Evaluating the Evidence: Cannabis and Psychosis, Part I


Over the last few days on facebook and across social media platforms, there has been the evocation of fear based in the findings from a new study around the evidence that high potency cannabis used daily may cause increase the risk for psychosis. While alarming at first glance, as someone who understands the endocannabinoid system and the benefits of cannabis, and as an advocate for patients’s rights to access this herbal medicine, I feel obligated to take a closer look at the evidence as presented in The Lancet. So feel free to join me on this journey of evaluating the evidence (or perhaps for those of you with advanced research analysis skills, take a look at the article yourself and see, regardless of your stance on cannabis, what the researchers did well and where they might be flawed). As President of the American Cannabis Nurses Association, my bias toward being pro-cannabis is clear, but I am also pro-patient and pro-safe use of cannabis, so I will do my best to provide an honest analysis. My approach here is the same that I would use in my work with my RN-BSN students, going through each area of the research, and using an approach to express my concerns that all levels of educated healthcare professionals can understand. 

The full text article can be found here: https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30048-3/fulltext

(Be sure to download the appendix as well, if you are following along!). 

My thoughts are in blue font.  

Title: The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): A multi center case-control study. (long title, but fairly clearly depicts what the study is about). The article is open access, which I like. 

Journal: Lancet Psychiatry (reputable!)

Authors:Lots of good credentials here; a mix of MDs and PhDs. There are over 30 authors, which I find interesting. Sometimes this is a good thing, sometimes it doesn’t mean much. In the field of nursing, 30 authors would be quite large; in the world of physics hundreds to even thousands of authors can get credit…but are they really authors? Here is a link that looks at this issue (if you care or if your dare!), but this seems reasonable in this case: https://physicstoday.scitation.org/doi/10.1063/PT.3.1499

Funding: This was funded by the Medical Research Council, the European Community’s Seventh Framework Grant, Sao Paulo Research Foundation, the National Institute for Health Research Biomedical Research Center, Maudsley NHS Foundation Trust (South London and University College London), Kings College London, and Wellcome Trust.

At least five of the authors report funding from pharmaceutical companies, though stating that they were funded for other studies, not this study. Check out the full list at the end of the article. Getting funded is part of people’s jobs within research. Its just one of those little tidbits, to keep in mind, that certain loyalties and biases may be playing a part in the research here. “Big pharma” can be viewed as having vested interests in people using cannabinoids (which they may eventually be producing medicines for us all to use someday) or people sticking with their traditional allopathic medicines (I won’t get into the poly pharmacy issue and all of those implications) or even creating pharmaceuticals that help people managing psychosis. 

Problem: In the beginning of the article, the authors state that with legalization movements, we may have “an increase in cannabis use and associated harm, even if the later only affects a minority of patients” (p. 1) and they go on to state that several studies “support a causal link between cannabis use and psychotic disorder”(p.1). Ideally I would have time to thoroughly analyze each of the 5 cited studies in the first paragraph, but seeing as nobody is paying me to do this work, I instead decided I would check out at least one of the articles cited. I went to the fifth article cited because of the researchers’ claim  that the research may “support a causal link” (which was very concerning to me, because I keep running around saying “correlation is not causation…!” and people don’t seem to get that). 

And it turns out that key word “support” is very important: when I reviewed the cited  study by Gage, Hickman, and Zammit (2016) entitled “Association Between Cannabis and Psychosis: Epidemiological Evidence”, their conclusions lead me to believe that they did not determine causation. Gage at al basically looked at the evidence from longitudinal studies, and in their findings, they distinctly refrain from making a “causal” statement: “Overall, evidence from epidemiological studies provides strong enough evidence to warrant a public health message that cannabis use can increase the risk of psychotic disorders. However, further studies are required to determine the magnitude of this effect, to determine the effect of different strains of cannabis on risk, and to identify high-risk groups particularly susceptible to the effects of cannabis on psychosis”. When people read articles like this one we are analyzing here, it’s just too easy to assume that somehow causation has already been proved, when it clearly has not. 

The authors in the introduction go on to state that there is a rising incidence of schizophrenia in the world. “Differences in the distribution of risk factors for psychosis, such as cannabis use, among the populations studied might contribute to these variations” (p. 1). Hmm, well,  this might be related to cannabis use, but when I checked out the articles cited, they had more to do with income, urbanicity, migrant status, age, race/ ethnicity, and whether or not the person owned their home. I think we just have to be careful as readers and consumers of evidence to pay very close attention to the subtle nuances. What the researchers are saying is that they think cannabis should be examined in light if rising schizophrenia diagnoses (though some of the literature I read as part of this process stated that schizophrenia is not rising, rather its falling as we do a better job of differentiating and diagnosing). More on this later…

In a  pink box on page 2, the authors summarize some of the previous work done in this area I found their review of the literature (I think that is part of the purpose of this box?), a bit compelling, though they only found 3 articles that matched their criteria for psychotic disorders in combination with specific terms like “high potency cannabis””skunk-super skunk” or “high THC cannabis”. Two of the articles were their own work, and the third article was much older, going back to 1965-1999 London where increasing rates of schizophrenia “might be related” to cannabis use in the previous year.

 I couldn’t find the authors of this rise in schizophrenia article cited on the reference list, so I asked Dr Google for some help. I did eventually find the article and review the abstract…it then lead me to wonder about the idea of increasing diagnosis of schizophrenia during this time period, which then lead me to stumble upon a major issue with the criteria for schizophrenia, how it was historically diagnosed, and the argument that there may be some big issues around valid DSM criteria for the various types of schizophrenia  (rabbit hole alert, check it out, check it out…https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5103459/). Though I worked in psychiatric nursing a few eons ago, I am clearly not up-to-date on all of the controversies that the DSM seems to spark. 

As near as I can tell, “psychotic disorders” are pretty much undifferentiated, and this is why the authors used this term vs chasing a more definitive diagnosis like perhaps bipolar or schizophrenia, which may be more difficult to make and of course may take time to differentiate. According to the NIH/NIMH, “psychosis” describes conditions where the person has a mind condition, and they have lost contact with reality: it can be a sign of a mental illness or physical illness, it can be caused by medications/ alcohol/drug abuse, 3% of the population experiences it, and symptoms include hallucinations, delusions, paranoia, and disordered thoughts/speech. Studies show that is common for people to have symptoms for more than a year prior to diagnosis.

 https://www.nimh.nih.gov/health/publications/raise-fact-sheet-first-episode-psychosis/index.shtml

This is extremely important to note because the researchers here looked at cases of first-psychosis, but there appears to be no follow-up regarding if these were “temporary” diagnoses, or if they persons were eventually diagnosed with schizophrenia or bipolar. They did use ICD-10 criteria to define the population eligible for the study : https://www.icd10data.com/ICD10CM/Codes/F01-F99/F20-F29/F20- but it remains vague to me as far as differentiating this population and they simply lumped all psychotic disorders together. 

It is known that adverse effects of cannabis can be things like hallucinations and paranoia, so I started to worry a bit and wonder if these folks were high at the time of intake into the ER, and if they were experiencing adverse effects vs a mental health diagnoses. Thankfully,  I do see some distinction of this in the article: if the symptoms were from acute intoxication, the person was not included in the study. Phew! I can assume they knew how to differentiate this.  

Participants: Participants were people age 18-64, they were diagnosed using the ICD-10 criteria for psychosis (which envelops a lot, check out link above). Control groups were apparently randomly selected from the same area using postal address, age, race, gender, ethnicity,  and lack of psychotic symptoms as the control criteria. The researches had participants in the 17 areas of England, France, the Netherlands, Italy,  Spain, and Brazil. The researchers were striving to assess 1000 first time psychosis and 1000 controls. I did not see in the study that cannabis use was ever confirmed by a urinalysis or blood test. This seems obvious to me, but since they are looking a year back, maybe it’s not needed? I really would have liked to have known their current status of testing positive for cannabis. 

The n for each group was good: control = 1237, cases= 901

Methods:

The researchers asked the participants about 6 measures of cannabis use: lifetime use (whether or not they ever used cannabis), current use, age at first use, lifetime frequency (pattern or most consistent use), money spent weekly (or during most consistent use period), The researchers then used data from the European Monitoring Centre for Drugs and Drug Addiction 2016 report to determine cannabis potency by THC.  (download it, you’ll like it, it’s fascinating: http://www.emcdda.europa.eu/publications/edr/trends-developments/2016_en) , however,  I actually ended up finding the data elsewhere on the website, where they have info about potency. The data available now is from 2018, I am assuming the researchers used 2016 data http://www.emcdda.europa.eu/data/stats2018/ppp_en

Okay, wait, what, don’t tell me…they didn’t ask the patients what specific strain they were using, nor actually test the cannabis strains the patients used, they conjectured from the data? I think I would have felt more comfortable if they would have collected some kind of data from patients beyond frequency of use that demonstrated that they were actually, truly consuming high potency cannabis. Additionally,  I had to dig around the website to find the potency, and the data is not well labelled. 

Also, another discovery in the EMCDDA report (figure 2.1) tends to show a downtrend in cannabis use in Europe, particularly in the 3 countries that previously were high prevalence countries such as Germany, Spain, and the UK. So while cannabis may be getting stronger, it’s use sure has dropped off greatly since the year 2000 in these 3 countries (which perhaps goes against the researchers thoughts that cannabis use is on the rise and posing a greater risk for psychosis).

 EMCDDA (2016). 

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Back to the Methods. I am directed to the appendix to further investigate how they determined “high potency”. I am feeling frustrated, because there is no appendix on the pdf I downloaded, and luckily I did find it on the main page. The appendix has lots of great further details and I am left to wonder why the editors had them put this crucial data in the appendix. 

Based on the data, low potency cannabis was <10% THC and high potency cannabis was >10% THC. Participants were asked to report the type of cannabis used, in their own language, and potency was estimated based on the data from EMCDDA. The participants seemed to give what I can only categorize as broad terms for the cannabis they were using, including UK home-grown skunk/sensimilla UK Super Skunk, Italian home-grown skunk/sensimilla , Italian Super Skunk, the Dutch Nederwiet, Nederhasj and geimporteerde hasj, the Spanish and French Hashish (from Morocco), Spanish home-grown sensimilla, French home-grown skunk/sensimilla/super-skunk,  and Brazilian skunk. (To clarify, in the UK “skunk” is a term used for all high THC % cannabis plants, but I could not find a clear definition for “skunk” in terms of strains or exactly what the cut off is for a plant to be called skunk). https://www.independent.co.uk/news/uk/home-news/uk-cannabis-market-skunk-drug-strength-weed-spice-street-sales-dealers-a8231426.html

This process of asking data based questions of patients experiencing first time psychosis brings up red flags for me: firstly, asking patients who are in first time psychosis what “type” of cannabis the participants were using seems highly unreliable to me. The problems with patients and participants self-reporting data are well known, and yet this whole study is about self report, I get it…we may not have better ways to collect the data (yet), but it remains an issue for me. They did also have some other questions around intoxicants, which is good, but I will get back to that with results. 

Secondly, the actual cannabis was never tested for true potency (back to the idea of the researchers claiming these patients used high potency cannabis, but the only evidence of them doing so was that they may have consumed cannabis in a geographical area where high potency cannabis is available), nor was there any indication that the patients were tested for THC (granted they could have tested negative and last use could have been some months before the episode). 

 

What about the actual findings????

Hang on for Part II of the analysis!  The findings and conclusion analysis coming up in Part II! 

 

References:

European Monitoring Centre for Drugs and Drug Addiction. (2016). European Drug Report 2016: Trends and Development. Retrieved from http://www.emcdda.europa.eu/publications/edr/trends-developments/2016_en

 

Forti, M.D., Quattrone, D., Freeman, T.P., Tripoli, G., Gayer-Anderson, C., Quigley, H….et al. (2019). The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): a multicentre case-control study. The Lancet, Psychiatry. Open Access. DOI:https://doi.org/10.1016/S2215-0366(19)30048-3

Jerry Soucy shares program on end-of-life care


Professionals in Oncology, Palliative, and End of Life Care
Join us a Free Film Screening and Approved Continuing Education Program
 
Sunday, February 10, 2019
9:30 – 11:30 am
 
The Virginia Thurston Healing Garden
Cancer Support Center
145 Bolton Road, Harvard, MA 01451
See the award-winning documentary End Game, and a discussion led by Brianne Carter, MTS,LICSW,OSW-C, and Jerry Soucy, RN,CHPN.
Space is limited. Registration required.


Call 978-456-3532
email kelly@healinggardensupport.org

Download your FREE color brochure NOW! (PDF)

Links to the film and reviews
IndieWire “Oscar 2019 Best Documentary shortlist.”
Review, Rotten Tomatoes – “End Game manages to transcend its genre peers and deliver something truly special and unique.”
Review, Stream it or Skip it? – “Stream it. It’s heavy stuff, sure, but it’s beautifully made – and we could all use a little reminding of how precious life is…”
Review, Life Matters Media – “Executive producer Shoshana Ungerleider, a hospice and palliative care physician…said she hopes audiences are empowered with information about hospice and palliative medicine so they can make better, more informed decisions when facing death.”
Review, Tricycle Magazine – “…the documentary invites us to participate in the penetrating intimacy of dying as seen from the perspectives of patients, their loved ones, and healthcare practitioners. We meet Kym, Bruce, Pat, Mitra, and Thekla at the ends of their lives… We don’t want these people to die, but they will.”
This Program is Presented in Partnership
The Virginia Thurston Healing Garden Cancer Support Center is the premiere provider of integrative oncology care in Massachusetts, located on 8 acres of serene woodlands in Harvard, MA. Our support groups, expressive and integrative therapies, and individual counseling services aim to optimize the quality of life for all those who are affected by cancer – men, women, and their caregivers – regardless of cancer type, prognosis, or financial ability to pay for services.

Good Shepherd Community Care provides care, treatment, support, and education to patients, families, clinicians, and the community facing serious illness, end of life, grief, and loss through its culturally-informed hospice, palliative care, bereavement, and educational programs.

Jerry Soucy, RN, CHPN is a nurse activist with a practice serving patients, families, caregivers, clinicians, and the community. He is experienced in multiple clinical settings, including specialty intensive care at a major medical center, outpatient hemodialysis, and community hospice. Jerry is certified in hospice and palliative nursing and blogs about serious illness and end of life.

Drug Wars, Drug Addiction, and Social Justice Issues


I have been reading Johann Hari’s Chasing the scream: The first and last days of the war on drugs. 

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This book provides a very detailed account of how we came to be an anti-drug \ and pro-prohibition nation that lead the way toward making criminals out of people who struggle with use of substances and millionaires out of people/ cartels who sell drugs on the black market to drink ayahuasca in the Andes. I have found the book in some aspects hard to read because the political manipulation of our global population and the injustices that have arisen from this global movement. I get angry about what has happened as I read and I have to step away for awhile.

Some key points from this text for nurses to consider:

  • The dominant medical establishment (in particularly the AMA) was initially very against “drug” prohibition, but key vocal players were forced into silence by the government.
  • Overall, 90% of people use substances we call “illicit drugs” without having addiction issues, yet we continue to think that people need to be cautious with drug use. For instance, many (not all) soldiers used heroin in Vietnam to get through the hellish experiences, yet many (not all) had no issues with heroin addiction when they returned stateside.
  • There is a clear connection between lack of social support, childhood abuse, and adverse childhood experiences (ACEs: see the CDc website for more info on this) with addiction. We need to be compassionate toward those who are suffering, because these childhood experiences literally changed how their brains function, making them very vulnerable toward addiction. Adverse childhood events impact young people across the socio-economic spectrum, and many people who came from “good families” have also experienced a lot of childhood trauma.
  • When it comes to death and illness, our two leading “drug use issues” are likely nicotine and alcohol, both legal, and both toxic and deadly. Yet, we simply put warning labels on these drugs and let folks self-determine their fate. Why are these drugs okay, but others are not? Because they are socially acceptable? Because they are “cheap”?

When we think of the opiate crisis, one of the biggest issues of course is people not having safe and affordable access to opiate medications: when people are cut off from safe supplies (ie, their pain prescriptions which the medical establishment has endorsed and prescribed, with potentially some of the cost covered by their medical insurance ), they may turn toward heroin and other “street” opiate medications. These drugs are expensive, sometimes hard to find, and in many ways they force or perhaps support people to live a life of crime in order to maintain their habits, if people have gone that far they must get help. And people overdose because they have no idea what is in the products they are obtaining.

Maybe, we have created an addiction monster in our society.

However, Portugal has found a way out of the addiction monster’s clutches. In 2001, with a growing heroin addiction problem, Portugal decriminalized all drugs and began to consider addiction to be a public and personal health issue. Drug addiction was viewed for what it is:  a chronic, debilitating illness. People caught with a 10 day supply of any drug are referred to a sociologist who helps to determine their treatment options. And what Portugal has realized is that not only is this a more humane approach, it is also far less expensive to provide adequate medical care and treatment to addicts versus incarcerating them. Portugal has experienced a 75% drop in addicted persons from the 1990’s, and their addiction rates are 5 times lower than the rest of the EU. Meanwhile, drug related HIV infections have dropped by 95%, and the stigma around addiction has lessened dramatically.

http://www.npr.org/sections/parallels/2017/04/18/524380027/in-portugal-drug-use-is-treated-as-a-medical-issue-not-a-crime

As nurses, we are concerned about social justice issues and public health issues. I would posit that nurses and politically active nursing organizations should be taking action around the opiate crisis in several ways:

  • Calling for safe injection sites and distribution of clean needles (or needle exchange centers) and free condoms.
  • Looking at prevention and early identification of at risk persons (both ending early childhood trauma through supporting parents at risk for enacting trauma and assessing for early childhood trauma both across the lifespan and across all populations to determine risks for addiction).
  • Supporting harm reduction techniques.
  • Supporting a view of addiction as a public health issue, and a chronic disease issue.
  • Considering a call toward decriminalization of drugs and ending incarceration for addicts (the Portugal Model).
  • Acting compassionately toward all addicts (even the “drug seeking” ones).
  • For emergencies, call medicaltransport.co.

If you are interested in this topic, I do recommend reading Chasing the scream. This text provides great historical insight into how we came to where we are at with the global  “war on drugs” and the escalating issue of for-profit prisons.

We have become the nation with the greatest number of incarcerated individuals (not %, but sheer number!): though we only have 5% of the world’s population, we incarcerate 25% of the world’s total prison population (this link looks at the complexity of these numbers and supports the idea of the truth that in the land of the free, we incarcerate a much higher percentage of people due to lack of alternative ways to provide help https://www.washingtonpost.com/news/fact-checker/wp/2015/07/07/yes-u-s-locks-people-up-at-a-higher-rate-than-any-other-country/?utm_term=.1ca70c3620af).

Columbia University’s CASA group has released multiple reports that link drug addiction issues to crime, incarceration, and repeat offenses. Sadly, while 65% of our prison population qualify for addiction treatment, only 11% actually receive treatment. Meanwhile, the majority of violent crimes are committed by those suffering from addiction. https://www.centeronaddiction.org/newsroom/press-releases/2010-behind-bars-II

Poverty, race, and income inequality also play a role in both addiction and incarceration, and as nurses, we are ethically obligated to advocate for change in healthcare and system wide policies that impact vulnerable populations. Raising awareness is a first step, but perhaps nursing organizations need to also start taking stances and lobbying for more humane treatment of those who struggle with addiction.

 

 

The Power of Ten!


Sigma Theta Tau has now published the 2nd Edition of the book “The Power of Ten,” a book of essays by nursing leaders that address ten top issues for nurses to rally around for the next few years.  These issues were identified prior to the results of the 2016 election, and now they are issues of increasing importance!  The essays provide ideas and inspiration for actions to strengthen nursing’s focus and activism.  The issues are:

  1. Educational Reform
  2. Academic Progression
  3. Diversity
  4. Interprofessional collaboration
  5. Systems thinking
  6. Voice of Nursing
  7. Global Stewardship
  8. Practice authority
  9. Delivery of care
  10. Professional handoff

This is an important resource for all nurses who are determined to act on the fundamental values of nursing.  The essays are a follow-up to the 2012 “Future of Nursing” report; the issues dovetail with the four recommendations of the report, and sine a light on the actions that nurses can take now to bring a culture of health to the center in shaping the future of nursing and healthcare.  The essays are short and to the point, and there are inspirational quotes from nursing leaders throughout that point the way forward.

Check it out! The book is available in several different formats directly from Sigma Theta Tau or from Amazon.  All proceeds from the book are being donated in equal parts to the American Red Cross nursing programs and the American Nurses Foundation.

The Call for Community, Art, and Artists in the Resistance Movement


This week, members of the Nurse Manifest Team gathered together by the warmth of our computer screens for engaging video conference. We took the time to welcome some new members and talk about the future of the movement. I have to say for me, being with like minded #NurseResisters was so energizing (even though I have been suffering through a bout of the flu this week!) and also very comforting.

It’s important for #NurseResisters to remember we are not alone and to gather those around us during these challenging times: when change seems to be happening at a rapid pace, when social media pages are filled with what resisters might find to be concerning or bad governmental news, when there are 10 things you would like to take action on, but you can’t be on the phone all day….it can become easy to become discouraged, overwhelmed, or burned out. This is where truly being with a like minded community can lift your spirits and buoy your endurance.

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And endurance is what we will need. I know right now it sometimes feel like a sprint…get out there and get things done now, get to this march, make your signs, write your emails and postcards, get on the phone….because the administration has been creating changes at a rapid pace, the media and social media have been bumping up our energy, and we feel drawn to create change now.

The thing is, this is not a sprint and it’s not a solo race…it’s more like a team based marathon or ultra-marathon, and it is going to take teams of like minded community members to both participate in and complete the race.

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Individual Sprint

Versus

Team Marathon

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We need to carry lights, march together through the dark night with our nightingale lamps, and strive toward unity. There is no clear finish line, and no medals for winners, second, and third place. There is a beautiful planet and population of people that need caring for and this endurance test is in part about not giving up that vision of a caring, compassionate, kind, peaceful, unified, and spirit filled world.

I suggest other #NurseResisters start gathering with your communities in real life or as we did last week, in real time via video or phone conferencing. Set aside thoughtful, meaningful time to be together, to discuss future actions, and also to just support one another, to laugh together, to share your stories. Communities can rejuvenate and recharge us, and they are a must for folks who plan to run the long race.

I also did want to share that part of our discussion last week focused on the use of humor, satire, parody, art, and music to support and gather people together. Saturday Night live is becoming a great example of the power of humor, parody, and satire to help us lighten our load, to help us rejuvenate, to connect us across time and space.

 

 

While there are many older political songs we can use (Carol King just re-released One Small Voice with free download!: https://soundcloud.com/user-844282824/one-small-voice), it remains imperative that we also create new art and new music that reflects our current siutation here, now in 2017. Until then, let’s be strong together:

“One small voice speaking out in honesty
Silenced, but not for long
One small voice speaking with the values
we were taught as children
Tell the truth
You can change the world
But you’d better be strong”

(Carole King/ copyright Rockingdale Records).