The legalization of cannabis is rapid and widespread. The medical use of cannabis is now legal in 36 states and DC. It's America's new big business.
The recreational use of cannabis is legal in 17 states and DC. Harvard neuroscientist, Jodi Gilman, who researches the effects of cannabis on teenage brains said it best when she said, "it's the only medicine ever voted on in a ballot box."
Right now, there are only four FDA approved cannabis medications to date, and they are for controlling, rare pediatric seizures, nausea in cancer, chemotherapy, and weight loss, and loss of appetite in people with HIV and aids. There are no other cannabis products that have been approved by the FDA.
VIDEO TRANSCRIPT
Dr. Patricia Halligan:
Hi, welcome to Recovery: The Hero's Journey. I'm your host, Dr. Patricia Halligan. The title of today's podcast is when someone you love has a problem with cannabis. The legalization of cannabis is rapid. It's widespread. America's new big business.
The medical use of cannabis is now legal in 36 states and DC. The recreational use of cannabis is legal in 17 states and DC. A Harvard neuroscientist, Jody Gilman who researches the effects of cannabis on teenage brains said it best when she said, and I quote, "It's the only medicine ever voted on in a ballot box, not approved through the FDA or backed by research". Right now, there are only four FDA approved cannabis medications to date, and they are for controlling rare pediatric seizures, nausea in cancer chemotherapy, and weight loss, and loss of appetite in people with HIV and AIDS. There are no other cannabis products that have been approved by the FDA as medicine.
What we have now are super high strength cannabis products that are sold through dispensaries. These products lack the quality control of FDA approved medicines. The dispensaries are not regulating the dose, the potency of THC or the purity of these products. Some products contain 75% THC or higher. Colorado is currently attempting to cap the concentration of THC at 15%.
Because of the vulnerability of their developing brains, adolescents and young adults are particularly at risk. Parents are worried and are wondering how to protect their children from developing problems with cannabis in a culture where the country is calling it medicine and all their friends are doing it.
I am super happy to introduce our expert guests today, Laurence Westreich, MD is a psychiatrist who specializes in the treatment of patients diagnosed with substance use disorders. Dr. Westreich completed a residency in psychiatry at New York's Beth Israel Medical Center, and a two year fellowship in addiction psychiatry at New York university Bellevue Hospital.
He is board certified in general psychiatry, addiction psychiatry, and forensic psychiatry. Dr. Westreich is associate professor of clinical psychiatry in the department of psychiatry, New York University School of Medicine, and the author of "Helping The Addict You Love" and "A Parent's Guide To Teen Addiction".
Dr. Westreich is past president of the American Academy of Addiction Psychiatry and serves as consultant on behavioral health and addiction to the commissioner of Major League Baseball.
Welcome Dr. Westreich. Thank you for coming today.
Dr. Laurence Westreich:
Well, thank you for having me.
Dr. Patricia Halligan:
What do you mean, to start off, by cannabis? Is that the same as marijuana? Weed? Pot?
Dr. Laurence Westreich:
Cannabis is a broad term for all kinds of preparations, which include THC. So I, and other people writing in the field used cannabis as a broad term to include both smoked marijuana, to include the gummy bears that have high amounts of THC in them, to include vaped THC. And so we're sort of using it to encompass all of the methods within which people can ingest THC.
Dr. Patricia Halligan:
Got it. And what is CBD?
Dr. Laurence Westreich:
CBD is another compound within cannabis. And the CBD of itself has some indications for treating pediatric seizures. And obviously you can see in the news and everywhere else that it's claimed to treat a number of other things. But what's clear, though, is that CBD has no psychoactive effects. So there's no dependence on CBD, no one gets high with CBD. And so in my view, in a lot of people's view, it's at the worst harmless.
The issue with CBD that I'd like my patients to be aware of is that all the preparations, except for the pharmaceutical grade CBD, which is not really widely available, are contaminated with small amounts of THC. So if you are having sophisticated drug tests and you take CBD, you may come up with a positive for THC. So that's a problem in an employment context and can be a problem in other other context. And I'm very careful not to make comments on the efficacy of CBD. That's really not my forte. I treat people with addiction problems, not who are using CBD for therapeutic reasons.
Dr. Patricia Halligan:
Okay, thanks. That helps quite a bit. Can you help us understand about the potency of today's cannabis? Because I remember I graduated from a fellowship in addiction psychiatry back in '98, and I don't know about you, but I don't remember seeing a lot of people with marijuana use disorder back then.
Dr. Laurence Westreich:
It's a very good point, and I'm glad you brought it up early on, cause it's very important. I have a practice which treats addiction and probably 95% of my patients are addiction patients. It's pretty typical of my practice that will someone will come in having smoked a few joints and ended up in an emergency department because they hadn't smoked marijuana since they were in college. And that was 15 or 20 years ago. And they think that the potency is the same. It's not. The potency of the available THC, both in smoked marijuana is probably double what it was 15 or 20 years ago. In the gummy bears and in the solutions of THC that are available, it can be up to 90% THC that first ingests. So this is what's associated in very short order with psychosis, with hallucinations, delusions and really scary stuff that happens. And it's usually by relatively inexperienced THC users who go back to the use of THC, which they did years ago.
Dr. Patricia Halligan:
And what about wax? I'm hearing a lot about wax and dabs. Apparently that's our most potent form of THC?
Dr. Laurence Westreich:
Well, it's the way to get into the central nervous system as quickly as possible. And there are all kinds of preparations that are being distributed at this point by supplement suppliers. The idea is at this point, not really to stay away from law enforcement. Because in most jurisdictions, it's not considered criminally illegal to use marijuana. But it's to stay away from others who might know you're using marijuana. So the mom and dad won't know that junior is using a vape pen or using wax in his or her bedroom because they can't smell anything. Maybe 30 years ago, you would've smelled the odor of marijuana out of the room. But now you can't smell anything. So the point is that people are able to get very, very potent THC into their systems very quickly, which causes much more severe problems than the lower potency preparations.
Dr. Patricia Halligan:
And I heard that dabs are now called the crack cocaine of marijuana and sometimes 85 to 95% pure THC, the concentrates. Yeah. I read a report that stated they took a, a survey of eight graders, 10th graders and 12th graders, and about 24% of them admit in their lifetime to using the concentrated dabs. Yeah. So yeah, it's not the same drug, is it as it was decades ago?
Dr. Laurence Westreich:
No, it's not. And unfortunately studies like you're referring to like monitoring the future studies from Michigan, you know, they, they rightly understandably ask about your use of marijuana, not realizing that it's a very different drug from what it was 20 years ago. So this is one of the main points I make the parent groups that, although it seems benign in, in some circumstances it's not benign. And since I'm an addiction psychiatrist, I see in my practice, those circumstances where people are really harmed by the use of THC,
Dr. Patricia Halligan:
Me too, especially over the last say, I'd say five to five to eight years more parents bringing in the high school kid who is, you know, having trouble in school or, you know, young college kids having trouble with marijuana even adults presenting with marijuana problems. So is it addictive? I know in the past people laughed and, and thought it was a soft drug and wasn't didn't have a reputation for being addictive. Would you say that it's addictive now?
Dr. Laurence Westreich:
Absolutely. you know, the DSM in 2013 added withdrawal to the list of consequences of THC. So it's very clear in the field that there is withdrawal from THC, that it is addictive and not withstanding all the advice that that people give their friends or that sometimes our kids here in health class certainly THC is addictive of the data are very clear that about between nine and 15% of people who try marijuana will meet DSM criteria for dependence six months later. Now it's true that dependence on marijuana is different than dependence on, on opioids and less dangerous and less likely to cause a fatal outcome. Nonetheless, they meet criteria for dependence in the sense they're spending a lot of time getting it. They're letting go of responsibilities that they would otherwise take care of because of the drug. And they have sometimes withdrawal and tolerance to the drug. So it's real dependence, it's real addiction. And it's real withdrawal.
Dr. Patricia Halligan:
I always feel badly for the young person with a problem primarily with marijuana because they say to me, I don't wanna go to a narcotics anonymous group. I'm just gonna be laughed out. You know, these are people who are recovering from, you know, crack ad, you know, dependency on crack cocaine or dependency on heroin. And they're gonna laugh at me if I was brought down by weed, but I'm, I'm really glad that you're making that point. It's a, it's a different potency, it's a different drug. And it's recognized for its addiction addictive potential. So if someone in the family or someone I loved had a problem with cannabis, how would it present? How would I know that this was indeed a problem?
Dr. Laurence Westreich:
It's a good question. And, and the response is the way you would with any other addictive substance. And, and I don't assess whether someone's got a problem with alcohol based on the volume that they drink. Some people have a drink every night for 40 years, never have a problem. Other people have a drink once or twice a month and crash the car every time. So, so we're looking for consequences of the use. So specifically for cannabis, the consequences can be difficulties in relationships because of the drugs. It can be difficulties as you point out in school or work because of the drug, sometimes health consequences long consequences from smokers, some of the serious consequences from vapors of THC, we're looking for consequences. And with THC, especially with high school students, you have to look at the possibility of legal consequences. There's not across the board, legalization this country. So you have to least look at that as a potential problem for the, for the adolescent. So, you know, I, I usually don't really pay much attention to how much of a substance the person is using. I pay attention to what effect the substance is having on the person's life.
Dr. Patricia Halligan:
So as a forensic psychiatrist, this is where it's very helpful, even if it's a state where it's legal, if it's somebody under the age of 21, who has the possession of marijuana and is caught by the police, is there still a possession of marijuana charge?
Dr. Laurence Westreich:
Yeah. In, in, in no jurisdiction is the use of THC legal for people under the age of 21. But even more than that people often make the mistake of thinking, even in states like California or Colorado, where there's been a, a decriminalization of, of THC, that's a criminal it's in the criminal aspect of the law in civil law, like in employment, there's no such, so someone can still be denied employment because they have a positive drug test for THC. They can still be terminated from their employment. If they have a positive test for THC.
Dr. Patricia Halligan:
I remember a family that brought in their teenager and he was becoming increasingly irritable. He was punching holes in walls, and this had been previously a pretty well behaved kid, but now he was 17 years old. He was punching walls and he threw a cell phone over his sister's head. The sister was scared of him, truant from school, failing grades, pretty aggressive with both parents. It definite personality change. The girlfriend was making complaints. She didn't like him smoking. Cuz he, he changed when he was smoking money missing just is that typical of a young kid who may be using on a, on a regular, a daily basis?
Dr. Laurence Westreich:
Well, it's typical of the kids. I see. And you see also you know, and, and I often say I see the tip of the iceberg. I see kids who have serious problems with THC. So what you describe is, is actually very common. You, you know, THC is a sedative and it's a hallucinogenic, so it shouldn't surprise us that people are disinhibited by it and do things they wouldn't otherwise do. It shouldn't surprise us that people have hallucinations when they use THC. That's what the molecule does. And then it causes people to do things like get irritable with loved ones. It causes people to take money that they otherwise wouldn't do. It causes people to say really weird things and do really weird things.
Dr. Patricia Halligan:
I remember one teenage boy that I saw a while back and he had, had gotten in a fight with his girlfriend and the girlfriend had gotten in her car and gone home. And he jumped in his own car, followed her at high speed, ran into the house, uninvited, ran upstairs where rooms screaming. The dad tried to throw him out. He was making all sorts of threats against the family. This, this was not a violent young person before he started smoking on a daily basis. He got in trouble with the law that day really mortified at his behavior, you know, and I think she actually followed a restraining order against him. So absolutely. Yeah. more irritability, more vol, more violent tendencies, more aggression. And the, sometimes parents will say to me he stopped playing lacrosse. He's given up playing the saxophone everything he used to do, you know, he, he no longer wants to do. He just, you know, he's, he's not the same person mm-hmm <affirmative> so, so what are the dangers of cannabis use?
Dr. Laurence Westreich:
The dangers, especially in the population that you're describing right there is that heavy long-term use has cleared neuropsychological damage that it does to the adolescent brain. So someone's, so someone's achievement is likely going to be degraded by heavy, early use of THC. That being said, even kids who use relatively less can still have impairment in their academic function because of the use of the THC. Even if it's just acute use, even if they miss a few classes or they're not as effective as, as they would be. And I see this often in younger people starting out their careers, where you see that the trajectory of their career has not taken the more you would expect, their level of intelligence and education should take them. And sometimes people recognize that and they realize that they, the marijuana they've been using has degraded their performance by 10, 15, 20%, which still allows them to succeed at work, but takes them off that early trajectory that would've led them to better achievement in their employment or better achievement in education or frankly, better achievement in relationships. So you know, it's very potent in the patients, you and I see.
Dr. Patricia Halligan:
And what about loss of potential loss of IQ points? If you're a marijuana user under, especially under the age of 16, like an early initiator. I remember a study way back. I think it was a New Zealand study of a thousand kids and I think it was up to eight IQ points they could, they could lose, right?
Dr. Laurence Westreich:
Yes. I, I think the data are very clear that early heavy use of marijuana is detrimental to neuropsychological functioning going forward, including memory, including executive function, including all the parameters that we used to succeed in the world. So that, that is disastrous and the prevention people are very clear that the child who starts smoking and drinking too at the age of 12 or 13 is much, much worse off than the late adolescent who starts drinking when he or she is 17, 18, 19. In addition to the fact that they have better judgment at that age the brain function has the brain morphology has improved to the point that they're less likely to be damaged at the older ages. I, I would say anyone below the age of 24, 25 who smokes marijuana regularly is taking a big chance with their neuropsychological functioning going forward.
Dr. Patricia Halligan:
I, I think there was a study in Canada that came out in an addiction journal before Christmas of 2020 that followed kids who were regular marijuana smokers paid them to stop for a month and followed, did extensive cognitive testing on them and found a dramatic improvement in memory. Even at the one month mark, when these young people had stopped smoking they probably all went back to smoking, but at right, what you're saying is it kind of suppresses, I guess it changes the brain structure and the brain function. It can heavy at a heavy doses at an early age.
Dr. Laurence Westreich:
Exactly. And I would say both things that study, you mentioned looked at at the acute effects of THC mm-hmm <affirmative>. So, you know, those subjects were smoking a fair amount of marijuana, but had not been for that long and even so they could find discrete cognitive deficits in those individuals, but for ones who start early and start heavy they probably have a lifelong deficit because of the use of THC. And, and so those are the patients you and I see there may be, you know, for every patient we see there may be a hundred kids out there who smoke marijuana once in a while, to me, it's like whether or not you're allergic to peanuts. I mean the ones who aren't allergic to peanuts eat peanuts and the ones who are allergic end up in our offices, you know, with serious problems. And I, I think that's the category of kid that has a problem with, with THC. They're just unlucky enough to be dependent on it.
Dr. Patricia Halligan:
And who are the kids that are most at risk to develop a cannabis use disorder?
Dr. Laurence Westreich:
In my view, they're the ones who have parents who have a drug or alcohol issue and whether or not they give the substance to their kids, but, but that's the environment that they have. I would say there is likely a genetic component to addiction in general. Certainly it's been proven with alcohol. And I think the, the geneticists tell us is very likely with THC. So ones who come from an environment where there's a lot of drug use and then ones who are genetically vulnerable. I think both the two of those together is is pretty pretty worrisome
Dr. Patricia Halligan:
And, and the a D D kids too, right? Those are the kids that I see a lot of in my office kids with a history of ADHD, right. And some of them even say it helps their a D D what, why you respond to that?
Dr. Laurence Westreich:
Yeah. I, I think that's a good point. The a D D people tell us that appropriately treating a D pulls kids away from substances of abuse because they're not trying to medicate their a D D and I believe those data sets. I also think that the, the student who tells me the, the marijuana makes a D D better, I don't buy it. I think it probably makes him feel a little better unless anxious about the failure in school. But it's, it's hard for me to believe that a SIB would make add better.
Dr. Patricia Halligan:
I am so glad that you hit that point home. I have so many parents who say to me, I'm not gonna treat my kid with stimulants. You know, there's this huge family history of drug addiction in the family. I don't wanna set 'em up to be a drug addict. He's gonna be addicted to meth. I don't wanna expose him to stimulants, but the studies, like you say that one of the biggest risk factors for developing cannabis used disorder is untreated a D D. And the way to treat it is to get the kid with a D D under the age of nine, put 'em on stimulants and treat them with stimulants for at least six years.
Dr. Laurence Westreich:
Right. And, and the important piece in what you just said is treat them with stimulants. So as long as they are monitored and their use of the medication is very carefully calibrated to their symptom picture. You know, the data are very clear about stimulants that they're effective. It's when they're, you know, prescribed headlessly by a physician who's not watching the prescriptions that they can become a problem.
Dr. Patricia Halligan:
Now, what can I say if my child argues that cannabis is natural and it's mostly legal
Dr. Laurence Westreich:
I have a whole pattern for when I get that line. The first thing outta my mouth is usually, yes, cyanide is natural too. That doesn't prove that it's safe. <Laugh>. but, but I also say that that's not really relevant. And I, I, I think it's fair for, for a student to understand that all molecules are just molecules. So sugars are white powder, you know, cyanides are white powder, whether THC is legal or illegal is irrelevant to the effects on you. And I, and I, the fact that it's on schedule one for the feds doesn't make any sense to me either, but it's irrelevant to the young person who, as you said, has quit. His or her sports team is not going to school and has lost his or her friends. So the fact that it's legal makes no difference. It's a, it's a political artifacts. It got nothing to do with clinical work. The fact that it's natural similarly is interesting, but totally irrelevant.
Dr. Patricia Halligan:
I agree. Is it a gateway drug?
Dr. Laurence Westreich:
That's a good question. That's been looked into quite a bit. And I'm not so sure that it is actually because the denominator is so big. I mean, it's true that everyone who, who uses heroin started out with marijuana. It's also true as my friend, Bob Millman used to say everyone who, who uses heroin also had milk on his cereal that morning. So it's hard to know if one caused another, but I usually respond when I in parents groups, when they ask that question, I say, it doesn't need to be a gateway drug. It's dangerous enough by itself. So if your child is using marijuana on a regular basis, that's what needs to be looked into. I mean, other drugs also would be harmful, but the marijuana of itself is dangerous enough to be looked at in a serious way. I think
Dr. Patricia Halligan:
Someone mentioned at a conference recently that if you use marijuana, so you're at an early initiator under the age of 18, that is the biggest risk factor for developing opioid use disorder. And I thought that was interesting. I think it was some co Colorado consortium lunch and learn, and I thought that's the first time I've ever had heard that.
Dr. Laurence Westreich:
I have, I've heard a lot of people say things like that. I haven't heard, seen any convincing data to that effect. Me neither. So I, I don't, I don't necessarily buy it. You know, sometimes people make causal links between things that are just associations
Dr. Patricia Halligan:
True enough. So yeah, more, more research needed on that one, right. Yeah. Right. Does cannabis have some medical uses
Dr. Laurence Westreich:
Experts in the field of medical use of cannabis? Tell me, yes. My understanding is that there's FDA approval for for treating some pediatric seizures that there is some benefit for pain syndromes. There's certainly benefit for nausea related to chemotherapy. And, and those are pretty convincing data sets. I'm told I'm not an expert in that. But the other things that it's touted for really have no data behind them, for instance, the psychiatric disorders. There's a lot of study being done about PTSD and about anxiety with THC. And if, if I see multiple randomized studies that are replicated, I'll believe it before that I wouldn't recommend a unregulated substance for the use of any of those conditions. Cause I think they're serious conditions. And that being said, I see people who have serious problems with, with THC. So if there are people out there who are well treated, they're not coming to my office,
Dr. Patricia Halligan:
|They're not coming to mind either. And I make people mad all the time. They come to me and say, please give me a card for medical marijuana, for my PTSD, for my anxiety, for my depression. And I rely on the statement, the American psychiatric association statement of 2019. And they basically say that it's, there's not enough evidence to support using cannabis to treat any psychiatric condition. And the APA does not recognize cannabis as medicine at this point. So I think to your point, they are looking for more in depth research that's convincing. Yes. And the APA actually says, in fact, cannabis typically makes psychiatric conditions worse.
Dr. Laurence Westreich:
And absolutely there there's a association between heavy cannabis use in first breaks and schizophrenia. So I certainly wouldn't recommend for the treatment of any condition that, but I only treat psychiatric conditions. So there we
Dr. Patricia Halligan:
Are me too. And at this time we're going to take a short break. I'm Patricia Halligan. And this is Dr. Lawrence Westlake. We'll be right back. Thank you.
Intermission:
Treatment of opioid use disorder is a CME approved video for healthcare professionals. This comprehensive video covers how to talk to patients about three FDA approved treatment options, the research behind each medication and how to help patients choose the right medication for them. You'll learn everything you ever wanted to know about these treatment options, to be able to treat patients in your office with ease. This video simplifies the prescribing of buprenorphine and includes buprenorphine home induction instructions for patients and pamphlets for patients and their families visit DrPatriciaHalligan.com for more information benzodiazepines. The epidemic we aren't talking about is a CME approved video for healthcare professionals. This very comprehensive video describes the dangers of taking benzodiazepines and Z drugs long term and teaches how to de-prescribe them safely and effectively. We outline how to talk to your patients before, during, and after a long slow volume taper, how to build your patient a village of support and offer a deprescribing toolkit. Find out more about this package and what it includes visit DrPatriciaHalligan.com. You are listening to recovery, the hero's journey. If you or someone you love struggles with a substance use disorder or prescription drug dependence, and would like information about resources that can help please contact one of the following organizations, the American academy of addiction, psychiatry, the American society of addiction medicine, or the benzodiazepine information coalition. Now back to recovery, the hero's journey,
Dr. Patricia Halligan:
And we're back to recovery, the hero's journey with our guests, Dr. Lawrence West rake and today's podcast is when someone you love has a problem with cannabis. So Dr. West rake, I think we'll pick up where we left off. What is the connection between mental health, if any, and cannabis
Dr. Laurence Westreich:
Often time psychiatric disorders are associated with the use of cannabis. And I'm saying that very carefully because sometimes psychiatric conditions can be caused by the use of cannabis. Certainly depression and anxiety can be worsened by cannabis. Sometimes there's simply an association. I mean, it's not uncommon for someone with psychiatric symptoms to medicate their own symptoms with cannabis because it is sedating. There's very worrisome association between heavy cannabis use in a late adolescence and first break of schizophrenia of psychosis when someone loses touch with reality and the data are becoming clearer that the heavy cannabis use can provoke the first break of schizophrenia. It's not necessarily saying that it causes a schizophrenia, but it probably causes it to happen earlier than it would have otherwise as clinicians. And I'm sure you would, in the same camp, we have to be careful of differentiating what causes, what sometimes people who are having psychosis will medicate themselves with marijuana in order to tamp down their symptoms. But it's a typical dual diagnosis problem. We have to pull it apart till we can get the right treatment going.
Dr. Patricia Halligan:
And can you give an example for the listeners who don't understand what psychosis looks like in a young person say heavy duty marijuana, smoker, cannabis user, you know, from say 16 to 20 comes into your office. What does psychosis look like?
Dr. Laurence Westreich:
Psychosis is a break with reality, so it can have cause problems with thought process or thought content thought content problems are things like hallucinations or delusions. People will see things that aren't there hear things that aren't there often with drugs there suspicious delusions like someone's listening to me or the police are after me and thought process disorders, which are also can also be caused by cannabis are when someone brings up all kinds of irrelevant detail into their speech is tangential and goes off into tangents, which don't really make any sense to the listener. And it's hard to know what causes a psychosis. It's, it's a symptom like fever. So fever can be caused by the flu. It can be caused by cancer. It can be caused by an infection of the joint. Psychosis can be caused by drug use. It can be caused by schizophrenia. It can be caused by, by bipolar disorder. And so it's incumbent upon the clinician to figure out what's causing the psychosis and then treat it.
Dr. Patricia Halligan:
I remember I had a patient maybe 10 years ago and he was smoking weed on a daily basis for several years. He was 20 years old. He went down to Florida to work with his cousin and got psychotic, broke into some random woman's home that he didn't even know got caught by the police thrown in jail for a month. And so he had this psychosis that didn't go away. It was untreated for a month. It took many months to get him unpsychotic non psychotic. And he, it was really terrifying for him, really super traumatic. Mm-Hmm <affirmative> what do you tell somebody like that? I remember another young person I had, and he went away to co college, an Ivy league school and smoking on a daily basis. And all of a sudden thought that TMZ was following him around to get an interview because of his sexual pros. Everybody was very jealous of his, his, he was very grandiose mm-hmm <affirmative> and he was going to arrange a golf game with the Kings of Leon, the rock band. And he was writing a letter to the prime minister of Britain. And these were kids with no family history of bipolar disorder or schizophrenia, no premorbid psychotic. What do you tell the family? What do you tell the young person at that point, when they say is this bipolar disorder with psychotic features, is this schizophrenia? What do you, what do you tell them?
Dr. Laurence Westreich:
The important thing to say is, I don't know, and there's no way to know once drugs are mixed into the picture what has to happen is the person needs to have an evaluation. The drugs need to be pulled out of the system. There's no way even the best psychiatrist can know what's causing a psychosis when there's that kind of input into the system. So, you know, if the person's unable to stop using outside of a hospital, he or she needs to be in a hospital where you are guaranteed, there are no drugs going into the person's body. And that way, you know, the psychotic symptoms, if they're due to the drugs will resolve and, and whatever else is there can be treated. Sometimes the psychotic symptoms don't go away. And I suggest that's usually because of a, of a psychiatric disorder that is masked by the drugs. But there has to be a sophisticated assessment of what's happening rather than just blasting away with some treatment or other,
Dr. Patricia Halligan:
And some that's, that's an important distinction. Sometimes the kids have to go back into the ring and do some more research and they go back to marijuana or cannabis and all of a sudden they're psychotic again. And they're, they wound up in a psychiatric hospital and they've lost their fraternity and lost their semester at college. And, and it's, it's humiliating. It's embarrassing. They are afraid now because they basically broke their brain. So it's, it's quite quite traumatic. And yeah, I say the same thing that you, that you said number one thing we do here is get rid of the cannabis, get rid of the alcohol, get rid of all, everything, let your brain heal. Mm-Hmm <affirmative> and hopefully this will go away. And it was just a substance induced psychotic episode. Really super scary. Now, how do you recommend parents talk to their kid? If they think that he has a problem with cannabis, this is touchy and what makes it difficult? I guess that's the question?
Dr. Laurence Westreich:
What makes it difficult is that usually people with a substance use disorder are hiding it from the people who love them and because they essentially have to do that in order to continue, you have to hide it from people who care about you, cuz otherwise they will do something to intervene. And I talk a lot with families about how to talk to their adolescent kids about their use of substances, including marijuana. I emphasize an empathic way of doing it. I emphasize looking at particular issues rather than any global concerns. And I emphasize getting them to help as soon as possible. And so I, if I'm talking with a family about how to talk to their adolescent about this substance use, I, I look at the level of anger. Sometimes parents are furious with their, their lovely child. Who's now been lying, cheating, stealing, and doing things because of the drug use and it's understandable. And so I helped him manage the anger, but focus on the problem at hand. And the problem is, as you alluded to earlier that juniors quit the lacrosse team. He's not going to school and, and his friends aren't coming around anymore. Mm-Hmm <affirmative> so let's focus on that. If the problem is serious enough, the person should go to inpatient.
Dr. Patricia Halligan:
Especially if he's not going to school if he's having psychotic features if he's violent and if he's unwilling to go, right
Dr. Laurence Westreich:
Absolutely I, and on an outpatient basis, often you can work with these kids and, you know, if they're willing to cut down or even move towards sobriety from the substance, I'll try to work with him. And oftentimes it works, frankly. I mean, I think that one of the keys is getting the adolescents aligned with another group of adolescents who can help him or her move towards a, a sober life. I love AA and it and I sent people to young person's meetings because they can meet other kids who are just like, they are, the only thing is they can't use drugs or alcohol. The problem you alluded to earlier is the real one. Sometimes kids will go to an AA meeting and the other kids are addicted to alcohol or cocaine. And the kind of the marijuana gets looked down on. The reality is in a lot of places, there are marijuana anonymous meetings, which are for marijuana in a lot of places, there are more sophisticated AA or NA groups who understand that for the kid who's dependent on marijuana, that's his or her drug of choice and it should be treated like other drugs of choice.
Dr. Patricia Halligan:
I love that you mentioned the marijuana anonymous meetings. And I think even now, because of the pandemic, you can go to a zoom meeting pretty much anywhere in the country. So you could find, I know in New York city you've got marijuana anonymous meetings. Right?
Dr. Laurence Westreich:
Absolutely. And I think that's, that's one advantage that we've gotten from the new zoom era with, with COVID that you can go to. Yeah, not only can you find an AA or an NA meeting any place around the country, but that if people wanna lurk in a AA meeting and see what it's like, it's, it's in a way, much easier than walking down into a church basement. So you can look at what's happening in the AA meeting, keep your camera off and realize it's a very empathic, lovely group of people who are there to help each other and re, and so it's a way to tip one's toes into the water, which I think is tough for adolescents to do. Understandably.
Dr. Patricia Halligan:
I think so too. And I love your point about anger and the parents. I believe a lot of fear is underneath that anger, right? They're really afraid the, the kids on drugs the kids outta control. And I think they're, they're just reacting. So it's like, if you can get away from your emotional reactive center take a break. If you find the kids you know vaping device under his bed, or you find a stash of cannabis don't react that day, right? Take some time, take some space, go for a walk and have a conversation. Like you say, that's curious and nonjudgmental, but still elicit some information from, from your, from your child. But, you know, do you find that parents oftentimes don't even know they have leverage, they'll say to me, well, he does, he won't go, he won't go to see a, a counselor. He won't go for a drug evaluation. You know, he won't go to school, he won't give it up. And I'm wondering, what do you, think's going on that they don't know they have any leverage. And what do you think gets in the way of using it?
Dr. Laurence Westreich:
I think you make a good point. I think on two levels, parents underestimate the amount of leverage that they have. I think the prevention experts say very clearly that you want your child to have in, in his or her head, that drum breed from mom and dad that we think this is bad. This is dangerous. So you're trying to push off the first use of the substance from that 12 or 13 year old till he's 16, 17, 18. So, so that's the first thing from a prevention perspective. You know, even though the, the kid may say, I don't care what you say, I'm not listening to you, they're listening to you. They can't help it. Mm-Hmm <affirmative>. But secondly, when the kid actually has a problem, I think you're right. Parents have much more leverage than they believe. And you know, I've kids too, and certainly try to be empathic and caring and supportive of them, but there are times when parents need to put their foot on.
And that does come when the child's function is impaired, especially at, at a late adolescent stage, when that function is going to really tell us what's gonna happen in the rest of that person's life. So if a adolescent needs to go to an I O P if he or she needs to go to see an evaluation with a therapist, if he or she needs to go to inpatient, I think parents need to, at some point require that. And that's a really hard thing to do. And I, a lot of my work is helping families, you know, approach that in, in an empathic caring, but serious way in the case, in the same way that you would approach your child, if God forbid he or she had cancer, I mean, it's serious. And the fact that you don't wanna get to treatment doesn't mean that you don't need to have
Dr. Patricia Halligan:
It. The parents really need help with support and help around boundary setting, help around drawing up a con consequence logical consequences flow chart, right? I think part of the resistance to setting down boundaries and consequences and using their leverage is there's so much reaction so much, so much of an outburst in that. And so much defiance, that's the response of the young person who's confronted around their drug their drug problem. And they can be quite vicious verbally, right. And parents don't like to be the bad guy.
Dr. Laurence Westreich:
Yeah, of course not. And I understand that. And I, that's why I recommend that if parents have a child who has got a looks like has a drug or alcohol problem, they, the parents should also have an advisor to help them manage the situation. And, and I have function in that role when I'm not treating the adolescent, someone else is treating the adolescent and you can help them frame their response. So it's the best possible response and prepare for those things that the adolescent is likely to say. Cause frankly, there are a few things that are likely to say, and it, it's not really a mystery, what they're gonna say. And it's helping parents set up those trip wires. I call them. So if, if, you know, if the child just smokes pot, once in a while, you may not like it. And you may say that, but if the trip wires that his grades start dropping, or his friends stop dropping, start dropping away where he changes activities or stops activities, that should be a trip wire to warn everyone. And I usually, you mentioned logical consequences. I'm glad you did because ones that are very logical are things like if you smoke pot, if you drink, we're not giving you the car keys.
Dr. Patricia Halligan:
Does that make sense? Doesn't
Dr. Laurence Westreich:
Right. And, and, and you can't really argue that one, although people do. But other ones that, you know, if your, if your performance in school is slipping we're not gonna allow you to use alcohol or marijuana now to say that to a 17 year old is hard, right? Because you can't really control what a 17 year old does outside of the house. But I often tell parents what it sounds like you tell them is that don't underestimate the power you have when you talk to your kids. And, you know, even if you're decreasing their substance use by 50%, when they're out of the house, you're still in a good place.
Dr. Patricia Halligan:
And research shows that one protective factor is the parental expectation of non-use. I expect you not to use drugs. Mm-Hmm <affirmative> I hope that you don't smoke marijuana until you are 24, 25 years old. Mm-Hmm <affirmative> I love you too much to continue to enable you to hurt your brain. Mm-Hmm <affirmative> yeah. It's my job to step in here. This is hurting you and I, I just can't stand by and do nothing.
Dr. Laurence Westreich:
Right. And I think that's the way to put it, not to get into the morality of it. Not even get the legality of it. No, I mean, not that it, you know, you could have a long, interesting conversation about the legality of THC, but it's irrelevant to your, to your 16 or 17 year old.
Dr. Patricia Halligan:
And they would use it against me also. And they would probably win if they were using the country's logic.
Dr. Laurence Westreich:
Sure. You can get a public health argument and we can talk about that. We'll go to our conference and talk about it. But if you're impaired by the substance, the public health argument is irrelevant.
Dr. Patricia Halligan:
Yeah. And I guess to bring up in a non shaming way in a non-violent way, just maybe list some of the things that you've seen you know there's two failed grades you know you've maybe you were kicked off the soccer team your girlfriend left and you know, there's money missing and you're smoking in the house mm-hmm <affirmative> and I'm worried about you, right? I'm very, very worried about you and studies show that this hurts teenage brains and the brains of young adults. And I'm worried about IQ and I'm worried about anxiety and depression and suicide, and I'm worried about your future. And I, I love you and I, I, I will help you every step of the way as, as we find someone to help you with your marijuana problem, I believe it's a problem we can agree to disagree, but I need you to follow through and go for an evaluation. Where do the parents go? How do you access how do you access an expert? And what's, what's the first line expert that they should seek out. I wonder
Dr. Laurence Westreich:
What they're looking for is someone who's knowledgeable about addiction. And I'm saying that very carefully, cuz not all physicians are knowledgeable about addiction. And some, you know, people with credentials like licensed professional counselor or licensed social worker are extremely knowledgeable. So I, I counsel parents to ask in the school counseling office who a good therapist is for their child ask their pediatrician who a good therapist is because usually those individuals have access and have knowledge of who's who does a good job organizations like the American academy of addiction psychiatry, or the American society of addiction medicine can direct people. SAMSHA has a website for directing people to addiction specialists. But I, I usually recommend that it's someone who really understands addiction because otherwise they really won't understand what's happening in front of them.
Dr. Patricia Halligan:
That's a very good point. And absolutely there's not much addiction training in medicine is there certainly wasn't in my med school or my, even, even my psychiatry residency mm-hmm <affirmative> right. So how are cannabis problems treated?
Dr. Laurence Westreich:
First an assessment, as we've been talking here to really look at what the problems associated with the cannabis are because before you can start treating a problem, you have to know what you're pointed at. And so I always use that as a basis for my treatment, especially with an adolescent look, the concern is here that you're not engaged with school as you want to be that your friends are dropping away. So if we can get a decrease in the THC use and the person has an improvement in, in those criteria, I I'm happy with that. I aggressively treat withdrawal from cannabis, cuz I think it does exist. It's probably the main reason people go back to using cannabis. And I treat it with, with psychotherapeutic maneuvers, but I also, there are a few medications which have been modestly helpful with the use of, for the, for the treatment of withdrawal.
The most important thing is to acknowledge that it exists. Mm-Hmm <affirmative> cause the user knows it exists, but people tell 'em there's no withdrawal from marijuana. You're crazy. He's not crazy. He's feeling irritable, he's insomniac, he's craving. And that if you treat it and acknowledge it, usually people feel a lot better and they, and they know that you understand what's going on. So that's the first part is getting someone engaged in treatment. Oftentimes, you know, even when someone hasn't used for a while you know, relapse prevention is important because you know, any 10 year old in America can get marijuana if he wants it. And so it's offered often. And so you have to have refusal techniques for understanding what you're going to do when you walk into the college dorm. And if someone else orders offers you a joint, what you're going to do, if you're on a date and the person says you wanna smoke, right. What you're going to do, you know, if you walk into a party and there's a waft of, of marijuana smoke all around. So those are the short term and the long term treatments.
Dr. Patricia Halligan:
I love that you say you aggressively treat marijuana withdrawal because it does exist. And it's probably the number one thing, sending them back to a relapse. What medications do you use? I'll tell you what I use.
Dr. Laurence Westreich:
You know, I, I don't use the THG analogs. I, I don't think the data are great. I use things like Trazodone to help with sleep. I use some anxiolytics like Gabapentin to help with the anxiety. So I wanna be very careful not to cause an addiction to some other substance or medication in the person, but I, I want to aggressively treat what they have. So I do with medications, but I also do it with self relaxation techniques and with just an acknowledgement that this is happening to you and it will actually resolve, it's not lifelong, but it is for many weeks to months.
Dr. Patricia Halligan:
I like Gabapentin. Also. I like Trazodone. I like a little bit of Mirtazepine for sleep mm-hmm <affirmative> and yeah, there's no FDA approved medication for the cannabis withdrawal yet, but I like all those and I think NAC an acetyl cystine that you can get at GNC I think up to 2,400 milligrams a day or 3000 milligrams a day my patients say the only thing side effect they get from that is a little bit of gas,
Dr. Laurence Westreich:
Right? Yeah. I, I haven't found that that effective, but it's perfectly legitimate to use it.
Dr. Patricia Halligan:
I don't think it can hurt.
Dr. Laurence Westreich:
Right.
Dr. Patricia Halligan:
You know, so I guess the last question I've got is if you have a child in middle school and or elementary school and you as a parent, wanna be proactive and do as many, I guess, preventative measures as possible, what kind of talk do you have with your kids? Say the kid in middle school, seventh grade about cannabis and about alcohol, I guess, but we could keep it to cannabis for this podcast.
Dr. Laurence Westreich:
Well, I'm glad you're bringing it up. Cuz parents often assume that the fifth, sixth, seventh graders has no idea that there's cannabis out there. And of course they do do. And, and the best advice is to use age appropriate language with that child to try to understand what's happening at the school and his or her social group. And I think that's not only for the age, but for the development of your particular middle schooler, cuz kids are different. I mean, some are extremely sophisticated and some are, are not. But I think asking questions and, and letting that child know that you're open to talking about whatever comes up at school, whether it has used, has to do with people, offering drugs, whether it has to do with sex and that you are there and, and will discuss these things in a non punitive and non shaming way. So I, I love it when parents come home, come to me and they say, my kid asked me this really weird question about drugs and she's only in seventh grade. I said, that's great. She's asking you, she's not asking her, her friends in the school yard about drugs. She's asking mom and dad. Oh, wonderful. So when you, when you have an uncomfortable conversation, it's great. And then you can, you know, educate your child as he, or she needs to be educated.
Dr. Patricia Halligan:
So you start with an open mind, you start with curiosity. This is, Hey, what are kids saying about pornography? Have you ever heard the word? What are kids saying about cannabis, marijuana, weed? Are any of your friends using it? Mm-Hmm <affirmative>, it's, it's information gathering and, and non punitive, just let's open the conversation. And I want you to know that I'm here and, and I just want you to know, you know, that your dad and I have a, or your mom and I have a rule in this house that we would like you not to drink and we expect you not to drink and we expect you not to use drugs. And that being said, if you ever find yourself in trouble give us a call or if you knows it's hard, isn't
Dr. Laurence Westreich:
It? That that double message is so hard, especially when they're in high school where you wanna say, I, I think as you said, we have an expectation that you're not gonna use drugs for alcohol, but if you do, and you are in trouble, you can call me anytime twenty four seven, and we'll discuss it later and I will pick you up. So, but, but it's look, it's a double message you have to give, you know, the children all along the line and understand usually when they're 18, they go someplace, they're not in your house anymore. So he, or she's going to have to make his or her own decisions. So you wanna set them up for those decisions when they're 12 and 13?
Dr. Patricia Halligan:
Absolutely. I would like to, before we close, I have two resources to offer for families of those struggling with cannabis use disorder. Before I do. What do you think of Allan on for parents of a kid with a, a cannabis problem?
Dr. Laurence Westreich:
I think the same thing about alcoholics anonymous. I think it's great to try out. I think parents should definitely go and see if it's productive for them as I recommend actually every patient try out an AA or an NA meeting. It's not helpful for everybody. Yeah. But it is a great place to start to get some understanding of what you're going through, frankly. It's a good place to get referrals too. Cuz often they're experts in finding good clinicians.
Dr. Patricia Halligan:
Oh, I, I think they've been through you know, three or four clinicians by the time they, they hit an Aon meeting. And I agree with you. I think nobody understands like another parent who's gone through you know having a kid with a, a substance abuse problem. There are two free resources I'd like to make people aware of Hazel and Betty Ford offers a free virtual family program. It's a one day format. They talk about the disease model, boundaries, communication, recovery management, and it's available in both English and Spanish Hael and Betty Ford also offers ongoing professional coaching for cost. So parents can sign up for six sessions, three months, 12 months, etcetera. And also if parents Google www.druginfo.org, that organization offers free parent coaching and free parent support groups. I think there's about five of them per week on zoom. So Dr. Westrick it's been really a real pleasure and I still appreciate you coming on the show and presenting some wonderfully clarifying information for our listening audience on cannabis. Thank you so very much. Thank you for having me. It's been a pleasure.
Dr. Laurence Westreich Bio:
Laurence M. Westreich, M.D. is a psychiatrist who specializes in the treatment of patients diagnosed with Substance Use Disorders (SUDs).
Dr. Westreich completed a residency in Psychiatry at New York’s Beth Israel Medical Center and a two-year fellowship in addiction psychiatry at New York University/Bellevue Hospital. He is board–certified in general psychiatry, addiction psychiatry, and forensic psychiatry.
Dr. Westreich is Associate Professor of Clinical Psychiatry in the Department of Psychiatry, New York University School of Medicine, and the author of Helping the Addict you Love (Simon and Schuster, 2007), and A Parent’s Guide to Teen Addiction (Skyhorse Publishing, 2017). Dr. Westreich is Past President of the American Academy of Addiction Psychiatry and serves as Consultant on Behavioral Health and Addiction to the Commissioner of Major League Baseball.
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