Evaluating the Evidence: Cannabis and Psychosis, Part II


As promised, I am back with more of the analysis. Before I jump into the findings, I do want to let you know I have been ruminating a bit about the issue of cannabis testing. 

To attempt to state my thoughts succinctly here, until we start testing the cannabis that patients in these types of studies are using, we won’t be doing good science. Granted, we know that THC is responsible for many of the side and and adverse effects of cannabis, but to state that the issue with the cannabis is that it has become so high in THC% is far too reductionistic. There is no specific proof that this one cannabinoid alone is the issue when it comes to the relationship between cannabis and new onset of psychosis. The researchers did state that they opted not to test patients’ cannabis because it provides only a snapshot of a moment of cannabis use in the person’s history.

However, relying on reports of what cannabis is available in the area, because it still in my mind, when I think of the wide variety of cannabis strains available, leaves too much of a gap in getting a handle on what patients are actually consuming. Cannabis is a complex plant with over 500 chemicals, but a few simple tests could provide a wealth of information when it comes to determining if high potency THC cannabis truly does play a role in onset of psychosis, or if something else is going on here.

If a similar study were run again, I would suggest testing the actual cannabis that these psychosis patients had used. Those tests should minimally include the cannabinoid and terpene profiles, in addition to testing for heavy metals and pesticides. While this would have some associated costs, it may at least let the researchers know if the profile of the last cannabis used, which could be very enlightening.

Another consideration with testing cannabis: there is a long history of concern when it comes to the role of heavy metal ingestion and the onset of psychiatric symptoms (Attademo , Bernardini , Garinella , & Compton 2017; .Orisakwe, 2014 ). Cannabis plants can easily become contaminated with heavy metals when grown in soils containing heavy metals. Pesticides can also contaminate cannabis, and the consideration of pesticides as both endocrine disruptors and a possible contributing factor to schizophrenia/.psychosis has also been researched over the years (Maqbool F1, Mostafalou S2, Bahadar H3, Abdollahi M4,, , 2016). What if what we really need to regulate or worry about is not the cannabis plant and THC potency so much as what contaminants are in the plant? In my thought process, this really becomes an ethical question of what we are researching, and what might actually bring harm to patients and vulnerable populations. One of the issues around the end of cannabis prohibition and the beginning of regulation of cannabis should be that people have access to a an herbal medicine that is tested and safe, so people know what they are consuming. Beneficence and autonomy come to mind.

This would encourage cleaner product to be produced and help support people with their own healing quests and/or help them to be a more informed consumer. While I don’t particularly care to draw analogies to alcohol (which comes with its own costly public health concerns namely that alcohol is potentially deadly and cannabis is not), imagine buying alcohol without knowing how strong it is, what is really in it, and so forth. Remember the days of prohibition of alcohol and all of the issues with people making “moonshine”?

And now I will continue to look at the findings. 

Participants: Theres seems to be a good split between male/female, with the median age of 36 for control and 31 for case. The median age coupled with the wide range of ages (18-64) included in the study was just a bit concerning, because we know that first time psychosis tends to happen in the early-mid 20’s. The vast majority of all participants were white with at least some college or vocational training and full time employment. It was also clear between case and control, there was much more use of cigarettes, cannabis, and other “drugs” (stimulants, hallucinogens, ketamine, etc) by the case group. Alcohol was not included the summary data table, but in the body of text it states there no difference in alcohol consumption amongst the case vs control groups. And this points to another issue, that it’s really hard to control these types of studies, because most people who are using “drugs” tend to use many different types of substances and it is hard to determine which is having the impact, particularly as we know their can be short term and long term implications. I began to question the issue of poly substance abuse perhaps being a greater issue here then just looking at the % of THC in cannabis, and that lead me to this research….

The International Early Psychosis Association published research by Neilsen et al (2016) that found that alcohol, cannabis, and other drugs increase risk for developing schizophrenia later in life. This was a large retrospective study with the Danish population. The full paper can be accessed here: https://pdfs.semanticscholar.org/1d58/2eaad2f2f9b61f5952f2ecf696bb81a55c7e.pdf Actually, as I ruminate and dig deeper into the Neilsen et al study, I discover it’s having the diagnosis of substance abuse that is correlated with the risk for being diagnosed with schizophrenia 6 fold.  Indeed both cannabis and alcohol greatly increased the risk for diagnosis, but Neilsen et al are careful to state that they cannot say alcohol and substance abuse caused the schizophrenia.

Let’s keep in mind with the study being analyzed DiForti et al (hopefully you aren’t getting lost as I move between the primary study and supporting studies I have included!) also found in their population that most people who have a substance abuse disorder do not use one substance alone. In fact the case participants in most of the drug categories used nearly twice as much as the control groups. So is poly substance abuse a factor here? 

And that brings me to my next thought: Self-medicating. I don’t see this addressed at all in this article, but were the participants asked about why they used cannabis? Seeing as most people with  psychosis have at least 1 year of symptoms prior to being diagnosed with the new onset psychosis, during that time they may be self-medicating or abusing many different substances. My mind starts to question: What if cannabis is actually helping them manage their symptoms, and they would actually would be worse off without it?

And then I come along this little article, that although it’s not in a peer reviewed journal, it clearly explains a possible link between THC, reduction in glutamate, lowered NMDA, weakened CB1 receptors, dopamine receptor D2 being elevated….all this comes together to create hypersensitivity in the limbic system, which may create an environment where schizophrenia could occur.  I didn’t see any of this info in the article be analyzed, f I missed it, somebody let me know! There is conflicting research on whether CBD might help with schizophrenia as it changes/modulates CB1 receptors, but we can ‘t forget that CBD % is an important consideration when looking at cannabis plant profiles. https://www.leafly.com/news/health/link-between-cannabis-and-schizophrenia

The leafy article also linked me out to another article looking at causation between cannabis use and psychosis. The authors Louise Arseneault (a1), Mary Cannon (a2), John Witton (a3) and Robin M. Murray

in their meta analysis of five other research articles found that while youthful cannabis use may create a two fold  a risk factor for psychosis, and may be responsible for up to 8% of the worlds schizophrenia diagnoses, it also is just one part of a “complex constellation of factors”, and of course vulnerable youth should avoid use of cannabis. 

What if people with mental health issues find some relief, for some period of time, from cannabis, that they don’t find from other medications or activities? Why are there so few qualitative studies around cannabis use and self-medication? And why do we have such a stigma associated with self-medication, in much the same we have a stigma around being diagnosed with a mental health issue? The questions go on and on in my mind. 

Overall Findings: Okay, let’s get down to the meat of the findings here. The statistical analysis seem logical and well run (I am not a statistician, in fact I found a statistician to work with as I am doing my own quantitive study on an unrelated topic at this time.).  

Simply stated, the findings correlate starting use of cannabis before age 15, using high potency cannabis (>10% THC), and  daily use as seeming to have the greatest correlation to psychosis (keep in mind causation is not proven here, and almost all of the case participants had also indulged in other substance use at much higher rates than the control group, the issue of possible contamination of ingested cannabis, the lack of knowledge around the full cannabinoid and terpene profile of the cannabis used, and so on). 

Conclusions: For me personally, this study did little to change my mind about cannabis and its safety profile, nor change my overall thoughts on safe use of cannabis, including the idea that cannabis should likely not be used recreationally by young people in their teens and early 20’s.

For most people using cannabis medicinally,  a high potency THC cannabis is likely not needed, but having safe tested cannabis helps people to make informed decisions about the quality of cannabis they are ingesting and the amount of THC they are consuming. High potency THC cannabis or escalating doses of THC may indeed be risky for some people, most likely young people, those with a predisposition to addiction or history of familial psychosis episodes, those with childhood trauma, those with familial history of substance abuse, and those who currently are poly- substance users. 

  • Avoid using cannabis (and really all “drugs” and alcohol) until one is in the mid-20’s and the brain is well developed. This does not account for the idea that teens will use substances, so I would say avoid poly-substance use, and cannabis is still generally safer than alcohol (psychosis risks aside). Alcohol is far more readily available for teens to access, also it too is a significant risk factor for psychosis (and of course immediate death if one becomes extremely intoxicated….you can’t die from cannabis ingestion).
  • Use tested cannabis that is free from heavy metals, pesticides, fungus, and mold.
  • Know the potency of the cannabis medicine you are using. Avoid long term use of “high potency THC cannabis”, or better yet know your THC consumption in mg and limit it to 15 mg max/ day (divided into TID doses), balanced with CBD (up to 20 mg/ day) and terpenes from whole plant medicine (MacCallum & Russo, 2018). 
  • Take regular cannabis breaks (for the recreational user,  avoid daily use and avoid regular use of high potency THC strains; for the medicinal user, consider working with your healthcare provider to determine what a break schedule might look for you, and use lower THC strains if they are still effective at managing symptoms). The website www.healer.com has great info about dosing. 
  • Medicinal users of cannabis: start low, go slow with the THC dosing. One does not need to be “high” in order to feel relief of symptoms, and with cannabis being a biphasic medication, sometimes less is more. For specific dosing guidance, see MacCallum & Russo (2018). 
  • For researchers: as prohibition ends and we move toward an era of regulation, let’s find ways to create the best body of evidence available when it comes to the benefits and risks associated with this herbal medication. Let’s base our public policy and educational efforts in sound science. Let’s not jump from correlation to causation, which means we will have to approach the study of this plant with a complexity lens. 

 

References:

 Arseneault, L.  (a1), Cannon, M.,  (a2), Witton, J.  (a3) & Murray, R.M. (a4 .

(2004). Causal association between cannabis and psychosis: Examination of the evidence. The British Journal of Psychiatry, 184(2), 110-117. https://doi.org/10.1192/bjp.184.2.110

Attademo L1, Bernardini F2, Garinella R3, & Compton MT4.(2017). Environmental pollution and risk of psychotic disorders. Schizophrenia Research, 18, 55-59.

MacCallum, C.A.. & Russo, E.B. (2018). Practical considerations in medical cannabis administration and dosing. European Journal of Internal Medicine, 49 , 12–19.

(Maqbool F1, Mostafalou S2, Bahadar H3, Abdollahi M4,, ,(2016). Review of endocrine disorders associated with environmental toxicants and possible involved mechanisms. Life Sciences, 145, 265-273. 

Nielsen, S.M., Toftdahl, N.G., Nordentoft, M., & Hjorthoj, C. (2016). Association between alcohol, cannabis, and other illicit substance abuse and the risk of developing schizophrenia: A nationwide population based register study. Retrieved from https://pdfs.semanticscholar.org/1d58/2eaad2f2f9b61f5952f2ecf696bb81a55c7e.pdf

Orisakwe O. E. (2014). The role of lead and cadmium in psychiatry. North American journal of medical sciences, 6(8), 370-6.

Improving Student Wellness by Understanding Microaggressions


Piri Ackermann-Barger, who is working with other Nursemanifesters on projects to promote civility in nursing, is presenting a webinar “Improving Student Wellness by Understanding Microaggressions” on April 9, 2019 from 3:00 PM – 4:00 PM ET.  This webinar is sponsored by the nursing Campaign for Action – the nation-wide initiative to put into place the “Future of Nursing” recommendations issued in 2012.

Piri is an assistant clinical professor at the University of California Davis Betty Irene Moore School of Nursing, and co-director of the Center for a Diverse Healthcare Workforce and the Interprofessional Teaching Scholars Program, both at UC Davis. She is also an adviser on diversity issues for the Campaign for Action.

Visit the Campaign for Action website to learn more and to register for this event!  There is no cost, but you need to register to attend!

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.

 

 

To Men in Nursing: Consider Your Privilege


I want to talk about men in nursing and privilege. I expect it will be a difficult, nuanced dialogue, but it’s an important one, and one particularly relevant to nursing, a profession so entwined with the ideals of egalitarianism, advocacy and feminism.

Before I begin, I want to clarify: I do not want to challenge the presence of men in our profession, their growth in numbers, their competency, or their intentions. I do want to challenge men in our profession to challenge themselves to analyze their privilege, and I want to challenge men in our profession who have already done this work to challenge others to do the same. Specifically, I want to challenge male nursing groups, particularly NYC Men in Nursing and the American Association of Men in Nursing, that provide networking and career opportunities for their mostly male members. Broadly, I want to challenge all male nurses who use their privilege, inadvertently or purposefully, to get higher positions and higher pay.

I identify as an intersectional feminist. Intersectionality is a term used by modern feminists to define the multiple identities that are subject to systems of oppression. An intersectional feminist holds that arguing against sexism is logically and ethically invalid if you do not also rally against racism, classism, homophobia, transphobia, queerphobia, ableism, ageism and religious discrimination in our society. Intersectional feminists work hard to examine their own identities of privilege (I, for example, am white, able-bodied, cisgendered and educated) and how they have benefitted us, and work to dismantle the systems that bolster that privilege. Intersectional feminists “call people in” instead of calling them out.

I often discuss experiences of discrimination in the workplace with other non-male identifying feminists, and through these conversations, I learned I am very lucky to be a nurse. Compared to tech or the restaurant service industry, for example, nursing is a feminist dreamland. Most men I have met in nursing have been respectful and compassionate. Disappointingly, however, only a few have demonstrated a deep understanding of the privilege they enjoy, both in our profession and society at large, due to their gender. Male nurses have great capacity to be intersectional feminists, but because they do not bear the brunt of gender inequality, it takes more work for them to recognize it than it does for women, and because it’s hard to say no to a leg up, it takes more self-sacrifice to shun its benefits.

As an intersectional feminist, I empathize with the position of men as a minority in an industry. They comprise only about 10% of nurses. Male nurses have historically been made fun of for being feminine (I’ve seen the movie Meet the Parents), which I’m sure can be hard for some men. Male-identifying nurses who are gay or queer suffer homophobia in the workplace. Our black male nurses come from identities that have higher rates of imprisonment, police brutality and death by homicide. Men are also more likely to be mistaken for doctors, according to one male classmate of mine, for whom I played my well-worn miniature violin. Seriously, though, I empathize with all of this and readily acknowledge that some identities men have (race, disability, sexuality) put them at higher risk for discrimination than some women. I even empathize with the doctor comment, but mostly just because I am proud to be a nurse. 

But we must remember, a minority population is not always a victimized one. Male nurses are more likely to hold advanced practice positions, and they earn more money than female nurses in comparable positions with comparable accreditation and experience. Men are less likely to be the recipient of sexual harassment from a patient or coworker. Men are less likely to be demeaned and ignored as professionals by MDs and other team members. Men are promoted faster and more often. Ultimately, the privilege men, particularly white men, still have within our profession is difficult to reconcile, and to me, despite my empathy, trumps their minority status.

As a student at NYU, the most active group at my school was Men Entering Nursing. Despite their good intentions, I could not shake my philosophical argument with the group. I keep coming back to one analogy:

Imagine that we had a student interest group for white students. Imagine that the group for white students became the most active group in the school. The group hosted events with all white presenters. The professor leading the group was friendly and available and helped you find jobs and study for tests. The group had a strong affiliation with the citywide white group, which provided excellent career guidance and networking opportunities. Of course, non-white students would be allowed as well, if they wanted to join the group and enjoy its networking and academic benefits. Some non-white students even sat on the e-board, but most avoided joining because they had enough on their plate trying to address non-white issues. To top it all off, one month after the election of Donald Trump, all the white students in the school (even if they weren’t Whites in Nursing members) were asked to gather after the last exam before graduation in their scrubs and take a group photo, and no one questioned it at all.

Even if white people only comprised 10% of the student and professional population, this would be inappropriate. I am a white person, and I would do everything I could to reduce this group’s influence at the university, or I would try to funnel the momentum of the group toward events and dialogue focused on privilege analysis. This is what I suggest men in nursing do in the future. 

This is my perspective, but I am open to others. I am open to being called wrong and being corrected. I am open to dialogue. Please share your ideas.

Jillian Primiano, RN, BSN, recently graduated from NYU Rory Meyers College of Nursing, where as a student, she worked with the Hartford Institute of Geriatric Nursing to develop education for geriatric care providers and improve health outcomes for older adults. Before earning her nursing degree, she studied History and Journalism at Boston University with a focus on Cold War anti-war activism, feminism and the Civil Rights Movement. After her first stint in college, she spent three years teaching English, American Studies and International Relations at An Giang University in Vietnam’s Mekong Delta, where she learned about her privilege in ways she could never have imagined.

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).