life, whether it be work, school, relationships with your family and children, and things like that.

And then lastly, like, misuse can become a problem if it gets you into trouble.

Like, you get hurt, you get physical health, like damage or illness, and if you're just finding yourself in trouble because of your cannabis use, kinda legal or otherwise.

So that's kind of like, a kind of collection of the types of, like, problematic symptoms you can have.

And when we're talking about misuse, it's some collection of those symptoms or maybe just one or two of those symptoms, but misuse is a little bit of a subclinical term as well, right.

So, so sometimes we use the word problematic cannabis use or cannabis misuse, but that's a little bit shy of a cannabis use disorder or a cannabis addiction.

- So Victor, if somebody is having problems related to their cannabis use, what should they do?

What are the ways to help a person in that situation?

- Yeah, that's a great question.

I think the first thing to do that's kind of a basic for any kind of lifestyle or health behavior is to do a self-assessment, and then do assessments with, you know, both loved ones and professionals, whether it's your doctor, your therapist, your clinician, things like that.

Because like I mentioned earlier, there is a range of use, and you know, frankly, there is recreational use that oftentimes is not harmful.

So when you're doing that self-assessment, obviously, that takes a little bit of both education and finding resources that are trusted.

And, you know, the best people for that is, you know, teachers, or healthcare providers, or people in the healthcare space.

So what you're trying to look for in terms of that self-assessment is kind of the potential harms that you could get from cannabis, both from the mental and physical health harms, as well as kind of like, the behavioral type of symptoms of addiction.

So, so that first category is figuring out if the cannabis use is related to things like your breathing problems or lung problems that you might be noticing, or heart problems that, or other medical conditions that you might notice may be a little bit destabilized.

And then to think about, you know, your current status in terms of your mental health.

How has your moods been, how's your anxiety been, how's your sleep been?

And one of the tricks with cannabis is that usually when people use cannabis, the effect is a little bit more subtle than people, than if people are like completely intoxicated on alcohol or another drug.

And so part of why I'm talking so much about self-assessment and doing that reflection is it's actually a little bit tricky to really tell kind of the causative effect of the cannabis to those things like your lung health, or your heart health, or your mental health and things like that, because these things can be subtle and slowly accumulate over time.

But the thing is to kind of educate yourself to realize that these things are related.

And the other aspect is to try to seek some help to see if you can get a clinical as well as a personal opinion on whether cannabis is affecting your day-to-day life.

And that's talking about a lot of symptoms about whether, you know, you feel like, or your doctor, your family member feels like you're smoking too much, basically.

People feel like you should cut down.

People feel like it's getting in the way.

You know, you said you would show up for this thing, but then you bailed 'cause you know you were high, or you were using cannabis, or you know, you're spending like a lot of time isolated using cannabis.

And again, a lot of this is both kind of personal reflections and reflections of people around you, as well as what a doctor might notice about, you know, subtle changes in your behavior.

- In talking about some of the psychiatric issues, I'd like you to speak about some of the risk that cannabis may be related to in terms of developing a full-blown psychiatric diagnosis such as schizophrenia or psychosis.

Tell us about that.

- Yeah, for sure.

So I can actually blend that answer with the previous question as well, because, you know, if it appears that the cannabis is affecting those types of mental health symptoms that you may be experiencing or a preexisting diagnosis that you had, for example, you've already had a diagnosis of bipolar disorder, then cutting down cannabis becomes part of the management of your mental health and your physical health.

And so typically, when you're trying to address problematic cannabis use, you're doing that hand in hand with the other health effects, right?

So if you're really trying to work on stabilizing your mood, or your perceptions, or your symptoms of psychosis, it's very likely that reducing your cannabis use is part of that.

So to reduce that, cannabis use comes with a lot of, like, principles of treating addiction in general.

And for that, it's getting counseling, or therapy, or peer support with skills to reduce your cannabis use, other coping strategies to reduce your cannabis use, and then perhaps some medical management.

In terms of dealing with withdrawal symptoms.

The thing we really worry about is psychosis and cannabis's effect on schizophrenia and schizophrenia spectrum disorders.

There have been a lot of studies now, especially higher quality studies that are longitudinal and look at things over, like, a longer-term trajectory that cannabis use, especially heavy cannabis use, can either precipitate psychosis or exacerbate people's psychosis if they already have a psychotic disorder.

I would say that on the range of kind of certainty of where the research literature is, that's probably the thing that we are most concerned about and confident about that concern.

When it comes to mood and anxiety disorders, it's a little bit more mixed.

You know, there is kind of two types of literature, basically.

Literature showing kind of, like, longitudinal associations, like, just how people that smoke cannabis over time, it affects their mood and anxiety over time.

And that kind of shows that, you know, perhaps people that use high doses of cannabis, or use cannabis daily or almost daily, or use high-potency products, and high-potency product is anything that has, like, a very high percentage of THC, which is the active chemical, like, the psychoactive chemical of cannabis.

And if you're in that, like, upper range of heavy use, then it probably worsens people's depression and anxiety.

And then there's this other kind of interest in seeing, well, do cannabinoids, or part of cannabinoids, some cannabinoids help with the treatment of mood and anxiety disorders?

Like, if you have a diagnosis of anxiety or depression, could cannabis help with that?

Honestly, the studies don't show that it is helpful, although the literature is a little bit mixed with just small studies or, like, poorly designed studies, so the jury's a little bit out on that.

I think the usual recommendation is that the most cautious thing to do is to avoid cannabis or significantly reduce your cannabis if you have basically any mood, or anxiety, or trauma-related disorder.

It's an active area of investigation whether there can be a therapeutic potential, but the safest thing is probably to avoid those things, because there there is a high chance of things worsening if you smoke or use cannabis and also have a mental illness.

- I wanna ask you about the use of cannabis for younger people, in teenagers, in young adults, 'cause we know that the brain is still developing through the mid-twenties.

Tell us about your concerns or the field's concerns about the use in younger people and their brains.

- A lot of young people use cannabis, and part of the proliferation of use is the popularization of other routes of use, like vaping, or edibles, or concentrates.

As the use of that has expanded, young people are finding different ways to use in more discreet ways, and in settings like schools and things like that.

Especially with vaping.

The brain's developing, and your brain develops, and important parts of the brain involved in attention, and decision-making, and learning and memory all the way into your early twenties or your mid-twenties.

And so essentially, any kind of substance use could interfere with that.

Younger people, because of their developing brains, are more vulnerable to those health effects on mood and anxiety.

The other concern is that we know even outside of the cannabis and substance use literature that most mental disorders start in young adulthood or before that.

So this is the time when people would otherwise maybe be struggling with their mental health, maybe struggling with stress in their environmental situations in adolescence.

And to throw cannabis into that mix not only affects the brain development side of things, but it also affects the development of healthy coping mechanisms.

And so what we commonly see is, like, a bit of, like, an opportunity cost there, right?

So instead of young people learning to deal with difficult emotions or deal with difficulties at school, you know, cannabis especially becomes increasingly accessible, becomes like an alternate route that is more or less maladaptive coping.

- Very important points that you're making, especially for young people.

I wanna sort of take a step from that and ask you about the use of cannabis as a stepping stone to the use of other drugs that could become a problem for a person.

Tell us about that.

- There's always been that concern.

And oftentimes we see that arc in people that they use cannabis before using other drugs that are illicit, or the harder drugs, or things like that, and it is a concern.

I think that some of that is related to access of any substance that kind of derails your emotional coping.

And so oftentimes, it's not only cannabis, but things like nicotine, and cigarettes, and alcohol.

And usually some amount or some combination of recreational drug use is a risk factor for more drug use or illicit drug use.

One special problem that happens with cannabis is that it's often mixed with other things.

And so, you know, subjectively or anecdotally, a lot of people will talk about it changing their high or changing their experience with drinking or with cigarettes.

And so therefore, you put them together and then that creates a different experience.

But as you might imagine, it kind of doubles or triples your risk of problems because you're kind of introducing multiple substances and the combination of those substances.

- I wanted you to speak a little bit more about treatment.

In addition to counseling, peer support, what other types of treatment are available to help people who are having a problem with their cannabis use?

- There are evidence-based manualized psychotherapies that have been developed specifically for cannabis use disorder, and they're typically with modalities called cognitive behavioral therapy and motivational enhancement therapy.

And so I can speak a little bit to those.

Cognitive behavioral therapy is something that we use across the mental health field to kind of link people's thoughts, feelings, and behaviors.

But what we know about cognitive behavioral therapy or CBT is that sometimes it's more helpful when it's focused to the problem at hand.

And so while CBT is out there for a lot of different things like mood and anxiety issues, it may be helpful for a person that's struggling with cannabis use disorder to find an addictions therapist or addictions-focused therapist that can do cognitive behavioral therapy specifically for cannabis use disorder.

And same thing for motivational enhancement kind of therapies, as well.

There have been other kind of psychotherapies that have been studied, especially in the context of youth, so there are kind of family therapies and family system therapies that could be helpful for young people struggling with their cannabis use.

With cannabis, like in many other substance use disorders, it's mixed into the family dynamics and the environment of the young person.

So oftentimes involving the parent or the caregiver into the substance use change and goals is very important.

As you can kind of hear, a lot of it is kind of psychotherapy and psychosocial focused and focusing on the person's behavior.

We are struggling a little bit to find effective and get approved medications for the treatment of cannabis use disorder.

Unlike other addictions, cannabis use disorder doesn't have any FDA-approved or FDA-cleared medications to treat that condition.

So it's something, an area of active investigation.

Treatment of cannabis withdrawal is a little bit of its own kind of subset of a problem in treatment, which is just basically that short term period when you get off cannabis.

derailing of your sleep, your appetite, your energy, feeling tense, and then you can kinda get some physical symptoms too, like headaches or kind of hot and cold sensations.

And so withdrawal syndrome is a very important thing to recognize, because, you know, one, if people don't think cannabis, you can get addicted or dependent on it, you might not associate stopping cannabis or skipping a day of cannabis to be triggering these types of symptoms, which can be misattributed to other things.

And also oftentimes, as in with other addictions, the withdrawal period is a big reason why people either relapse or go back to the substance use, which it's just too unpleasant to try to get off of this stuff.

Anyway, when it comes to treatment for withdrawal, sometimes you do need some pharmacological management for that.

And for that, that's a little bit, you know, personalized with your doctor in terms of safe and effective medications to treat insomnia, or anxiety, or low appetite in the short-term.

There've been some studies done using, like, synthetic THC or cannabinoid-like preparations as, like, a replacement for cannabis in the withdrawal period.

And it does help with that withdrawal period, but it's not clear that these things are very effective in the long-term for treating the overall cannabis use disorder.

And then the last thing to talk about treatment is the setting.

And so sometimes people may find that going to a detox facility, a detoxification facility, or an intensive treatment program, or a, like, rehabilitation center may be helpful for that because it takes people out of that cannabis using environment and puts them into more intensive treatments.

We don't think about it that often for cannabis as much as we do for other things like alcohol or other drugs, but it does happen, and it can be a very effective way for people to kind of break the cycle of their cannabis use disorder.

- I wanna ask you about the co-treatment, and we alluded to it earlier, the co-treatment of another psychiatric condition such as depression or anxiety along with the cannabis use, and whether it be use of medication or other types of treatment such as transcranial magnetic stimulation.

I'd like you to talk about some of the treatment to treat both aspects of a person's condition.

- The basic principle of that is that a person should be treated holistically and have their problems treated concurrently.

And so if somebody has a diagnosed other mental illness and a cannabis use disorder, a cannabis problem, they should be treated concurrently, and those treatment plans should be well=integrated.

And that's a very important thing to say off the bat because people may struggle with treating one thing if the other thing is not addressed.

And most people that struggle with cannabis use or other substances understand this kind of, like, intimate relationship between their mental health symptoms and their cannabis use.

In terms of what might be effective in that regard, a lot of active research is being done in kind of repurposing other mental health drugs for the use of cannabis use disorder.

And so the idea is that some medications, like varenicline for tobacco use disorder, or the use of, like, anti-convulsants or mood stabilizers for bipolar disorder may also be helpful for cannabis use disorder.

I mean, the evidence is mixed for using those types of psychiatric drugs right now for cannabis use disorder.

But definitely, if you have a diagnosis of that primary mental health disorder, those medications and those treatments should be used.

You mentioned transcranial magnetic stimulation, and so we often use things like neuromodulation or brain stimulation for depression and other mental illnesses.

And you know, those things should still be pursued and encouraged even if people are having troubles with their cannabis use as well, as long as your doctor who's administering those brain stimulation therapies feels that it can be effective.

The other important thing, you know, even before you get to, you know, the prescription pad or the TMS chair is to have a very thorough assessment that focuses on primary mental health symptoms and cannabis-induced mental health symptoms.

You know, quite frankly, it's sometimes very difficult to tell or even impossible to tell if someone is using cannabis all day every day and they're depressed all day every day.

You know, it becomes a big chicken or the egg problem.

And in a subset of those cases, if you remove the cannabis use, the depression or other mental health symptoms may get better.

So sometimes I tell people, and you know, there's some literature to support this, which is that stopping your cannabis use or definitely significantly reducing it can be its own antidepressant or can be its own anti-psychotic, because removing these kind of, like, you know, so-called offending agents may alleviate the symptoms of your other health disorder, and that also might help reduce the burden of, like, piling on with medications and other types of treatments.

- I wanna ask you, what do you say to somebody, especially a young person who's watching right now who is aware of cannabis being legalized all around them.

What do you say to them about, hey, this could be risky, be careful.

- You should still kind of follow the laws and the health policy regulations of legalization, which is that you shouldn't use cannabis or you shouldn't buy your own cannabis under the age of, well, it depends on your area, but under the age of 18, or the age of 19, or 21, or wherever you live.

So young people shouldn't be purchasing cannabis, even if it's legalized, like, really young people like adolescents.

The other thing is that I would say to the young person that a lot of the reasons why cannabis has been legalized is not necessarily for health reasons.

It's not that we suddenly discovered that cannabis is completely benign or helpful for this and that.

A lot of it is for kind of, you know, criminal justice and political type of reasons.

So, you know, it's for the young person to understand that the intention of legalization shouldn't be kind of misconstrued.

I think the other thing too is that, for people to understand that there is a limit to everything, right?

And people should have a recognition of not only their limits, but, like, the public health recommended limits.

And so there's a lot of things that are legalized or widely available around us that are not healthy, especially at a certain level, right?

Alcohol, nicotine, cigarettes, and all of those types of things.

And the other thing is that legalization and these kind of, like, societal or public health policies don't do a perfect job of assessing your individual risk.

So you as a young person or any person has your own kind of individual differences in risk profiles, right?

So if you specifically have a, for example, a history of mental illness or you have a lot of family members that have developed mental illness or other risk factors such as that, or you have a lung condition or a heart condition, things are riskier specifically for you that things like legalization or broad strokes public policy maybe missed.

And so yeah, it's very important to think about how that messaging needs to be filtered for your specific needs.

- Victor, I wanna thank you for really excellent information, and also thank you for the work that you've done over the years and will continue to do in this important area.

Thank you so much.

- Thank you, Jeffrey.

It's a pleasure to speak with you.

(gentle music) - If you find that cannabis use is getting in the way of your functioning, whether it be at school, at work, in relationships with family and friends, don't suffer in silence.

Seek help.

Remember, with help, there is hope.

(gentle music continues) Do not suffer in silence.

With help, there is hope.

This program is brought to you in part by the American Psychiatric Association Foundation, the John and Polly Sparks Foundation and the WoodNext Foundation.

(gentle music continues) (gentle music continues) (gentle music fades)