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Educational Rounds 2018 1

TEACH Educational Rounds

An Update on Cannabis and Mental Health in an Age of

Legalization Date: August 15, 2018

Dr. Peter Selby, MBBS, CCFP, FCFP, MHSc, dipABAM, DFASAM Chief – Medicine in Psychiatry Division, Deputy Physician-in-Chief of Education and Clinical Scientist – Addictions, CAMH Professor, DFCM, Psychiatry, and the Dalla Lana School of Public Health, University of Toronto @drpselby www.nicotinedependenceclinic.com

http://www.nicotinedependenceclinic.com/

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Presenter Dr. Peter Selby MBBS, CCFP, FCFP, MHSc, DipABAM, DFASAM [email protected] Peter Selby is the Chief of Primary Care, Deputy Physician-in-Chief-Education, and a Clinician Scientist at the Centre for Addiction and Mental Health (CAMH). He is a Professor in the Departments of Family and Community Medicine, Psychiatry, and the Dalla Lana School of Public Health at the University of Toronto. He is also a Clinician Scientist in the Department of Family and Community Medicine. Dr. Selby is the Executive Director and creator of the TEACH project - a continuing education certificate program in Applied Counselling for Health with a focus on smoking cessation, through the University of Toronto. Dr. Selby’s research, as a Principal Investigator at the Ontario Tobacco Research Unit, includes smoking cessation especially in smokers with co morbid conditions. As the Principal Investigator of the STOP Study, he investigates the effectiveness of NRT and counselling in different types of intervention settings. He is also the PI of CANADAPTT- a unique Canadian Smoking Cessation Guideline development and dissemination project. Dr. Selby also continues his clinical research with pregnant women who use substances and is the PI of a knowledge translation program (PREGNETS) to increase the adoption of evidence-based interventions with pregnant smokers.

He has received grant funding totaling over 85 million dollars from CIHR, NIH, and Ministry of Health and has published 135 peer reviewed publications. He has published 5 books (including 4 edited), is the author of 30 book chapters, and 32 research reports prepared for the government. He is the Chair of the Canadian Centre on Substance Abuse National Task Force on Treatment for Prescription Drug Misuse and the Chair of the Medical Education Council for the American Society of Addiction Medicine. Dr. Selby mentors Fellows in Addiction Medicine and Addiction Psychiatry, junior investigators and medical students. The use of innovative methods to communicate messages makes Dr. Selby a sought after speaker for various topics including addictive disorders, motivational interviewing, and health behavior change.

mailto:[email protected]





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Disclosures (5 year) Grants/Research Support: • CAMH, Health Canada, OMOH, CIHR, CCSA, PHAC, Pfizer Inc./Canada, OLA, • Medical Psychiatry Alliance, ECHO, CCSRI, CCO, OICR, Ontario Brain Institute, • McLaughlin Centre, AHSC/AFP, WSIB, NIH, AFMC, Shoppers Drug Mart, • Bhasin Consulting Fund Inc., Patient-Centered Outcomes Research Institute

Speaking Engagements (Content not subject to sponsors approval)/Honoraria: • Pfizer Canada Inc., ABBVie, Bristol-Myers Squibb

Consulting Fees: • Pfizer Inc./Canada, Evidera Inc., Johnson & Johnson Group of Companies, • Medcan Clinic, Inflexxion Inc., V-CC Systems Inc., MedPlan Communications, • Kataka Medical Communications, Miller Medical Communications, • NVision Insight Group, Sun Life Financial, Myelin & Associates

Other: (Received drugs free/discounted for study through open tender process) • Johnson & Johnson, Novartis, Pfizer Inc.

NO TOBACCO or ALCOHOL or FOOD INDUSTRY FUNDING

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Potential sources of bias outlined on the following slide have been mitigated by making this information accessible and available to all participants at the time of registration and the presentation date.

Disclosures

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Content of the TEACH Curriculum slides are primarily based on evidence based guidelines

including:

• CAN-ADAPTT Canadian Practice Guidelines Initiative – developed in collaboration with national

experts in tobacco cessation and health behaviour change (www.can-adaptt.net)

• US Guidelines Treating Tobacco Use and Dependence: Clinical Practice Guideline 2008 Update. US

Department of Health and Human Services, Public Health Service

• Rethinking Stop-Smoking Medications: Treatment Myths and Medical Realities OMA Position Paper,

January 2008.

The development and delivery of the TEACH curriculum is not influenced or funded in any part

by tobacco industry. TEACH has not received funding from the tobacco industry. The

development of the TEACH curriculum has not been influenced by pharmaceutical industry.

Information presented on pharmacotherapy refers to generic products only, and

recommendations are based on existing research, including the CAN-ADAPTT and US guidelines.

TEACH Curriculum Development

http://www.can-adaptt.net/







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These materials (and any other materials provided in connection with this

presentation) as well as the verbal presentation and any discussions, set out only

general principles and approaches to assessment and treatment pertaining to

tobacco cessation interventions, but do not constitute clinical or other advice as to

any particular situations and do not replace the need for individualized clinical

assessment and treatment plans by health care professionals with knowledge of

the specific circumstances.

Disclaimer

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Copyright

Copying or distribution of these materials is

permitted providing the following is noted on

all electronic or print versions:

© CAMH/TEACH

No modification of these materials can be

made without prior written permission of

CAMH/TEACH.

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Learning Objectives

1. Identify the risks and benefits of cannabis use in patients with mental illnesses and addiction

2. Explain the risks and benefits of cannabis use in patients with mental illnesses and addiction

3. Discuss treatment approaches to cannabis use in clinical populations

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Agenda 1. Case

2. Brief overview of Cannabis

3. Why legalize?

4. Psychological effects of Cannabis

5. How to intervene with patients

– Pharmacotherapy interventions

– Psychosocial interventions

6. Summary

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Case

• 25 year old female

• ED- 3x visit

• Vomiting, abdo pain cramping, no diarrhea

• IV fluids both visits

• This visit reports that after a hot shower, noticed improvement

• Then vomiting began again

• Pregnancy test negative

What’s going on?

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Brief

Overview of Cannabis

13

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Brief Overview of Cannabis

• Flowering plant (male and female)

• Alkaloids- Cannabinoids, terpenoids (smell)

– THC (tetrahydrocannibinol)

– Psychoactive constituent

– Binds to CB1 receptors

– Cannabidiol – Non-psychoactive compound

• Dried flowering buds= Marijuana

• Resin= hash

www.leafy.com

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Educational Rounds 2018 15 Warf, 2014

1st Med MJ

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Historical Overview – Cannabis

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Who Died of an MJ overdose?

https://tigr.net/wp-content/uploads/2014/11/Drug_danger_and_dependence-en.png

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...And During Prohibition

Medical Alcohol- who knew?

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Key Issues: Canadian Cannabis Use

Cannabis

not used for

recreational purposes.

25 convictions

for cannabis

possession in Canada.

Increase in cannabis use.

Canada signs the UN’s

Single Convention on Narcotic Drugs.

Le Dain Commission

concludes Canada’s

prohibition laws create

little respect for law

enforcement, congestion

of judicial system, and

strengthening organized crime.

Marihuana Medical

Access Regulations –

Canada 1st to legalize

marijuana for terminal

illness and chronic conditions.

Ontario Superior

Court sought to prohibit the

possession and production of

marijuana. Medical marijuana is now legalized.

Cannabis Act will

legalize and regulate

recreational cannabis

by Oct 17, 2018. Policy

focuses on health

impacts and public safety.

1930s

1930- 1946

1960- 1970s

Early 1970s

1987

Canada’s Drug

Strategy, the most

severe in the world,

addresses supply

and demand

reduction.

2001

2011

2018

Maistro et al., 2013; Health Reform Monitor 2018

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Educational Rounds 2018 20 CTADS, 2013

10.6

0.9 0.2 0.6 0.4 0.1

0

2

4

6

8

10

12

Perc

en

tag

e

Illicit Drugs

Illicit Drug Use Within the Past 12 Months, Canada (2013)

Cannabis is the most widely used illicit drug

76% reported alcohol

consumption

15% smoking

prevalence

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Why Legalize?

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Why Legalize?

~60,000 Canadians arrested/yr =3% of all arrests

>500,000 Canadians carry a criminal record Cost of

enforcement

~$1.2 billion

http://www.war-on-drugs.com/1.html

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Who Uses Cannabis?

In 2015, 12.3% of Canadians 15 years or older reported using tobacco in the past year

14.9%

Males

9.7% Females*

Statistics Canada, 2015; Health Canada 2015

**Prevalence in the past 3 months was highest among

adults 20-29 years old

13.3% Age 20-24**

13.7% Age 25 – 29**

9.1% 10.2%

12.3%

0%

2%

4%

6%

8%

10%

12%

14%

2011 2012 2015

*Significant difference from males

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Prevalence of Past Year Cannabis

Use, by Province, Canada (2012)

12.3%

12.2%

10.8%

15.7%*

11.6%

11.9%

12.0%

11.1%

9.9%*

11.1%

14.3%*

Ontario 12.0%

Nova Scotia 15.7% (highest); Saskatchewan 9.9% (lowest)

Statistics Canada; 2012

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Prevalence of Cannabis and Mental Illness

2001/2002 (DSM IV)

n = 43,093 Less Than Weekly,

% (95% CI) At Least Weekly,

% (95% CI)

Cannabis Use Disorder,

% (95% CI)

No mental illness 1.1

(0.9 – 1.2) 0.6

(0.5 – 0.7) 0.4

(0.3 – 0.5)

Any mental illness 5.4 *

(4.9 – 6.0) 4.4 *

(3.9 – 5.0) 4.0 *

(3.6 – 4.5)

Any axis I disorder a 4.4 * (3.8 – 5.1)

3.8 * (3.2 – 4.5)

3.5 * (3.0 – 4.2)

Any axis II disorder b 5.0 * (4.3 – 5.8)

5.3 * (4.5 – 6.2)

4.8 * (4.1 – 5.5)

Any substance use disorder c 12.3 * (11.0 – 13.7)

10.4 * (9.2 – 11.8)

10.2 * (9.1 – 11.4)

a Any mood (bipolar I, bipolar II, major depression disorder, dysthymia) or anxiety (panic, social phobia,

specific phobia, generalized anxiety disorder)

B Any antisocial, avoidant, dependent, paranoid, schizoid, histrionic personality disorder

C Any alcohol or drug use disorder (excluding cannabis)

* Significantly different from respondents without any psychiatric disorder, p<0.0001.

Lev-Ran et al., 2013

Lev-Ran et al. (2013). Cannabis use and cannabis use disorders among individuals with mental illness. Comprehensive Psychiatry, 54, 589-598.

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Physiological Effects of Cannabis

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Cannabinoid Receptors

Fonseca et al. (2013); hawaiianethos.com

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Physiological Effects of Cannabis

Maistro et al., 2013; Volkow et al., 2014

Acute Effects

Long-term Effects

1. Increased risk of respiratory

infections and pneumonia

2. Increased in heart and pulse

rates

3. Increased risk of lung cancer,

myocardial infarction, stroke,

and transient ischemic attacks

1. Bloodshot eyes

2. Increase in heart and pulse

rates

3. Decrease in general motor

activity

4. Hunger

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Effect of Cannabis on Brain Development

During this time, brain is more vulnerable

to THC

Earlier age of cannabis onset = greater

neuropsychological impairment

Volkow et al., 2014

Brain is in a state of development from prenatal period until 21 years of age

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Effect of Cannabis on Brain

Development

Volkow et al., 2014

• Regular cannabis use during adolescence impairs

neural connectivity, thereby:

– Reducing alertness and self-conscious awareness

– Memory and learning impairments

– Reduced inhibitory control

– Down regulation of CB1/CB2 receptors

– Decline in IQ

– Impaired school performance

• Increased risk of dropping

out of school

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Effect of Cannabis on Brain Development

Scholastic Inc. 2016

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Brain Effects of Cannabis

Maistro et al., 2013; Hoch et al., 2015

Behavioral effects:

• Decrease in psychomotor activity (relaxation,

motivation) and motor performance (coordination,

signal detection)

Cognitive effects:

• Impaired short-term memory, cognitive functioning

• Perception of time (time moves slowly)

• Attention

• Retentiveness

Emotional effects:

• Mood changes (happy, euphoric, excited)

• Laughter

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Additional Effects of Cannabis

Volkow et al., 2014

• Persons testing +ve for THC are 3-

7x more likely to be responsible for

a motor vehicle accident

• Possible role as a gateway

behaviour

• Increased risk of ED visits

– Possibly due to an increase in the

potency of THC content

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Evidence

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Cannabinoids for Medical Use

Condition

Number of Trials and Patients

Odds Ratio (95% CI)

What does this mean

Nausea and vomiting due to chemotherapy

3 Trials (n = 102)

3.82 * (1.55 – 9.42)

The use of dronabinol or nabiximols were associated with a 3.82 greater odds of

complete remission of nausea and vomiting compared to patients treated with placebo

Chronic pain (minimum 30% reduction)

8 Trials (n = 1,370)

1.41 (0.99 – 2.00)

Use of Smoked THC and nabixmols was not associated with a 30% reduction in chronic

pain compared to patents treated with placebo

Neuropathic pain

6 Trials 1.38

(0.93 – 2.03)

Use of cannabinoids were not associated with a reduction in neuropathic pain

compared to patents treated with placebo

Cancer pain 2 Trials 1.41

(0.99 – 2.00)

Use of cannabinoids were not associated with a reduction in cancer pain compared to

patents treated with placebo

Whiting et al., 2015 * Significant at p < 0.05

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Marijuana used alone = significant increase of 100% in the number of ED visits during 2004 to 2011

Marijuana used in combination with other drugs = significant increase of 62% in the number of ED visits during 2004 to 2011

Volkow et al., 2014

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Frequency of Cannabis Use and

Psychosis Symptoms

Number of Studies and Sample Size

Odds Ratio

(95%CI)

Ever used cannabis 7 studies

(n = 61,485) 1.41 *

(1.20 – 1.65)

* Significant at p < 0.05

Moore et al., 2007

22q11 snp rs4680 (Val Met) COMT (Dunedin study) not replicated.

The odds of experiencing psychotic

symptoms were 1.41 times higher when

using cannabis

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Cannabis Use and Psychosis: Patient

views

Large et al., 2014; Gomez Perez et al., 2014; Gill et al., 2015; Mane et al., 2015; Bruins et al., 2016

Benefits:

• Mood enhancement

• Social motives

• Belonging to a group, avoid isolation

• Self-medicate

• Relax

• Decrease hallucinations and suspiciousness

Risks:

• Increase in psychotic symptoms (positive and general symptoms)

• Increase in episodes of violence and convictions for non-violent offences

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Cannabis Use and

Mental Health Prognosis

van der Meer et al., 2015

Discontinued cannabis users showed improvements in positive and general symptoms compared to persistent

cannabis users

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Cannabis Use and Mental Health

Prognosis

• 3 year follow up study was part of a multi-center study in the Netherlands and Belgium, 678 participants

• There is no association between timing

of cannabis cessation and clinical outcomes

• Furthermore, the impact of cannabis on

severity of symptoms is reversible


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Cannabis Use and Mental Health Prognosis


Early Discontinuation (n = 47)

Mean (SD)

Late Discontinuation (n = 210)

Mean (SD) P-value

Positive Symptoms Scale (PANSS)

1.44 (0.55)

1.57 (0.60)

0.179

Negative Symptoms Scale (PANSS)

1.60 (0.66)

1.64 (0.78)

0.777

General Symptoms (PANSS) 1.43

(0.41) 1.52

(0.46) 0.195

Global Assessment of Functioning Scale Symptoms

64.28 (16.68)

59.40 (16.42)

0.163

Global Assessment of Functioning Scale Disability

65.00 (15.96)

61.75 (16.12)

0.371

Psychotic Relapse 0.28

(0.58) 0.34

(0.80) 0.629

Early discontinuation: Patients stopped using cannabis within 3 years of psychosis onset

Late discontinuation: Patients stopped using cannabis after 3 years of psychosis onset

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Dose-Response Relationship with

Psychosis

Toftdahl et al., 2016

• Purpose:

– Evaluate impact that cannabis has on individuals with

established psychotic disorder

• Longitudinal study:

– Post-treatment (6 months)

– Follow-up (10 months)

• Individuals: N=60

– Diagnosed with cannabis use disorder

– Diagnosed with either schizophrenia,

schizotypal, and delusional disorders

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Dose-Response Relationship with

Psychosis

Toftdahl et al., 2016

Severe use was associated with

more severe symptoms

Reducing use had greatest

improvement in symptoms for every

symptom scale

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Meta-Analysis of Dose-Response

Relationship with Psychosis

Marconi et al., 2016

Pooled Results:

Severe cannabis

users:

OR = 3.90 (2.84 –

5.34)

Any cannabis users:

OR = 1.97 (1.68 –

2.31)

Increased risk of psychosis-related outcomes with higher levels of cannabis

use

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Cannabis Use and

Mania Symptoms


Gibbs et al., 2015


Odds Ratio

(95%CI)

Cannabis use 6 studies

(n = 14,918) 2.97 *

(1.80 – 4.90)

The odds of experiencing mania

symptoms were 2.97 times higher when

using cannabis

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Cannabis Use and Anxiety

Number of Studies

Odds Ratio (95%CI)

What Does This Mean?

Anxiety and cannabis use 15 studies 1.24 *

(1.06 – 1.45)

The odds of anxiety is 1.24 times higher when using

cannabis

Anxiety and cannabis use disorder

13 studies 1.68 *

(1.23 – 2.31)

The odds of anxiety is 1.68 times higher when diagnosed

with a cannabis use disorder

Anxiety + depression and cannabis use

5 studies 1.68 *

(1.17 – 2.40)

The odds of anxiety and

depression is 1.68 times higher when using cannabis


Moore et al., 2007

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Temporal Association

Cannabis Use Anxiety

Symptoms

Anxiety

Symptoms Cannabis Use

Baseline Follow-up

5 studies

1 study

OR = 1.28 *

(95% CI: 1.06 – 1.54)

OR = 0.94

(95% CI: 0.86 – 1.03)


Kedzior et al., 2014

Baseline cannabis positively associated with anxiety

symptoms at follow-up

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Cannabis Use and Depression

Degenhardt et al., 2003

The US National Longitudinal Alcohol Epidemiologic Survey found that individuals meeting criteria for DSM-IV major depression within the past 12 months had 6.4 times the odds of meeting criteria for DSM-IV cannabis abuse/dependence as those without major depression (6% vs 1%)

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Plausibility for Causation

• Depression:

– Cannabis may impact serotonin, dopamine, or

other neurotransmitters and thus regulating

emotional experiences symptoms

– Cannabis use could exacerbate events,

circumstances, or environments that increase

the likelihood of the depression

– An unknown factors, social, biological,

physiological, mediate the relationship

between cannabis use and depression

Degenhardt et al., 2003

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Confounders

Caron et al, 2010; Large et al., 2014; Gill et al., 2015; van der Meer et al. 2015

Cannabis use is more likely among:

Males Less

educated

Young

individuals Earlier age of

psychosis onset

Other substance

users (e.g., alcohol)

High symptom

score

Don’t control for

tobacco use

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How to

Intervene

with

Patients?

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Interventions for Cannabis Use

Disorders • Pharmacotherapy interventions

– THC preparations

– SSRI antidepressants

– Mixed action antidepressants

– Anticonvulsants or mood stabilizers

• Psychosocial interventions

– Cognitive-behavioural therapies

– Motivational interviewing

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Pharmacotherapy

Interventions

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Completion of Treatment Number of Studies and Sample Size

Risk Ratio (95%CI)


Preparations containing THC vs placebo

2 studies (n = 207)

1.29 * (1.08 – 1.55)

Using preparations containing THC

increases the likelihood of completing

treatment by 29% compared to placebo

SSRI antidepressants vs placebo

2 studies (n = 122)

0.82 (0.44 – 1.53)

Using SSRI antidepressants does not increase the likelihood of completing

treatment compared to placebo

Mixed action antidepressants vs placebo

2 studies (n = 169)

0.93 (0.71 – 1.21)

Using mixed action antidepressants

does not increase the likelihood of

completing treatment compared to placebo

Anticonvulsants and mood stabilizers vs placebo

2 studies (n = 75)

0.78 (0.42 – 1.46)

Using anticonvulsants and mood

stabilizers does not increase the

likelihood of completing treatment compared to placebo


Marshall et al., 2014

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Abstinence Number of Studies and Sample Size

Risk Ratio (95%CI)


Preparations containing THC vs placebo

1 study (n = 156)

1.14 (0.56 – 2.30)

Using preparations containing THC

does not increase abstinence rates compared to placebo

SSRI antidepressants vs placebo

1 study (n = 52)

2.33 (0.68 – 8.05)

Using SSRI antidepressants does not increase abstinence rates

compared to placebo

Mixed action antidepressants vs placebo

2 studies (n = 179)

0.82 (0.12 – 5.41)

Using mixed action

antidepressants does not increase abstinence rates

compared to placebo

Anticonvulsants and mood stabilizers vs placebo

1 study (n = 19)

1.08 (0.50 – 2.34)

Using anticonvulsants and mood

stabilizers does not increase abstinence rates compared to

placebo

Marshall et al., 2014

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Effects of fixed or self-titrated dosages of

Sativex on cannabis withdrawal and cravings

Intervention Sample Size Outcome

• 8 week double-blind placebo-controlled trial

• One week each of: • Self-titrated placebo • Fixed dose placebo • Self-titrated Sativex • Fixed dose (up to 108mg

THC / 100mg CBD) Sativex

• Washout period (smoke as usual) between each condition

• Conditions randomized and counterbalanced

N = 9

• 54 screened • 16 eligible • 9 completed the

entire experimental sequence

• 7 of 9 participants remained abstinent during treatment with Sativex (fixed/self-titrated)

• The number of occasions participants relapsed and the total amount of cannabis consumed did not statistically differ between Sativex and placebo conditions (p>0.05)

• Sativex well tolerated, significantly reduced cannabis withdrawal during abstinence but not cravings

• Results warrant further systematic exploration of Sativex as a treatment option for cannabis withdrawal and dependence

Trigo, et al (2016)

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Psychosocial

Interventions

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Harm Reduction: Frequency of

Use


Mean Difference

(95%CI) What Does This Mean?

CBT vs inactive control 1 study

(n = 134) 10.94 *

(7.44 – 14.44)

Individuals receiving CBT used cannabis on

11 fewer days in the last month compared with the inactive control

MET vs inactive control 4 studies (n = 612)

4.45 * (1.90 – 7.00)

Individuals receiving MET used cannabis on

4 fewer days in the last month compared with the inactive control

CBT + MET vs inactive control

4 studies (n = 612)

7.38 * (3.18 – 11.57)

Individuals receiving CBT + MET used

cannabis on 7 fewer days in the last month compared with the inactive control

Gates et al., 2016

Cognitive-behavioural therapy (CBT); Motivational interviewing/motivational enhancement therapy

(MET)


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Harm Reduction: Quantity of Use


Standardized Mean

Difference (95%CI)


CBT vs inactive control 2 studies (n = 306)

4.60 * (2.21 – 7.00)

Individuals receiving CBT used

fewer joints per day compared with the inactive control

MET vs inactive control 4 studies (n = 611)

3.14 * (2.66 – 3.61)

Individuals receiving MET used

fewer joints per day compared

with the inactive control

CBT + MET vs inactive control 4 studies (n = 683)

4.91 * (3.29 – 6.54)

Individuals receiving CBT + MET

used fewer joints per day compared with the inactive control

Gates et al., 2016

Cognitive-behavioural therapy (CBT); Motivational interviewing/motivational enhancement therapy (MET)


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Point Prevalence Abstinence


Risk Ratio (95%CI)


CBT vs inactive control 1 study

(n = 171) 4.81 *

(1.17 – 19.70)

Receiving CBT increased abstinence rates by 381%

compared to inactive control

MET vs inactive control 1 study (n = 197)

1.19 (0.43 – 3.28)

Receiving MET did not increase abstinence rates compared to

inactive control

CBT + MET vs inactive control

5 studies (n = 798)

2.17 * (1.10 – 4.32)

Receiving CBT + MET increased abstinence rates by 117%

compared to inactive control

Gates et al., 2016

Cognitive-behavioural therapy (CBT); Motivational interviewing/motivational enhancement therapy (MET)


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Intervention Sample Size Outcome

• Double blind randomized clinical trial

• As-needed nabiximols up to 113.4mg THC/ 105 mg CBD OR placebo daily, concurrently with MET/CBT for 12 weeks

N = 27

• 68 screened • 50 eligible • 40 dosed • 27 completed the

entire experimental sequence

• Nabiximols in combination with MET/CBT was well tolerated and allowed for reduction of cannabis use.

• Nabiximols may help to decrease cannabis use, with no increase in craving or withdrawal

• Results suggest that the combination of doses above 20 sprays per day of nabiximols + MET/CBT should be explored further for its potential as treatment for cannabis use disorder (CUD)

Trigo, et al (2016)

Nabiximols combined with motivational

enhancement/cognitive behavioral therapy for the

treatment of cannabis dependence: A pilot

randomized clinical trial

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Lower Risk Guidelines • Use is delayed until early adulthood

• Frequent (daily or near‐daily) use is avoided

• Users shift away from smoking cannabis towards less harmful (smokeless) delivery systems such as vaporizers

• Less potent products are used, or THC dose is titrated

• Driving is avoided for 3 to 4 hours after use, or longer if needed

• People with higher risk of cannabis‐related problems (e.g. people with a personal or family history of psychosis, people with cardiovascular problems, and pregnant women) abstain altogether

Fischer et al

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• Cannabis use is common in Canada

• Cannabis use has some benefits, however persistent use can be harmful

• Cannabis use has demonstrated a significant association with mental illness

• The severity of symptoms associated with cannabis use are reversible

• Psychosocial interventions are the foundation for treatment of cannabis use disorders/dependence

Summary

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Resources

• Canadian Centre on Substance Abuse

www.ccsa.ca

• Substance Abuse and Mental Health

Services Administration

http://www.samhsa.gov/

• Centre for Addiction and Mental Health

www.camh.ca

http://www.ccsa.ca/




http://www.camh.ca/

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Questions or Comments?

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References • Bruins et al. (2016). Cannabis use in people with severe mental illness: The association with

physical and mental health – a cohort study. A pharmacotherapy Monitoring and Outcome

Survey study. Journal of Psychopharmacology, 30(4), 354-362.

• Canadian Mental Health Association. (2016). Fast facts about mental illness.

http://www.cmha.ca/media/fast-facts-about-mental-illness/#.WA4dIMlgmb0

• Caron & Liu. (2010). A descriptive study of the prevalence of psychological distress and

mental disorders in the Canadian population: Comparison between low-income and non-

low-populations. Chronic Diseases in Canada, 30(3), 84-94.

• Degenhardt et al. (2003). Exploring the association between cannabis use and depression.

Addiction, 98(11), 1493-1504.

• Fonseca et al. (2013). Endogenous cannabinoids revisted: a biochemistry perspective.

Prostaglandins & Other Lipid Mediators, 102, 13-30.

• Gates et al. (2016). Psychosocial interventions for cannabis use disorder. Cochrane Review

of Systematic Reviews. Issue 5. Art. No.: CD005336

• Gibbs et al. (2015). Cannabis use and mania symptoms: A systematic review and meta-

analysis. Journal of Affective Disorders, 171, 39-47.

• Gill et al. (2015). Reasons for cannabis use among youths at ultra high risk for psychosis.

Early Intervention Psychiatry, 9(3), 207-210.

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References • Gomez Perez et al. (2014). Reasons and subjective effects of cannabis use among people

with psychotic disorders: a systematic review. Actas españolas de psiquiatría, 42(2), 83-90.

• Government of Canada. (2013). Canadian Tobacco, Alcohol, and Drugs Survey (CTADS).

http://healthycanadians.gc.ca/science-research-sciences-recherches/data-donnees/ctads-

ectad/tables-tableaux-2013-eng.php#t8

• Health Canada. (2012). Canadian Alcohol and Drug Use Monitoring Survey. http://www.hc-

sc.gc.ca/hc-ps/drugs-drogues/stat/_2012/summary-sommaire-eng.php

• Health Reform Monitor. (2018). The Canadian Cannabis Act legalizes and regulates

recreational cannabis use in 2018. Health Policy. 122, 3. 205-209

• Hoch, E., et al. (2015). Risks associated with the non-medicinal use of cannabis. Deutsches

Arzteblatt International, 112, 271-278.

• Kedzior et al. (2014). A positive association between anxiety disorders and cannabis use or

cannabis use disorders in the general population – a meta-analysis of 31 studies. BMC

Psychiatry, 14, 136.

• Large et al. (2014). Systematic meta-analysis of outcomes associated with psychosis and

co-morbid substance use. Australian & New Zealand Journal of Psychiatry, 48(5), 418-432.

• Lev-Ran et al. (2013). Cannabis use and cannabis use disorders among individuals with

mental illness. Comprehensive Psychiatry, 54, 589-598.

http://www.hc-sc.gc.ca/hc-ps/drugs-drogues/stat/_2012/summary-sommaire-eng.php











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References • Marconi et al. (2016). Meta-analysis of the association between the level of cannabis use

and risk of psychosis. Schizophrenia Bulletin, 42(5), 1262-1269.

• Maistro et al. (2013). Drug use and abuse. 1st ed. Nelson Education Ltd. Toronto, ON.

• Mane et al. (2015). Relationship between cannabis and psychosis: Reasons for use and

associated clinical variables. Psychiatry Research, 229, 70-74.

• Marshall et al. (2014). Pharmacotherapies for cannabis dependence. Cochrane Database of

Systematic Reviews. Issue 12. Art. No.: CD008940.

• Moore et al. (2007). Cannabis use and risk of psychotic or affective mental health outcomes:

A systematic review. Lancet, 370(9584), 319-28.

• Scholastic Inc. (2016). The Science of the Endocannabinoid System: How THC Affects the

Brain and the Body. http://headsup.scholastic.com/students/endocannabinoid

• Statistics Canada. (2012). Prevalence and correlates of marijuana use in Canada, 2012.

http://www.statcan.gc.ca/pub/82-003-x/2015004/article/14158-eng.htm

• Statistics Canada. (2015). Canadian Tobacco, Alcohol and Drugs Survey, 2015

https://www150.statcan.gc.ca/n1/pub/75-006-x/2018001/article/54968-eng.htm

• Toftdahl et al. (2016). The effect of changes in cannabis exposure on psychotic symptoms in

patients with comorbid cannabis use disorder. Journal of Dual Diagnosis, 12(2), 129-136.

http://headsup.scholastic.com/students/endocannabinoid

http://headsup.scholastic.com/students/endocannabinoid
















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References

• Trigo JM, Lagzdins D, Rehm J, Selby P, et al. (2016). Effects of fixed or self-titrated dosages of Sativex on cannabis withdrawal and cravings. Drug and Alcohol Dependence 161, 298-306.

• Trigo JM, Soliman A, Quilty LC, Fischer B, Rehm J, Selby P, et al. (2018) Nabiximols combined with motivational enhancement/cognitive behavioral therapy for the treatment of cannabis dependence: A pilot randomized clinical trial. PLoS ONE 13(1): e0190768. https://doi.org/10.1371/journal.pone.0190768van der Meer et al. (2015). Course of cannabis use and clinical outcome in patients with non-affective psychosis: A 3-year follow-up study. Psychological Medicine, 45(9), 1977-1988.

• Volkow et al. (2014). Adverse health effects of marijuana use. New England Journal of Medicine, 370, 2219-2227.

• Warf. (2014). High points: An historical geography of cannabis. Geographical Review,

104(4), 414-438.

• Whiting, P. F., et al. (2015). Cannabinoids for medical use: A systematic review and meta-

analysis. Journal of the American Medical Association, 313(24), 2456-2473.

https://doi.org/10.1371/journal.pone.0190768van der Meer et al. (2015). Course of cannabis use and clinical outcome in patients with non-affective psychosis: A 3-year follow-up study. Psychological Medicine, 45(9), 1977-1988.












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Thank you!

Dr. Peter Selby

[email protected]


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Remember …

• A link to the Evaluation and Post- Learning Assessment will be sent by e-mail by this afternoon. You will have one week to complete this Post-Learning Assessment in order to receive your Letter of Completion.

• If you participated as a group, make sure to email [email protected] with a complete list of participants by 2:00 PM EST today.


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Remember …

Next Educational Rounds Webinar:

Trauma Informed Care Presenter: Dr. Inbal Gafni, MSc, MD

Date: Wednesday, September 26, 2018 | 12:00-1:00pm EST

**Registration Open Soon**

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TEACH Educational Rounds Archives:

Missed the beginning of today’s presentation?

Want to view it again?

Interested in seeing previous TEACH webinars?

No problem! View the archived webinar links on our website! How do you access the archives?

The TEACH Project records all Educational Rounds webinars for later viewing, in case you are not able to attend the live session.

In order to access the archived webinars please visit our website

www.teachproject.ca “TEACH Educational Rounds” “Archive and Self Study” (here).

http://www.teachproject.ca/

https://www.nicotinedependenceclinic.com/English/teach/Pages/Continuing Medical Education/Webinar Series Archive and Self-Study.aspx

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