Featured topic and speakers
Learn about potential for cannabis addiction, withdrawal symptoms and overdose. Board-certified physician at Stanford Medicine, Smita Das, MD, PhD, MPH, reviews screening, models of care and treatment for cannabis use disorder.
Speakers
- Tricia Wright, MD, MS, DFASAM, OB-GYN and addiction medicine physician, University of California San Francisco
- Jesse Ehrenfeld, MD, immediate past president, American Medical Association
- Michael Suk, MD, JD, MPH, MBA, professor and chair, Musculoskeletal Institute and the Department of Orthopedic Surgery, Geisinger Health System; chair, AMA Board of Trustees
Listen to the episode on the go on Apple Podcasts, Spotify or anywhere podcasts are available.
Transcript
Dr. Ehrenfeld: Welcome to Moving Medicine, a podcast by the American Medical Association. Today’s episode is part of the Cannabis Education series, brought to you by the AMA Cannabis Task Force.
I'm Dr. Jesse Ehrenfeld, senior associate dean, tenured professor of anesthesiology and director of the Advancing a Healthier Wisconsin Endowment at the Medical College of Wisconsin. I'm also the immediate past president of the AMA and co-chair of the AMA Cannabis Task Force. Michael, take it away!
Dr. Suk: Thanks, Jesse. I'm Dr. Michael Suk, professor and chair of the Musculoskeletal Institute and the Department of Orthopedic Surgery at Geisinger Health System. I'm chair of the AMA Board of Trustees and your co-chair of the AMA Cannabis Task Force.
Through expert discussions and insights, this podcast series features information that can help physicians of all specialties understand cannabis and the health effects of cannabis use.
Dr. Ehrenfeld: The AMA forms mission-specific task forces like this one to tackle current medical issues in our nation. Make your voice heard by becoming a member today. Visit ama-assn.org/more. And now, on to the show.
Joining me today to talk about cannabis use and addiction potential, withdrawal and overdose is Dr. Smita Das, clinical associate professor in psychiatry and behavioral sciences at Stanford Medicine and American Psychiatric Association Council chair on addiction psychiatry.
Welcome.
Dr. Das: Hi, it's so great to be here.
Dr. Ehrenfeld: Dr. Das, thank you for taking the time to record this today. I'd like to start by discussing the addiction potential of cannabis. What do we know about the development of cannabis dependence and cannabis use disorder?
Dr. Das: That's a great question. I think the first thing I wanna make sure that I make very clear is that there is a such thing as an addiction to cannabis. There is a such thing as a cannabis use disorder. It's a widespread misconception that cannabis is not addictive. So often, I hear people surprised when I even bring up the topic. And what we know is that as access has increased through say state legalization, so does the cannabis industry and the potency of cannabis. As a result, the drug is even more powerful and is increasing that risk of cannabis dependence and addiction.
I'll briefly talk about the distinction between the two. So, dependence is usually the physical part of the symptoms of addiction, developing things like withdrawal symptoms when stopping, symptoms that don't feel good when stopping a drug and developing tolerance, or in other words, needing more to get the same effect.
When I have a patient who may have a cannabis use disorder, I like to discuss what that means. In the DSM-5-TR, which is the Diagnostic and Statistical Manual, or the book that describes all of the psychiatric diagnoses, including addictions, we consider an addiction to be there when someone has two or more of several criteria and are using a substance. This includes dependence, which I mentioned earlier, the tolerance and withdrawal.
But also includes other things that I really like to check in with the patient about. How is their use affecting their relationships? How is it affecting work, school? How much time do they spend getting it? Have they tried to cut down and have been unsuccessful? And so on. These are all elements of the DSM criteria. What this does is it helps a patient who's using cannabis and may not even have come in to see me for cannabis use disorder, but it helps them to start thinking about how cannabis is affecting their lives.
Currently one in 10 people who uses cannabis actually has a cannabis use disorder. And among people who are using daily, that number is closer to one in three. There is also, I mentioned how cannabis is increasing in commercialization. There's a correlation between commercial cannabis use and hospitalizations.
There's also been, interestingly and notably for many of the people listening, an uptick in cannabis-related ER visits in adolescents and young adults since the beginning of the COVID-19 pandemic. It's really important to point out that some of these groups are, like young adults, are more affected. Young people have all-time highs of use as well as daily use. As well as people who have mental illness are also at risk of using cannabis more.
Speaking of young people, again, a very recent NIDA study, the National Institute of Drug Abuse is NIDA, found that those who initiated cannabis use in their teenage years as opposed to after were double the risk of developing a cannabis use disorder compared to those who started later. So, it's really important to think about cannabis use in our patients, but furthermore, to consider cannabis use disorder or the addiction to cannabis and know that it is often something that might be lurking, but our patients may not come to us for initially.
Dr. Ehrenfeld: So, one challenge for physicians when caring for patients with cannabis dependence and cannabis use disorder is the risk of withdrawal or overdose. Could you speak to what a physician might need to be aware of for cannabis withdrawal and potential overdose?
Dr. Das: Yeah, that's a great question. So, while, luckily, while many patients may feel super uncomfortable during cannabis withdrawal, it is not life-threatening. The timeframe for symptom onset and psychological withdrawal might be experienced with cannabis cessation. About half of regular independent users do report withdrawal. And it can include many symptoms. It can include things like anxiety, irritability, reduced motivation, difficulty sleeping.
And this timeframe can be anywhere from a week to several weeks. Cannabis is able to hang around in the body for longer. And so, as a result, the withdrawal can be protracted compared, to say, other substances. It's important to note that again, that this is very uncomfortable, but it's not necessarily life threatening. And so, I try to reassure patients that this is going to be something that you will experience for a while. It’s not going to be pleasant and you will be able to get through it.
In terms of overdose, there is no evidence or reported cases of overdose directly in adults. But I noted that the cannabis industry is growing and there's a lot more ways to get cannabis and it's very potent. And so, it is important to think about other populations. So, increased ER visits and poison center calls have been related to cannabis, especially among children and youth. And this oftentimes has to do with how this cannabis is packaged. It might be in something that is attractive to young people like candies or chocolates or flavored juices and so on. And these are getting, again, increasingly potent over time.
It's really important as a result for folks to properly store their cannabis products in safe containers, so that young people aren't affected. There's some very disturbing statistics about how many reports there are of cannabis ingestion. For example, in 2017, there were 207 reported cases, but in 2021, there were 3,054 cases. This is an increase of 1,300% of, pediatric cannabis edible ingestion. And so, these are those things again, like the candies and the chocolates and so on. And most of this happens in the home. So, it's really important for people to think about how they're storing things.
Dr. Ehrenfeld: Wow, that's a really important statistic there. What are some of the risk factors in developing cannabis use disorder? Do we, do we know anything that can protect patients?
Dr. Das: That's a good question. Let's first start with kind of how cannabis use disorder is affecting the population at large. So, we know from our clinical practices and just from kind of being in the community that a lot of people are using cannabis. It's becoming more and more common. These days when I'm doing intake and doing screening for cannabis, I basically ask everybody, you know, how much cannabis they're using, instead of are they using cannabis because it is so widespread now.
We do have some statistics of folks who are using that can be helpful but isn't always 100%. For example, nicotine use, folks who have had adverse childhood experiences, males might be more prone to using cannabis. But again, all of that is shifting as it's becoming more available.
As I mentioned earlier, younger use is associated with developing an addiction. And something that I really like to point out to clinicians is that folks … when people are coming in to see us and they happen to be using cannabis, it's usually because they are trying to do something with it. They may have the impression that it can help with their anxiety or their depression or their sleep. Maybe a friend was using it or they heard about it. Or that's how it's being marketed, often. And so, when somebody's coming in to talk about these other things that I might be seeing them for, anxiety, depression, so on, and we find that they're using cannabis, I try to understand more if their use is associated with them trying to do something about these other underlying conditions.
And then I try to talk about what are actual evidence-based options to truly help them with that. So, there's a lot of overlap in terms of why people are presenting for treatment and the risk of cannabis in terms of trying to treat those symptoms. What we do know, though, is that usually the use of cannabis can make those symptoms worse over time.
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Dr. Ehrenfeld: So, with more and more cannabis use happening across the country, what can you tell us about evidence-based tools that physicians can use in their practice to screen for both cannabis use and cannabis use disorders?
Dr. Das: Yes, so screening is incredibly important. As I said, with so many people using it, it is important to not just ask if somebody is using but when they're using, how much they're using, what form they're using. And really making it a normal part of the conversation. I wanna make sure that when somebody is in my office, that they feel that it is free of stigma and judgment because I want to actually have that information so that then we can integrate that use into our treatment plan and what we're going to do.
There's several models of care that are available for screening. And one of them is the very popular and well-researched SBIRT, or screening, brief intervention and referral to treatment. And really for alcohol use, which is where this was first really proven out, it's similar to cannabis use, where you would screen. You would understand that somebody is using cannabis and then that cannabis use is affecting them negatively and then refer them out to treatment. There's many screeners that are out there. The Cannabis Use Disorders Identification Test is probably one of the most popular ones. And the thing that I like to come back to often though is how much is the cannabis use affecting their functioning.
And that's really where the DSM is useful because essentially for every substance, it's the same criteria. Is it affecting your life? Is it affecting your work? Are you trying to cut down unsuccessfully? And so on. And so, I like to center in on that. It's something that the patient can really relate to and understand. And we address together whether or not the cannabis use is impacting them. And that's a really sufficient screener and something that I'll have to note in my documentation anyway.
Dr. Ehrenfeld: So, given the prevalence and impact of cannabis use disorder, it seems that we really need effective treatments. So, what would you recommend to clinicians regarding the availability of evidence-based treatments for cannabis use disorder?
Dr. Das: That's a great question. So, screening, as I said, is extremely important. That's the first place to start. So, if every clinician were kind of universally screening for cannabis use and then considering how to integrate that into their plan, that, it would be a step in the right direction. It is important to approach treatment in a patient-centered manner. Not everybody wants to quit entirely.
Or they may not be at that point yet. They may not be that the symptoms of cannabis use disorder are affecting them so much that they want to quit. And so really taking that patient-centered approach where we're doing shared decision-making and understanding what their goals are. Is their goal to only, say, use on the weekends or use socially instead of using at home, every day, by themselves all day long? That's a perfectly fine goal because it will result in there being some reduction in use.
There are no medications that are approved, FDA-approved for the treatment of cannabis use disorder. However, there are excellent psychotherapy options. So, motivational interviewing and cognitive behavioral therapy with return to use prevention are gold standards of treating substance use disorders, including cannabis. Now, not every physician or clinician can go through all of the elements of CBT or cognitive behavioral therapy, but we can certainly help with motivational interviewing.
To help a patient move along the stages of change in their journey. For many of our patients, they're not even thinking about quitting cannabis. And so just putting it on their radar with that general screening, as I mentioned, will make a difference. It is also important to note that if they're struggling with something else, as I mentioned, there's other diagnoses that folks may have, but another one that's really near and dear to my heart is tobacco use.
And so, folks who are using cannabis and smoking tobacco may have a more difficult time in quitting. And so, keeping these things in mind, are they struggling with anxiety? Are they struggling with depression? Are they gonna go through worse withdrawal because of XYZ? Those are gonna be important parts to integrate into their plan and how they move forward.
Dr. Ehrenfeld: Dr. Das, thank you so much. I've learned a ton through our conversation today, and I know our listeners will as well. Really appreciate you sharing your knowledge with us on cannabis use, addiction potential, withdrawal and overdose. Before we conclude, could you just summarize a few key points that you'd like to make sure our audience takes away from our discussion?
Dr. Das: Absolutely. So, cannabis use disorder is a real thing. It can occur in anywhere from one in ten users of cannabis to one in three daily users of cannabis. And so, it is very relevant amongst our communities and our patients. A good first step in the right direction is to understand the withdrawal symptoms associated with cannabis, as well as implement screening within our practices.
And then if we can go a step further, it would be wonderful to engage in some motivational interviewing, and if possible, cognitive behavioral therapy with return to use prevention when it comes to cannabis. There is hope our patients can improve with their goals when it comes to cannabis, and we can do a lot when we're trying to align with them on those goals.
Dr. Ehrenfeld: Well, Dr. Das, thanks again for sharing your knowledge of cannabis addiction potential, withdrawal and overdose.
Dr. Das: Thank you.
Dr. Ehrenfeld: Don’t miss the next episode in this series—be sure to subscribe to Moving Medicine on your favorite podcast platform. This content is for educational and informational purposes only and does not constitute medical or legal advice. The viewpoints expressed in this podcast are those of the participants and do not reflect the views and policies of the AMA, unless otherwise indicated.
Dr. Suk: And this has been Moving Medicine. Thanks for listening.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
