Three Things Your Cannabis-Using Patients Know That You May Not

The increasing ubiquity of cannabis use, both for recreational and loosely defined medical purposes, has occurred with great speed. Despite the reservations and concern raised by our profession about the potential risks of cannabis use [1], the American public is increasingly in favor of loosening laws that govern cannabis [2]. 

If your clinical practice is like mine, you’re seeing more patients who are using cannabis, or are more willing to admit to using the drug. For many clinicians, this shift in cultural mores occurred more quickly than their ability to keep up with a changing clinical and cultural picture. Here are three tips to keep you up to date. 

1)    Smoking is but one way to use cannabis. 

Smoking, whether it is a joint, a pipe, or a water pipe (bong) remains a common way to use cannabis, being both convenient and easier to titrate dose to effect. However, increasingly, users are also vaporizing (heating cannabis to just below the point of combustion in order to volatilize and inhale the cannabinoids in the plant) and eating cannabis. 

“Edibles” refer to a wide range of orally consumable goods, from the homemade brownie, to more commonly, semi-professionally produced candies, oils, and tinctures. As New York Times columnist Maureen Dowd recently discovered in Colorado when she carelessly ate a large quantity of cannabis candy [3] before becoming paranoid and delusional, one must be careful with the quantity consumed. 

Eating avoids the lung irritation associated with smoking but can be difficult to titrate, and large doses are irretrievable once ingested. Standardization and regulation of cannabinoid food products, in much the same way that volume of ethanol is standardized and labeled in alcoholic beverages, would go a long way towards helping consumers make careful choices. 

Additionally, cannabis can be made into topical products such as creams and salves for pain management. Such products do not generally result in large absorption of psychoactive ingredients such as THC. 

2)    Not all cannabis is created equal. 

Cannabis has come a long way since the plastic baggie of dried plant matter of questionable quality and origin. Contemporary cannabis is often grown indoors from genetic clones, which gives growers greater ability to control the cannabinoid concentrations in the plant. 

Historically, cannabis was grown for high levels of THC, the psychoactive ingredient in cannabis. Increasingly, growers select for a favorable ratio of THC to cannabidiol (CBD), a non-psychoactive cannabinoid that has shown early promise as having antipsychotic, anxiolytic, anti-inflammatory, and anticonvulsant benefits [4]. Curiously, CBD acts as a noncompetitive inverse agonist against THC at the brain’s receptor for cannabis, the CB1 receptor, partially limiting the psychoactive effects of THC [5]. 

Cannabis can be the sativa species, which often is more THC predominant and often thought to be more stimulating, or the indica species, which contains THC and greater quantities of CBD and is considered more sedating. Many plants are hybrids of sativa and indica, selected for desired psychological and physiologic effects. 

3)    Cannabis is now available in concentrated forms 

Cannabis has long been concentrated as hashish, the dried and compacted sticky trichomes of the cannabis flower. More recently, cannabis producers have turned to butane and other solvents as a means of dissolving and concentrating the THC-containing resins in cannabis. 

Sometimes these resins are crystalized and dried. These concentrated products, known as butane hash oil (BHO), wax, shatter, or dab, can be smoked or vaporized and can contain very high levels of THC (up to 70% vs 10% to 20% in dried flowers), making them quite potent. Some users, particularly those who have developed a tolerance to THC, find them attractive. 

In my own clinical practice, I have heard from many users who found these concentrates to be too strong and resulted in rapidly increasing tolerance to THC, so they returned to using dried cannabis flowers, which have lower concentrations of THC. 

Ultimately, conversations with your cannabis-using patients can be an excellent source of information about the rapidly changing cannabis subculture. Just as cannabis is not all the same, neither are cannabis users. Not unlike my patients who use alcohol, most are able to use without compulsivity or disruption of other aspects of their lives, whereas other people clearly are unable to control their use, even though it is causing widespread disruption in daily functioning. 

Maintaining a respectful and curious open-minded approach will often yield a greater treatment alliance than a confrontational attitude, and with this treatment alliance, clinicians can better have conversations with patients about starting to make changes in their substance use behaviors. 

If you’d like to learn more, please come to my session “Medicine or Menace: Working with Cannabis Use in a Time of Legalization” in Orlando, Florida at the 27th Annual U.S. Psychiatric & Mental Health Congress.  

References

1. Zaman T, et al. APA Official Actions: Position Statement on Marijuana as Medicine. December 2013. www.psych.org/File%20Library/Learn/Archives/ps2013_MarijuanaMedicine.pdf. Accessed June 12, 2014

2. Pew Research Center for the People & the Press. America’s new drug policy landscape. April 2, 2014. www.people-press.org/2014/04/02/americas-new-drug-policy-landscape/. Accessed June 12, 2014

3. Dowd M. Don’t harsh our mellow, dude. New York Times. June 3, 2014. https://www.nytimes.com/2014/06/04/opinion/dowd-dont-harsh-our-mellow-dude.html?ref=opinion&_r=0

4. Pertwee RG. Br J Pharmacol. 2008;153(2):199-215. Morgan CJ, et al. Br J Psychiatry. 2010;197(4):285-290. Henquet C, et al. Br J Psychiatry. 2010;197(4):259-260. Bostwick JM. Mayo Clin Proc. 2012;87(2):172-186.

5. Marco EM, et al. Front Behav Neurosci. 2011;5:63. ElSohly M. In: Grotenhermen F, et al (Eds). Cannabis and Cannabinoids: Pharmacology, Toxicology, and Therapeutic Potential. New York, NY: The Haworth Integrative Healing Press; 2002:27-36. Seely KA, et al. Mol Interv. 2011;11(1):36-51. Ohno-Shosaku T, et al. Neuroscientist. 2012;18(2):119-132. Zhornitsky S, et al. Pharmaceuticals. 2012;5(5):529-552.

 Andrew Penn was trained as an adult nurse practitioner and psychiatric clinical nurse specialist at the University of California, San Francisco. He is board certified as an adult nurse practitioner and psychiatric nurse practitioner by the American Nurses Credentialing Center. Currently, he serves as an Assistant Clinical Professor at the University of California-San Francisco School of Nursing. Mr. Penn is a psychiatric nurse practitioner with Kaiser Permanente in Redwood City, CA, where he provides psychopharmacological treatment for adult patients and specializes in the treatment of affective disorders and PTSD. He is a former board member of the American Psychiatric Nurses Association, California Chapter, and has presented nationally on improving medication adherence, emerging drugs of abuse, treatment-resistant depression, diagnosis and treatment of bipolar disorder, and the art and science of psychopharmacologic practice.

The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors. Blog entries are not medical advice.