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Psychiatric News Special Report: Clinical Considerations of Cannabis Use in the Inpatient Medical Setting · The Medical Mind

0:13
Everybody, welcome back to psychiatric news special report for the month of June.
0:19
We have a wonderful article as we go into the summertime.
0:24
~ clinical considerations of cannabis use in the inpatient medical setting.
0:28
I'm your host, Dr. Sulman Aziz Merza,
0:31
triple board certified adult psychiatry,
0:33
child adolescent psychiatry, and addiction medicine.
0:36
So this is gonna be a fun one.
0:38
~ I I think it's something I get to put on my addiction medicine hat and then
0:42
Partly my child adolescent had,
0:44
and then the adult one as well,
0:45
because we're seeing this in all settings.
0:48
And I think it's something as we progress in 2026,
0:53
and you know, substance use and especially cannabis use is becoming more
0:58
and more prevalent. We all have to become just more aware of how this shows
1:02
up in our world. So let's introduce our guest.
1:07
Welcome our guest, Dr. Heather Murray from University of Colorado.
1:10
I'll let her introduce herself.
1:12
Her bio background and her blah blah blah.
1:15
Hi, thanks for having me today.
1:17
I'm excited to be here. ~ so again,
1:19
my name is Heather Murray. I am a CL psychiatrist at the University of Colorado,
1:24
~ hospital and CU Medicine Psychiatry Department in Aurora,
1:27
Colorado. I did medical school at Emory,
1:30
have an MPH in epidemiology, and went to Denver for residency and
1:34
my CL fellowship and haven't looked back.
1:37
Yeah, it's it's a wonderful place.
1:38
I got to I don't know how many people have a chance to like go out to Denver,
1:43
Colorado area. I did part of my like going through the Caribbean Med School
1:47
is they send you to rotations all over the country.
1:49
And I did my my my twelve weeks of internal medicine in Colorado and I was like,
1:53
Wow, this is earthy crunchy munchy Denver and Colorado and it's just beautiful
1:59
out here going up to the mountains and so a wonderful,
2:02
wonderful place. I encourage everybody to ~ visit.
2:06
Yeah, it's fabulous. And I will say the ~ the people are so friendly here
2:09
and the food has gotten a lot better in the last 10 years.
2:12
Yeah. Or things are looking up in terms of the spice level.
2:15
Yeah, I it was it was bizarre.
2:16
I had it was with a good group of people and we were like we need to find like some
2:20
Indian Pakistani food and I found we found this like this wonderful like Punjabi
2:24
restaurant in Denver. I think it was like India's Pearl,
2:27
I think was the name of it. And it was like fantastic.
2:30
I was like, They have like good Punjabi food over in Denver.
2:32
This is bizarre, but we'll do we'll take it.
2:35
Yeah, I think a a little known fact about the area,
2:38
Ro Roar and specif like specifically,
2:40
is they have it's one of the most diverse counties in the country.
2:43
We have refugees, immigrants from all over the world.
2:46
And I think that just makes it such a special place and also has contributed
2:51
to the food scene dramatically.
2:53
Which which is always always key for finding a place to settle down and live.
2:57
So All right, awesome.
2:57
Yeah, exactly.
3:00
One of the other unique things about Colorado is the f it was,
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I think, as we all kind of know,
3:06
is the first state to really fully legalize I think first state,
3:09
right? To fully legalize cannabis,
3:11
right? It was that or Washington.
3:12
For recreational use in particular.
3:15
Yeah, so it's a it's a unique spot to kind of get into this topic
3:19
and where this kind of article is coming into.
3:21
So Doctor Murray, tell us a little bit about what made you focus
3:25
on this specifically in the inpatient medical setting.
3:29
Yeah, so you've already actually alluded to a big part of my journey to this topic.
3:33
So I moved to Denver, Colorado for my adult psychiatry residency training in 2012,
3:38
which was the actual year that recreational cannabis was legalized here in Colorado.
3:43
~ because we were one of the first states with recreational use,
3:46
anecdotally, I found that many of my patients moved here specifically because
3:51
of the availability of cannabis.
3:52
And during the following years,
3:54
throughout residency, while a lot of patients reported improvement
3:57
in quality of life.
3:58
With cannabis use, I found a similar amount would also mention struggling with
4:03
escalating cannabis use, particularly of high potency formulations that we'll talk
4:09
a ton about. And actually started to identify correlation between high-potency
4:13
cannabis use and adverse psychiatric and medical symptoms.
4:16
I ended up doing my CL fellowship at Colorado as well,
4:19
have been faculty at our large academic level one trauma center for
4:23
the past five years. And during this time,
4:26
the trend has only become more apparent.
4:28
because of our university's location in Colorado,
4:31
our department has some excellent research and subject matter expertise
4:35
in this area generally. And I've been lucky enough to have been working with
4:38
a few people on different projects.
4:40
But one thing I found throughout this work is that there's actually not
4:43
a ton out there available for psychiatrists working in the acute medical care
4:48
setting or within my specialty of CL psychiatry.
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So I wanted to contribute to the literature through my own discovery and education.
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So that's what led me to this ~ article.
4:58
Yeah, it's it's definitely something we're seeing.
5:02
Again, people who are doing a lot of clinical work,
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you know, it's it's just a byproduct of what's out there and what people have access
5:10
to. You know, I say it all the time when I'm working,
5:13
especially with teens, and you know,
5:15
the the parents bring the teens into the office and they're like,
5:18
Can you tell my child to like stop smoking weed?
5:21
And I'm like, Well, it's not that simple,
5:23
right? And a lot of times, you know,
5:26
one of the
5:27
avenues I have to go to and discuss is especially when parents are kind of like,
5:34
well, you know, it's just cannabis.
5:35
If they're trying to minimize it or they're saying,
5:38
well, at least we'll I I'll be okay with them using that is like it's not,
5:42
you know, your your daddy's cannabis nowadays,
5:45
right?
5:45
Right. That's so funny. I always joke with patients.
5:48
I say, Well, it's not your mama's swag.
5:50
because it's so different from what it was back in even the nineties,
5:53
early two thousands. Yeah.
5:55
And it's this idea, like I think there's you know,
5:57
again and you have people who are gonna come for I wanna say contra,
6:01
but people who are again people online who will say things like,
6:04
it's natural and it's organic and you and that you should be able to like just
6:08
use what's of the earth and blah blah blah.
6:11
And it's like I don't think there's such a thing as like natural and organic,
6:17
like the original cannabis flo plant that exists anymore.
6:22
It is like become the most GMO planned out there.
6:27
It has become so modified, so crossbred and high breded
6:32
to become these high pointsy strains that are out there.
6:37
I was like, there's no such thing as like again,
6:39
natural organic cannabis anymore.
6:41
Exactly. And yeah, it's so it's interesting because we,
6:45
you know, humans have had a relationship with cannabis for thousands of years.
6:48
And that relationship, I think,
6:51
has been culturally special to so many people.
6:53
But the reality is that, like you mentioned,
6:55
it has been bred to be higher and higher potency.
6:58
~ and that's something that we'll definitely talk about in a lot of detail.
7:02
But I think the potency piece is particularly important.
7:05
And we can actually see a lot of analogies to that with let's say,
7:09
you know, looking at opium.
7:11
Coming into heroin and now fentanyl with Kratom 70H,
7:15
right? We're creating these really potent substances that actually have completely
7:20
different mechanism of action and psychopharmological properties in
7:25
the brain and the body in particular.
7:26
They're like a different drug.
7:29
Yeah. I mean, they are totally different drugs.
7:31
Like I think like you bring up the kratom thing with kratom as well,
7:34
especially we know that like low doses of kratom work as like a stimulant
7:39
and higher doses work as an opiate.
7:40
And, you know, I have plenty of people coming into my clinic who are trying
7:44
to get off of opioids and they're like,
7:47
Well, or I don't want to do suboxone or buprenorphine and I'd rather
7:51
do kratom and then they they'll do that on their own and then they will say,
7:55
Well, now I can't get off of the kratom now we have to go
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go to the buprenorphine and it becomes this back and forth ping ponging that occurs
8:02
with it. So
8:04
And it's very expensive as well.
8:06
Both cannabis and Kratom. So expensive.
8:08
Yeah. So it's not always like the best option of for for these patients.
8:12
So
8:13
But it's also understandable, right?
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How people end up there and they're doing the best thing in their perspective
8:18
for their health, for their body.
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And so much of it I think does come down to,
8:22
you know, how we market it both as a specialty within medicine,
8:25
but also more from a public perspective.
8:28
~ it's that's really important as well.
8:30
Yeah. Let's talk about let's you know,
8:34
we're we're talking about the potency.
8:35
So yeah, tell us about the potency shifts and then that's,
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you know, one of the things the article,
8:40
one of the topics of the article that really is really stands out.
8:44
And think something if people are just either reading the article
8:48
or listening to the podcast, like the the I think that's the biggest takeaway,
8:51
if nothing else.
8:53
Yeah, I I agree. That actually has been my biggest takeaway through
8:56
my own learning and research over the past few years on this topic is that,
9:01
~ you know, just because something is called cannabis doesn't mean it's
9:05
the same drug as the other thing called cannabis.
9:07
so like I mentioned, it's been used for thousands of years.
9:10
The plant itself actually consists of over a hundred active compounds,
9:14
including terpenoids, phytophytocannabinoids,
9:18
flavonoids, cannabidiol, THC.
9:21
So THC is the chemical most implicated for psychiatric psychoactive effects
9:25
of cannabis, while cannabidiol is thought to be largely protective against these
9:29
effects. So in the 1990s, when we measured ~ the concentrations of
9:35
THC in the average cannabis strain,
9:37
it was about 4 to 5%. That was kind of as high as it would get.
9:41
And then CBT is generally a lower concentration,
9:44
around 0.2 to 0.5%. However, most recently,
9:48
and this is
9:49
The case in Colorado, for example,
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I've gone to dispensaries to see what is what is the potencies that I can get.
9:55
I couldn't find anything below 20% concentration of THC.
10:00
So we're really breeding these cannabis strains now to have super high
10:05
concentrations of C THC. Well,
10:07
some simultaneously, we're not also increasing CBD or these other protective
10:13
chemicals, right? So you end up with a ton of this psychoactive substance
10:16
and super high potency.
10:18
On top of that, so not only do we have the flour with this high concentration
10:22
of 20 to 40, 50 percent, we now create these concentrates for recreational use.
10:27
~ so concentrates in general, you might hear them referred to as shard,
10:32
oil, ~ shatter, dabs, wax,
10:36
and they can come in concentrations as high as 90 to 95 percent THC
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and can be either ingested or inhaled through vaporizers.
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So, pretty potent ~ chemicals that really are.
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very new over the last 15 years or so.
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And I think part of the issue is that the industry and the regulation
10:55
are outpacing research and medical and psychiatric understanding
10:59
of these substances that it's hard for us to keep up as medical providers.
11:04
And with that, I mean like it's you know,
11:06
it it's ridiculous to see. Again,
11:08
like you're talking about ninety something,
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I've seen like ninety-seven percent,
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I think. ~ you know, it's it's just out of control.
11:15
And it's like w we kind of lose sight of the fact that this is
11:18
a substance that's going to negatively affect us,
11:22
you know, especially, you know,
11:24
like has been if if anything has kind of been like everyone
11:27
talking around has been C B D is the good part of it and THC is the bad part.
11:31
And it's like, well, why are we increasing the THC concentrations while dropping
11:35
the C B D ~ concentrations in in these plants and this and these substances?
11:40
So it's like a little bit problematic,
11:42
right?
11:43
Yeah, absolutely. And I think part of the issue too is tolerance.
11:46
You know, people develop tolerance and you just are they're asking
11:49
for higher and higher concentrations,
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which have these just catastrophic effects from a psychiatric perspective
11:55
on occasion.
11:58
Do you feel like clinicians are keeping this idea
12:04
of like the cannabis is this like low potency substance,
12:07
like they're just holding on to this idea versus fully moving
12:11
and understanding they're like,
12:12
no, it's it's a whole different thing than what it was,
12:14
like you're saying ten years ago,
12:16
fifteen years ago, twenty years ago and beyond.
12:18
Yeah, I, you know, I have certainly noticed a shift in the understanding.
12:22
I would say in the last, we probably were a little bit ahead
12:25
in Colorado just because we had it recreationally earlier.
12:28
~ but as I think especially the last five years,
12:30
I'm starting to see that it's part of the main culture of medicine.
12:33
It's the primary understanding,
12:35
I think, in medical practice that cannabis has just changed as a substance.
12:39
but again, you know, that's 10 years after really the changes started happening.
12:44
So it takes time. Anything, anytime research happens in medicine,
12:47
there's a delay in translation to practice,
12:49
right? And there are a lot of cultural factors at play there.
12:51
People kind of want to see studies replicated,
12:54
see the evidence determined over and over again.
12:56
But I think that the culture is now shifted in medicine where people
12:59
are really starting to understand this change in cannabis.
13:03
Yeah. With for like inpatient docs,
13:08
people who are inpatient psychiatric units or kind of like yourself,
13:13
CL psychiatry. What are people seeing?
13:19
I guess what are clinicians missing with cannabis related complications?
13:23
How do they show up within the inpatient setting,
13:25
especially for like people who are daily users,
13:28
the Wake and Bakers per se?
13:30
Right, yeah, exactly. I think if I if I think about it from
13:34
the perspective of someone who,
13:36
like starting with inpatient psychiatry or emergency psychiatry,
13:39
right? So some of the most interesting experiences I had
13:43
in emergency psychiatry here as a resident was seeing people coming
13:46
to Colorado for cannabis tourism.
13:48
~ and one of the effects, for example,
13:51
were edibles. And so with edibles,
13:53
it can take 90 minutes to two hours to start really feeling the effect
13:56
of the cannabis.
13:58
And that leads to people maybe after 30 minutes saying,
14:00
you know what? Maybe it's just not impacting me that much and ingesting more
14:04
and more of it. Plus, they're cookies,
14:06
candies, they taste good, right?
14:08
And you don't understand how you're gonna react to it.
14:09
So I would see really profound panic attacks,
14:13
anxiety. People would come in thinking that they had a pulmonary embolism,
14:17
a heart attack. And it turns out it was,
14:18
you know, panic from cannabis intoxication,
14:21
as well as psychotic symptoms,
14:23
right? So delusions and paranoia in particular.
14:26
~ and I know we'll go into a lot more detail about the evidence there,
14:30
but I think intoxication itself can certainly cause psychosis with
14:35
the paranoia in particular. And then you also notice some people have
14:38
a lot of cognitive blunting. So issues with short-term memory,
14:42
~ spatial tasks, processing speed can be pretty,
14:47
pretty remarkable. And then once someone actually gets admitted to the hospital,
14:51
so let's say within like the first day or so.
14:53
I think that we often underdiagnose or recognize cannabis withdrawal,
14:58
which is a huge issue and has actually been associated with discharging against
15:02
medical advice and is something that is treatable.
15:05
And then on top of that, of course,
15:07
it's, you know, sort of differentiating in this young person,
15:10
maybe with a family history of psychosis,
15:13
who has started using cannabis with new onset psychotic symptoms that haven't
15:17
resolved with intoxication. Is this actually a new schizophrenia?
15:22
Or is it more kind of a substance-induced psychosis and trying to parse
15:26
it out in someone who can't, you know,
15:28
has a hard time abstaining from cannabis use for more than a week or
15:31
two on the inpatient setting? And then on the medical side,
15:35
certainly, you know, considering diagnoses such as cannabis hyperemesis syndrome,
15:39
could it be contributing to issues like encephalopathy or delirium
15:43
as well as catatonia?
15:45
And I think one of the biases that I often see within myself and others
15:49
is people of certain ages. they wouldn't be using cannabis.
15:52
But I think we have to remember kids find edibles,
15:56
they think are gummies, they find brownies,
15:58
cookies, they eat them. So kids can come in with cannabis intoxication.
16:01
Older adults too, they use cannabis and sometimes are more likely
16:06
to become delirious with cannabis use than someone who's younger and healthier.
16:10
So I think there's a lot actually to consider from the psychiatric perspective
16:14
and cannabis use. And you know,
16:16
the struggle is that it's so new with these high potency formulations.
16:19
A lot of us weren't taught these things in medical school or residency.
16:23
So we're having to learn it along the way,
16:25
which can be really challenging.
16:27
Yeah. you you touched on a lot there,
16:29
so I like, we'll try to break it up a little bit,
16:32
but I'll I'll share kind of like a a funnyish story.
16:36
so my elder,
16:39
my uncle, ~ he is dealing with some effects
16:44
of a t type of adenocarcinoma,
16:47
a type of lung cancer. ~ and he's like,
16:50
you know, he's fighting it. He's going.
16:53
It's been a few years and he's going and and one of you know,
16:55
my I have a cousin, his daughter,
16:57
who is like a cannabis pharmacist.
16:59
So she does she makes like some suppositories for him.
17:03
And then, you know, whether it's you know,
17:06
he he sh you know, will knock on wood and say,
17:08
like, you know, he should have been gone a couple of years ago normally.
17:11
You know he's he's in his nineties and he but he's chugging along and,
17:14
you know, my mom's stock and myself and everyone's like,
17:17
you know, he's he's going and we don't know if these suppositories
17:20
are doing something or not for him,
17:21
but like he's going.
17:23
But the the s the funny part is or the story part is like,
17:26
you know, my cousin was making some stuff at home and was using like a little
17:31
~ a bowl to kind of create the suppositories and,
17:34
you know, sh kind of gave it a little rinse.
17:37
Then later ever, you know, my dad was over,
17:38
my mom was over, somebody else was over,
17:41
and they were making like breakfast omelets and they,
17:43
you know, end up using the same bowl without giving it a proper rinse.
17:48
So my dad is
17:49
you know, to my knowledge, has never used cannabis before.
17:52
He's like seventy something years old.
17:54
And, you know, they eat the omelets and my ~ I think one of my other cousins
18:00
was over as well at the time. You know,
18:02
a few hours later they start feeling ill and,
18:04
you know, they're like, What's going on?
18:06
My cousins like gets they get in the emergency room or the ambulance comes over,
18:09
takes them to the emergency room.
18:11
You know, it becomes the becomes the whole thing where like someone's having
18:14
a panic attack. My dad is like,
18:16
What's going on? And again, like you know
18:19
Luckily it was just an emergency room,
18:20
nobody got admitted and they you know,
18:22
they did a the drug test and were like,
18:24
it's cannabis and what's going on here and then they were like they know they're
18:27
able to the detective work and find out what was going on.
18:29
But and that's, you know, a funny story in the moment,
18:32
but or in retrospect a funny moment,
18:34
but in the moment everyone's kind of like freaking out and being like,
18:37
What's what's happening right now?
18:39
Right, especially if you don't know that that was what you were exposed to.
18:41
It could be a number of things that are scary.
18:43
Yeah. Yeah, especially like on someone someone who's like seventy something years
18:46
old, kn naive to it, it's like a a whole whole situation.
18:50
but you know, luckily all's well that ends well.
18:53
But
18:54
Well I'm glad to I'm glad to hear your uncle's doing so well.
18:57
Yeah. So
18:58
yeah, it's a good thing. ~ which is it's interesting,
19:03
right? Because we have we we talk a lot.
19:06
I know in the in the preface of the article you talked about something about like
19:11
this is kind of like some we're focusing a little bit on the negatives,
19:13
but there are potential positives,
19:15
right? So tell us a little bit about that.
19:17
Like so and we'll pivot a little bit for that.
19:20
Like some some of the positives that come from cannabis.
19:23
What are some
19:24
potential uses that we have. I think we we all know I think from medical school
19:27
at least like, you use it for like appetite and like chemotherapy patients.
19:31
But like aside from that, what else we got?
19:35
Yeah, so that's of course the main one.
19:37
When you think about jabinol, right?
19:38
Sort of our medical ~ formulation of THC.
19:41
It's FDA approved for both the nausea and vomiting related to chemotherapy,
19:45
but as well as appetite ~ for folks struggling with HIV/AIDS-related illness.
19:51
so those are two of the technical FDA-approved indications.
19:55
But there also is some data for other symptoms.
19:59
So, for example, spasticity due to a variety of neurologic illnesses
20:03
can be managed with cannabis. ~ and we'll talk a little bit more about this,
20:07
but even within psychiatry, I think with short-term use,
20:11
people do report improvement in things like REM sleep disordered behaviors,
20:15
sleep onset, ~ acute anxiety and PTSD symptoms.
20:19
Though the long-term results turn out to be not associated with improvement,
20:24
but I think it's important.
20:26
That we recognize again, cannabis is very complex.
20:29
Again, there are over a hundred chemicals.
20:31
And I think that we need to be really nuanced with our take on it.
20:35
It's not all good, it's not all bad.
20:37
It's complex, like most things in life,
20:39
and most things, especially in psychiatry.
20:42
And so I really appreciate that you asked that question because I think there
20:45
are a lot of people who have found incredible quality of life improvement with
20:50
cannabis-related products. And I think it's important to validate that experience.
20:55
While simultaneously making sure that we're doing the due diligence
20:58
of researching some of the other unintended consequences
21:01
or negative adverse effects, so that we can provide folks with
21:05
a really balanced take of risks and benefits so they can make decisions that
21:09
are best for them as individuals.
21:12
Yeah, it's it's one of those things I get into the conversation with especially
21:16
the teens, right? When they're like,
21:17
you know, this is helping me for my anxiety.
21:19
And it's like, Well, I'm I'm not gonna lie to you and say that I can't do that.
21:23
You know, like you know, it doesn't make it's not genuine of me to kind
21:27
of take that approach and say,
21:27
Well, no, you're wrong, even though you're saying you you're saying that it's
21:31
helping your anxiety, I I'm gonna tell you that you're wrong.
21:33
Like, no, it you I've I've lost the rapport already from day one if I if
21:36
I start off with that approach.
21:38
So
21:39
It's something, yeah, like you're right,
21:40
we have to kind of balance. It is nuance.
21:42
Nuance isn't always sexy when we're trying to like get clicks and headlines
21:45
and all that stuff out there. But it's something that is we have
21:49
to understand that a lot of it comes with exposure and then dependence,
21:54
tolerance, all that comes along with with the cannabis use as a whole.
21:58
Right. And I think actually another topic that is is important and fairly recent
22:02
is that for the first time, cannabis use has actually outpaced use of alcohol,
22:08
especially with kind of more moderate usage.
22:10
And younger generations are really replacing a lot of alcohol use with cannabis.
22:15
And I think an argument can be made from like a harm reduction perspective
22:19
in that sense, right? Because alcohol is not benign despite it the fact that
22:23
it has been so ingrained in our culture and legal for so long.
22:26
so I think that you know, there are a lot of purposes of cannabis.
22:30
So again, it's really about just making sure we have good understanding
22:34
of these risks and benefits so we can really help counsel people.
22:37
Yeah, I I always kinda like talk about that when I talk about like substance
22:41
use and talks. So it's like we always asked to like do the opioid talks
22:45
and like the cannabis talks. But then it's like we have to remember
22:49
the alcohol is like it's on a whole different chart,
22:51
whole different level. ~ like It's a killer.
22:53
Yeah. It's it's it's terrible.
22:55
And we we just kind of like
22:58
assume that it's there and then just be like we're just throw our hands
23:01
up and just say we can't do anything about it.
23:02
It's like no, it's we could do it.
23:04
And then yes, it's it's great that like I get your you pointed out that like
23:07
the alcohol use has dropped while cannabis has kind of like taken over that.
23:11
So it's like again, is it the greatest thing?
23:13
Maybe, maybe not, who knows? But it's it's something that we're seeing from
23:18
a harm and point of view. Yeah,
23:19
absolutely. So Yeah. You talked also about like withdrawal.
23:24
So talk to us about the cannabis withdrawal because that's something that's
23:28
Interesting, I think people don't always understand it or underestimate
23:31
it at times too.
23:33
Yeah, absolutely. So you're again,
23:35
you're gonna hear this theme over and over again the increased pot potency,
23:39
right? So I I think of it as dosage.
23:40
~ so 20 years ago, you would have to smoke so much weed to
23:44
get the THC concentrations that you can get it with casual use today.
23:48
And so with higher doses, your body is reaching homeostasis with regular usage,
23:55
similar to regular alcohol use,
23:56
right? And so if you abruptly stop that,
23:58
say with a medical admission, for example.
24:01
All of a sudden, that substance is no longer in your brain.
24:04
And ~ often people will experience symptoms of cannabis withdrawal within about
24:09
24 hours of cessation. And so symptoms often will include things like irritability,
24:15
anxiety, insomnia. ~ they'll have difficulty with focusing
24:21
and even somatic symptoms like nausea,
24:24
~ tremors, or diaphoresis. It's really uncomfortable.
24:28
I think part of the reason we overlook it is it's just not one
24:31
of the withdrawal syndromes that leads to significant medical outcomes.
24:35
And so it tends to be sort of minimized,
24:37
right? Especially in the inpatient setting where we're really thinking about,
24:40
okay, what is acutely going to harm this patient right now.
24:43
However, because it has been associated in studies with self-directed discharge
24:49
of patients, it can indirectly lead to adverse medical outcomes,
24:52
right? If someone's sitting there similar to nicotine withdrawal
24:55
and we're not treating it.
24:56
They're totally uncomfortable.
24:58
They just want to get out of the hospital,
25:00
not be there anymore. And they might actually not treat the medical cause that
25:05
led them to the hospitalization in the first time,
25:07
which could lead to worsening and bad outcomes.
25:10
Yeah, I I think a lot of people underestimate the effect of like that withdrawal
25:14
and that that craving for it. I've had you know,
25:18
like when I was when we had PHP where I was working,
25:20
partial hospitalization program and teens coming for that,
25:23
like I've had patients eloping from the building,
25:26
running into the streets literally just 'cause of the nicotine
25:30
and cannabis withdrawals and there's like people don't under don't under you know,
25:35
they just don't realize that this is some of the effects of this is like people are
25:39
It's really hard to just stop it and say,
25:41
like, no, you have to just not use it while you're here for these six hours a day.
25:45
Yeah, exactly. Like easy peasy,
25:46
right? And I think too, especially if you have underlying psychiatric conditions
25:51
that you're sort of treating with these ~ substances,
25:54
let's say PTSD, for example. And now we take this substance away,
25:57
we put you in this acute medical care setting where you have very minimal agency.
26:01
People are touching you without your permission,
26:03
bugging you all the time. You're already becoming irritable.
26:06
You have hyper vigilance symptoms,
26:08
hyper arousal. It just can really exacerbate psychiatric symptoms in
26:12
the hospital in particular.
26:14
So on that like level, what could hospitals do,
26:18
~ inpatient teams, what can they do to kind of manage withdrawal,
26:23
cannabis withdrawal, ~ to prevent these discharges,
26:27
AMA discharges?
26:29
Yeah, I mean, I think that cannabis,
26:31
you know, screening should be a part of any medical
26:34
and psychiatric screening interview on admission.
26:36
Obviously, some people are too medically acute.
26:38
Let's say after a car accident,
26:40
they're admitted to a trauma surgical team.
26:42
You know, oftentimes they do that sort of first initial trauma evaluation.
26:47
And then once the patient's stabilized,
26:48
they go back and do their second evaluation.
26:51
The similar can be said for a lot of like our social and substance history
26:54
in in patients. So once the patient's more medically stable,
26:57
Go back and ask them these questions that are actually really important,
27:01
particularly with substance use.
27:02
And I think cannabis should always be included.
27:06
And when we're evaluating cannabis use disorder,
27:08
we're not just asking, like, hey,
27:10
do you like smoke weed? ~ you want to ask them questions like what formulation,
27:14
if they know the THC concentrations,
27:17
~ you know, are they doing things like the chai concentrates?
27:21
Are they doing flour? You know,
27:23
are they smoking? Are they ingesting,
27:25
for example? So you want to know.
27:27
Formulation and the potency, so you can have a better understanding of the dose.
27:30
So, how frequently are they using it throughout the day as well is going
27:33
to be really important. And then,
27:34
of course, last time they used it.
27:36
So, if they used it a couple weeks ago,
27:38
I'm not worried about cannabis withdrawal.
27:39
If it was, if they're using heavily daily and last use was yesterday
27:43
and now they're feeling irritable,
27:45
that might be the cause of it.
27:46
And so I think from my perspective,
27:49
like anything, if you're thinking about it.
27:52
Then it's easier to diagnose it and easier not to miss it.
27:56
And I think it's it can be such an easy thing to treat,
27:59
in a sense, in the hospital. ~ so there have been some studies actually,
28:04
quite a few trials looking at treatment of cannabis withdrawal.
28:07
~ there have been some antidepressants that have been looked at,
28:11
and nothing has shown good effect aside from mertazepine,
28:14
which might help with insomnia and appetite,
28:17
but actually has no effect on cravings or rates of relapse.
28:21
they've looked at baclefin, which can be helpful with cravings,
28:24
but worsened sleep and cognitive performance.
28:26
Gapapentin actually can be really helpful.
28:29
That's one that I'll occasionally use,
28:30
depending on what else is going on.
28:32
In particular, this one trial found that it was helpful for improvement in cravings,
28:36
withdrawal, and executive functioning.
28:38
quitiapene is the only antipsychotic that I found studied.
28:43
But it does in another trial was found to be significantly associated with reduced
28:48
cannabis withdrawal symptoms, generally compared to placebo.
28:51
~ And interestingly though, it did not improve sleep,
28:54
which I was surprised by. Zulpinum,
28:57
you can use to sleep for sleep as well as sleep architecture,
29:00
which a side note, cannabis, like we mentioned earlier,
29:04
it can help treat REM sleep behavior disorders.
29:07
And part of that is because it actually reduces.
29:10
It increases time to REM sleep as well as reduces the actual ~ time of REM sleep.
29:16
And so it can be really helpful for those behaviors in the short term.
29:20
You can imagine how important REM sleep is for memory and learning
29:24
and just feeling not fatigued the next day.
29:27
So that's where Zulpinum can come in and be helpful in particular.
29:31
Guanfacine has also been looked at for irritability and improved sleep.
29:34
I actually really like guanfacine in the hospital,
29:37
especially because I do see a lot of patients with significant trauma histories
29:42
who have exacerbation of hypervigilance and hyperarousal in the hospital.
29:46
So it's a nice go-to. There is some more evidence looking at NAC
29:50
and to pyramate more long-term for cravings,
29:52
especially in adolescence.
29:54
And then given the ~ benefit of agonist replacement therapy and other conditions,
29:58
right, like opioid use disorders,
30:00
alcohol use disorder, there has been a lot of focus in research
30:03
on CB1 receptor agonists like drenabinol,
30:06
which we mentioned earlier. And that has actually been found to
30:09
be associated with decreased cravings,
30:11
increased appetite, improved mood,
30:14
and decreased tension in three separate studies.
30:17
~ so they found that it works in a dose-dependent fashion.
30:21
And so what I'll I'll often actually start with drenabinol,
30:24
the really the biggest issue that I see is people underdose.
30:28
So generally you want to start at minimum with a dose of 10 milligrams three times
30:33
a day. And often what I'll see is like 2.5 scheduled twice daily,
30:37
because those are often the doses we'll use before,
30:39
say like lunch and dinner in patients struggling with appetite who have cancer.
30:44
For cannabis withdrawal, you need to get up there with the doses.
30:46
So start with 10, three times a day and don't be afraid to increase that dose
30:51
quickly based on withdrawal symptoms.
30:53
And then I'll I'll oftentimes adjunct to with these other meds that I mentioned,
30:57
like the guanficine, the mertazepine,
30:59
quatiapine, based on other medical and psychiatric diagnoses or symptoms,
31:05
and trying to, you know, kind of theoretically hit multiple birds with
31:08
one medication while they're in the hospital.
31:12
It's it's you know, for all the psychiatrists and everybody else listening
31:16
is like get your template ready of like how you know,
31:19
optimize your template for how to do a substance use history.
31:22
And like I I think what you're talking about it was like the right w right
31:26
way to do it, like what there's what they're using,
31:28
how they're using it, how much,
31:29
how often, you know, and especially last use,
31:32
you know, whether again like it's the week before or it's,
31:35
you know, in the waiting room right before or the bathroom right before
31:39
the appointment, cause
31:41
That happened to me somewhat recently where I was like,
31:43
I shared the bathroom. I was like,
31:44
I smell something in here that shouldn't be here in this bathroom.
31:48
And then now I see you in my office.
31:50
I was like, I s I know what's going on here.
31:51
So that that happens.
31:53
Yeah. And actually really something to always consider if your patient
31:57
has a a mental status change that maybe lasts for a few hours in the hospital.
32:01
Super common for patient to take edibles,
32:04
vape in the bathrooms, in their hospital rooms,
32:06
right? Like family members will bring it in or they just have
32:09
it in their belongings. So always have ~ substance use on your radar for patients,
32:15
even if they've been admitted for weeks to months.
32:18
Tell us a little bit about I know people are familiar with cannabis hyperemesis
32:22
syndrome, they are familiar with the term,
32:24
but can you tell us a little bit about that a as a whole?
32:28
Yeah, I think, you know, I think actually some of my residents will ask me,
32:32
wow, why do you know so much about cannabis hyperemesis syndrome?
32:35
You're a CL doctor. This doesn't make much sense.
32:37
~ but I think that it we actually get consulted a lot for these patients.
32:41
so backtracking a little bit, cannabis hyperemesis syndrome was only first described
32:47
in 2004. So it's actually a really new diagnosis,
32:49
really recent. ~ and like I mentioned earlier,
32:52
translation to practice takes time.
32:55
Really, it's defined as symptoms of cyclical vomiting related to high dose cannabis
33:01
use that's associated with compulsive use of hot baths and showers
33:05
to control symptoms, which I'll expand upon in a minute.
33:07
they do have something called the Rome diagnostic criteria that was updated within,
33:12
I think, the last few years that requires symptoms to be present for
33:15
at least three months. Episodes tend to last under a week.
33:19
You have to have at least three episodes in the past year.
33:22
And there should not be vomiting in between episodes.
33:24
So you pretty much return back to normal functioning between episodes.
33:27
~ a lot of these patients are young and healthy,
33:30
and they'll just show up to the ER during an acute episode while they're
33:34
in the emergency department. As long as the workup doesn't show any,
33:37
you know, severe infectious, emerging etiologies,
33:40
the doc will be like, okay, you know,
33:42
nothing severe going on. Get some rest,
33:44
drink some fluids, come back if these things happen.
33:47
And because they
33:48
Get back to feeling better within a few days,
33:50
they often, you know, these patients often don't show up to their PCP to
33:52
try to get a diagnosis. So, one of the issues with cannabis hyperemesis syndrome
33:56
is that there's a super long delay in diagnosis,
33:59
you know, you know, five to ten years for a lot of people going through this,
34:03
which you can imagine is a long time to be suffering with chronic intermittent
34:07
nausea. And the description of cannabis hyperemesis syndrome probably sounds
34:11
familiar. it's really similar to cyclical vomiting syndrome.
34:14
Some people actually consider it as a subtype.
34:17
Of cyclical vomiting syndrome,
34:18
but that where and where we know the exposure and the actual etiology
34:23
and cause of it. ~ so patients are often initially diagnosed with cyclical vomiting
34:28
syndrome. And if you're again,
34:29
if you're not thinking about it,
34:31
you're not gonna ask about cannabis use.
34:33
But when you are taking a history when it comes to cannabis hyperemesis syndrome,
34:37
~ 90% of patients in one large study actually reported improvement with
34:43
hot showers and their symptoms.
34:45
That is a very specific feature of this diagnosis.
34:48
Always include it when you have cannabis hyperemesis on your radar,
34:51
because that is really, really specific to this diagnosis.
34:56
Then the other part to so let's talk about you mentioned before kind
35:03
of the correlation versus causation with cannabis and it's this hot button topic.
35:09
I think you know, I don't know if we're ever gonna get like a real true answer
35:13
on it, but you know, schizophrenic form psychosis,
35:17
psychotic spectrum disorders and cannabis use,
35:21
again, correlation and causation.
35:23
We know that there is a correlation there that is
35:26
undeniable is it causing it that's T B D,
35:30
but can you expand expand on that a bit?
35:34
Yeah, I mean, I think you raise really the three big questions that I think
35:37
we have when we're looking at this is one,
35:40
does cannabis directly cause schizophrenia?
35:42
Two, are individuals with schizophrenia more likely to
35:46
use cannabis to self-medicate?
35:48
Or three, does cannabis increase the risk for development of psychosis
35:52
in someone with genetic predisposition?
35:54
Right. So I think those are the three questions that I have when it comes
35:57
to the research.
35:59
You know, I think the challenging part is that psychiatric research,
36:02
especially for rarer outcomes,
36:03
it's expensive, it's time consuming.
36:05
And then you have ethical implications of giving people THC in
36:09
a randomly contr randomized controlled trial and seeing if they develop
36:12
a psychotic disorder, right? So most of our information at this point
36:15
is based on epidemiologic studies.
36:17
These are really helpful, like you mentioned,
36:19
for determining association, but less indicative of causation.
36:23
So it can be challenging because there are so many confounding factors.
36:28
More recently, because of the increased prevalence of cannabis access use,
36:33
these changing formulations, there has been a lot of ~ research
36:36
in psychiatry looking at cannabis use and risk for specific symptoms and diagnoses,
36:41
with psychosis, I think, being the one that's been most heavily examined.
36:44
~ a few things that I think stand out to me based on the research.
36:48
One, it's well established that intoxication with cannabis can lead
36:52
to psychotic symptoms while intoxicated,
36:55
right?
36:55
~ and then there does seem to be a dose-dependent nature to that.
36:59
So we do have some more kind of prospective or retrospective studies that look more
37:04
at this kind of causation question.
37:06
~ they found that more frequent high potency use is associated with increased risk
37:12
for development of psychotic symptoms.
37:13
And by more frequent use, I'm talking at least weekly,
37:17
more likely daily.
37:19
There was in this one study that I examined,
37:21
there was no association with risk for development of schizophrenia
37:25
or psychosis in patients he used more recreationally,
37:28
say once a month or a couple of times a year.
37:31
so I think at this point, you know,
37:33
the what my takeaway as a psychiatrist is that I don't know if
37:39
it directly causes schizophrenia.
37:41
But I do think that there's enough information that tells me that exposure,
37:45
especially in people with a genetic predisposition,
37:49
increases the risk for development of schizophrenia.
37:52
And again, would they have developed schizophrenia regardless?
37:55
It's hard to say because we don't have,
37:57
you know, this kind of alternate world where we can do the exposure and
38:00
not do the exposure. But I have enough data to say that that population
38:04
in particular, people with a family history,
38:06
particularly adolescent brains.
38:09
That I'm really, really concerned about.
38:11
And I think that the adolescent piece,
38:13
as a child adolescent psychiatrist,
38:15
you are well aware of this, is so important.
38:18
So something to keep in mind is that CB1 receptors,
38:22
which are part of our endogenous cannabinoid system,
38:25
are really critical, both during fetal development,
38:28
but again, actually during synaptic pruning and adolescence.
38:32
And because of this activity, ~ it's it's important for development of learning.
38:38
For neurodevelopment. And we've found that people who have chronic exposure
38:43
to CBD have downregulation of CB1 receptors during this critical neurodevelop
38:50
developmental time, which has been associated to adverse outcomes
38:54
in things like learning, ~ occupational functioning,
38:58
as well as even more long term IQ issues.
39:02
And on top of that, that is probably a time that's incredibly important
39:06
in the development of schizophrenia.
39:08
Yeah, I like you mentioned, I I when my teens patient comes in there,
39:14
I always tell him I was like, you know,
39:16
if if we're having this discussion ten years from now,
39:19
it's a different story, right?
39:21
But right now, I always tell you guys it's like try to avoid it right now.
39:25
Try to avoid like the heavy use right now.
39:27
Yeah. 'Cause your brain is going through those changes and your risks are there.
39:32
You know, I can I can't say for sure that this is what is gonna cause
39:36
you to become a psychotic, but we
39:38
We know that there is a relationship that exists.
39:40
Association Napolie exists that we can't can't argue with really.
39:44
Yeah, and I think like anything in medicine that does have such like polygenetic
39:48
risk factors, you want to think about environmental exposures.
39:52
What can I reduce environmentally to at least reduce the risk of someone developing,
39:56
say, this cancer, this autoimmune disease?
39:58
Same thing with schizophrenia.
39:59
How can we reduce those environmental insults so that someone has the best chance
40:03
of having this healthy, productive life?
40:06
Yeah. On the opposite spectrum from like our teens and adolescents,
40:10
we have like delirium and then also I mean,
40:12
catatunia also pops in here and there,
40:14
but like let's talk about delirium and catatonia because I think that's something
40:18
that a lot of people don't always talk about with cannabis.
40:21
They don't know what's associated with that.
40:23
Yeah. So ~ with catatonia and delirium,
40:27
you know, I most of us as healthcare clinicians,
40:30
we work through illness scripts.
40:32
You know, these illness scripts are developed over time through experience
40:35
and attained knowledge. It's a wonderful framework that allows us skills that
40:40
are beyond what a Google search or even these large language models can reproduce.
40:44
But sometimes our scripts can actually contribute to anchoring
40:47
and confirmation bias. So again,
40:50
I sound like a parrot here.
40:52
Cannabis has changed so much in the last 15 years.
40:54
So if we sort of grew up in this time of medicine where we learned about delirium
40:59
and catatonia, ~ you know, let's say in the early 2000s and the 90s,
41:03
it was not something that was clearly associated.
41:05
But when I did a literature review,
41:07
what I found was really in the past 15 years,
41:10
people are starting to write up case reports and case series.
41:13
Yeah, it's not the most robust ~ kind of evidence base,
41:18
but I do kind of wonder.
41:20
how that might be in relation to the increasing potency of cannabis.
41:24
So for example, ~ let me see if I can find it here.
41:27
So there was ~ a really comprehensive literature review that actually sorry,
41:34
we might have to backtrack. I found it.
41:36
Okay. I don't know if we could just edit that part out.
41:38
Okay.
41:39
so I did find there was a comprehensive literature review published in 2024,
41:44
and they identified 26 cases, so case studies or case series
41:47
of catatonia associated with cannabis or synthetic cannabis use.
41:52
~ out of these cases, 84% were male,
41:55
aged 15 to 36. Eleven had a history of synthetic cannabis use,
41:59
15 with recreational or medical use.
42:01
Interestingly, you know, in the majority of these cases,
42:04
they did a Naranjo score.
42:06
And determined that the cannabis was the most likely etiology of the catatonia.
42:11
And very few of these cases had any psychiatric history.
42:15
~ And so when I think about synthetic cannabis in particular,
42:20
we know that it's quite potent and it really binds strongly to the
42:24
CB1 and CB2 receptors. And so when we compare that to these changing concentrations
42:31
and potencies of cannabis in these modern strains and concentrations.
42:35
I have to ask the question, you know,
42:37
is modern cannabis more similar to these synthetic cannabinoids
42:43
in some sense than it is to the traditional formulations of cannabis that
42:47
we were using prior to twenty,
42:49
thirty years ago. And if that's the case,
42:52
then I I have a feeling we're gonna see more cases of catatonia associated with
42:56
cannabis in cannabis withdrawal.
42:58
Yeah, I I agree. I I mean I you know,
42:59
I always kind of say when I'm talking w teaching to like
43:02
the residents and everything and people online is like dose makes the difference.
43:06
Right. What's you know, like the difference between like desoxin,
43:10
methamphetamine that you pick up at the pharmacy versus methamphetamine that
43:14
you buy in the streets is dose,
43:15
right? Like that's that lithium.
43:17
Look at lithium.
43:19
Right. Again, lithium oritate that like people are like using as
43:21
a supplement to like, you know,
43:23
balance their mood out versus,
43:24
you know, lithium toxicity. Like again,
43:26
this this is the dose makes a difference with everything.
43:29
And it's the same with cannabis,
43:30
alcohol, et cetera, everything that's there.
43:32
So good.
43:34
And I think one one way I like to approach these,
43:36
I cause you know, I think especially this is the case in CL and academic centers,
43:40
we see some weird stuff, less common,
43:42
rare things. And I always try to take a step back and think about okay,
43:45
what is the possible underlying pathophysiology that's happening here?
43:49
Does this make sense conceptually in a logical sense?
43:53
~ and so, you know, we do know that THC can actually increase the brain's
43:58
~ levels of GABA.
44:00
And decrease glutamate. And so abrupt cessation from THC can actually
44:04
put both of those ~ neurotransmitters out of balance
44:07
and theoretically develop catatonia.
44:09
THC also impacts NMDA receptor activity,
44:13
right? So again, that's something that we see in catatonic syndromes.
44:16
It's part of our treatments. so I think if you know the theory makes sense,
44:19
then it might be worth considering it and at least looking into data,
44:23
starting with case series, case studies,
44:25
collecting that and then going to higher levels of evidence.
44:29
And another part that we have to like understand and realize is that like THC,
44:34
C B D cannabis as a whole, like doesn't always play well with our medications,
44:39
correct?
44:40
yeah. definitely. Yeah,
44:43
I think this was one of my biggest takeaways,
44:46
actually, kind of going through and putting this paper together.
44:49
so we've talked a lot about sort of,
44:51
you know, the brain and the function of cannabis on different receptors.
44:55
But one thing that's really important for psychiatrists and really
44:58
any medical provider that's prescribing medications are going to
45:01
be metabolism and drug interactions.
45:03
~ so these usually occur through the SIP enzymes.
45:08
So 2024 study actually found that most drug classes have the potential
45:12
to interact with cannabis through CIP enzyme reactions.
45:15
So THC is metabolized by CIP2C9 and CYP3A4.
45:21
And it also acts as a competitive inhibitor for a bunch of other CIP enzymes.
45:25
And then similar to cigarette smoking,
45:28
smoking cannabis can produce these polycyclic aromatic hydrocarbons that then
45:34
induced CYP1A2.
45:36
Enzymes, so that can impact the metabolism of a ton of different medications,
45:40
including including, of course,
45:41
clozapine. ~ so these different SIP interactions can then affect serum levels,
45:46
both of the drugs, as well as cannabis itself.
45:48
And I think we have to keep in mind too,
45:50
THC is super lipophilic, so it stores in the fat for a very long time
45:55
and can continue to leach out well after cessation.
45:58
So you really want to think about interactions with cannabis like weeks
46:01
to maybe a month or two after someone discontinues usage.
46:05
Yeah, it's it's, you know, for all the med students who may be listening,
46:09
it's another another thing to add to those charts about the CYP enzymes that
46:14
we have to remember. And just again,
46:15
as it becomes more and more prevalent,
46:17
we have to be aware that it's gonna interact.
46:20
And, you know, I think we see it a lot of times when parents come in again from
46:24
to my office and they ask, like,
46:26
can can the kids smoke on this or use this while they're taking some of their SSRIs?
46:31
And it's like ideally not. But you know,
46:34
like
46:35
We have to be be realistic and understand that it's gonna happen and
46:38
and the effects that are can occur with them.
46:41
Exactly. And I think it's it's interesting.
46:44
It's something that comes up a lot in transplant evaluations and not just because
46:48
of the direct effects of cannabis and smoking on whatever organ systems involved,
46:52
but because of the interactions with a lot of the transplant medications themselves.
46:56
Yeah. And seizure meds too, right?
46:58
~ huge seizure meds. And especially with like,
47:02
you know the then investigations of CH or THC in seizure Medicaid
47:08
as as an anti epileptic itself,
47:10
~ that's something we just have to be aware of as well.
47:14
Right.
47:15
Exactly. And valproic acid, which is a very common med in psychiatry.
47:19
Yeah.
47:20
Do we as we kind of like wrap it up a bit,
47:22
like s stigma. I know we're again like we we're the article kind of gives that
47:27
a little disclaimer, kind of like then we're talking in the negatives about it.
47:30
But like as we kind of like talk about that,
47:35
how do we avoid recreating stigma around cannabis so that yeah,
47:40
our patients can be honest and we can help them the best?
47:43
Because you know, honesty is the best policy and you know,
47:46
we we want our patients to
47:47
let us know what's going on so we can help them the best and we have
47:50
the most information to do so.
47:51
How could we just kind of say,
47:53
like, let's not stigmatize this and shame on you for using this and this
47:57
is what happens if you do it.
47:59
I know I actually even struggled in,
48:01
you know, thinking about submitting this article for publication or even coming
48:04
on this podcast and talking about it.
48:06
You know, is you know, I'm I am talking about all these negative impacts
48:09
in the medical setting. How might that contribute to stigma?
48:13
Right. I don't want to be harmful in that way.
48:14
So, you know, I think the big thing again is is taking that step back
48:19
and remembering that life has so much nuance and gray in it.
48:22
~ and in particular when it comes to even our medications we use,
48:27
right? I mean.
48:28
There are risks and benefits of so many meds,
48:30
especially in psychiatry. I almost take the same perspective on cannabis.
48:34
You know, what is the reason that someone's using the cannabis?
48:37
Having that very non-judgmental approach with the patients,
48:41
but also not feeling that internalized stigma myself,
48:44
right? So if I'm tiptoeing around the cannabis use,
48:46
I'm not normalizing it, right?
48:48
And I'm making them feel judged in a way where it's this kind of dirty topic that
48:52
we're talking about.
48:53
versus me just kind of outright asking about it in kind of a normal manner,
48:57
using language that people often use in the community and not trying
49:00
to over medicalize everything.
49:02
So I think coming at it as a from that very judgmental,
49:05
motivational interviewing perspective,
49:07
right? Trying to discover what is it about cannabis that keeps keeps
49:11
you going to it? What is it helpful for?
49:13
What do you like about it? You know,
49:15
how is it impacting your life in a negative way?
49:17
And having the patient tell you and kind of come up with that and really
49:20
say it out loud to themselves.
49:22
is really important. And then again,
49:24
I think all we can really do as psychiatric providers is try stay as up
49:29
to date on this very evolving ~ wide breadth of literature on this topic
49:35
and do the best we can to be a good consultant to our patients and give them
49:39
a much as much information that's not biased on the risk and benefits
49:43
so that they can make that well informed decision on their own.
49:45
Yeah but yeah, never shame someone for anything like that.
49:49
That's a good takeaway.
49:50
Yeah, I'm I'm glad to hear that like we've got that overlapping in in regards
49:53
to ask how we're asking the questions of like what what are you what's
49:57
it doing for you? You know, like and just kind of like you ask that question
50:00
a lot of times when you lead with that question of like instead of saying
50:04
why are you using it, saying right,
50:05
we're what's it doing for you?
50:07
What what are you getting from it positively that changes the whole tone
50:11
of the conversation and allows hopefully openness and then again being able
50:15
to synthesize that information and
50:18
come up with whatever treatments or helps that they're looking for and just yeah,
50:21
understanding that part of it.
50:22
So
50:23
Yeah, exactly.
50:25
Wrapping up again, big big picture.
50:27
What are you hoping after like reading this article,
50:29
listening to this podcast, what do you hope that psychiatrists,
50:32
trainees, doctors as a whole, society maybe,
50:35
what do they get from this?
50:38
I think the big takeaway, honestly,
50:40
is coming down to that whole conversation about dose and you know,
50:44
what is the actual specific compound.
50:46
~ so I think that remembering cannabis as a word can mean
50:52
so many different things, right?
50:54
It can mean sort of traditional 4% flour,
50:57
~ or it can mean this 90% concentrate.
51:00
And those two substances are completely different and have totally different effects
51:05
on the body.
51:06
so really getting down and asking someone,
51:08
what are you using? How much of it,
51:10
when, what's the frequency, right?
51:12
what's the route of utilization?
51:14
I think that thinking of it in terms of dosing is really key to help
51:19
us from there extrapolate, okay,
51:21
is this actually kind of a concerning dose and formulation?
51:24
If so, then we can go down this route of education working on it versus maybe it's
51:29
something that they're using infrequently,
51:31
like once a month recreationally,
51:33
and it's having no adverse effects,
51:35
right?
51:35
So I think that's probably my biggest takeaway.
51:38
And then number two would just be to remember that if you're not thinking about it,
51:42
you're not going to ask about it and you're not going to diagnose it.
51:45
Right. So having this index of suspicion for cannabis being related
51:49
to different issues, whether it's anxiety,
51:51
insomnia, catatonia, vomiting cyclically,
51:55
all of these different conditions that can be related to heavy cannabis use.
52:01
especially as it becomes more and more common as it's recreationally legalized.
52:05
I think we're only gonna be seeing more of these conditions.
52:07
So as long as it's on your mind on your radar and you're asking about it,
52:11
then everything kind of works out from there in terms of identification.
52:16
Yeah. And I always kinda like to ask ~ our guests on here,
52:20
Doctor Murray, what do you like to do for your own self care?
52:24
~ before just you know, we have to as we want to make sure that
52:27
we have psychiatrists are around for a long,
52:30
long time. So yeah.
52:31
I I love that question. I have gotten super into native plant gardening,
52:37
which I always joke that gardening in Denver is on hard mode because
52:40
our weather is so extreme here.
52:42
And we probably only get about five months of real flowering gardening weather.
52:46
~ but I have been slowly replacing my entire yard with natives
52:50
and this season especially have noticed so many more birds and pollinators that
52:55
I am just delighted. So that has been my major self-care the last couple of years.
53:00
Awesome.
53:01
Awesome. Awesome. Well, thank you so much,
53:02
Dr. Murray, for joining us on this very,
53:05
very relevant and on topical topic.
53:10
so this was our podcast for the month of June.
53:15
You can find it online, psychiatryonline dot org.
53:19
Again, the article is clinical considerations of cannabis use
53:22
in the inpatient medical setting.
53:24
~ please follow along with the podcast,
53:27
subscribe on
53:28
iTunes or all whatever the podcast apps are,
53:31
give us a like, comment, and let us know what you'd like to see and hear
53:34
in the future. And thank you again for joining us.
53:36
Thank you.