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.

Spiritual consciousness and healing


This is my first time posting a blog and the experience has been both exciting and a little uncomfortable. I am moving out of my comfort zone, writing from my heart and soul. I’m thankful for the experience and hope to get better with time.  Here it goes!

As a young child, growing up in a rural village in the Pines region of Mississippi, and spending time with my mother’s side of the family in my beloved Louisiana, I was in love with the beauty of the infinite universe. I was very connected to the earth that I loved to play in and smell, the flowers I loved to smell and pick, the tomatoes, okra, onion, squash, peas and butterbeans that I loved to eat and that I helped my grandfather nurture and pick when they were ripe, the love and care of my father and mother and older brother, my ancestors, grandparents – both maternal and paternal – and great grandparents, great aunts and uncles and cousins and the infinite universe of goodness, simplicity, love, and beauty. The freedom and love of being a child of the infinite universe allowed me to sense into the universal rhythms of light and dark, activity and rest, stability and change, being and becoming, even though I didn’t have an advanced vocabulary for these things at that time. All of these experiences represented a universe where healing, love, and nurturing occurred. In the past few years, I have come to see these experiences as reflecting spiritual consciousness. I cherish being in touch with spiritual consciousness, and, thus, carefully tend to it patiently as a potentiality for nursing’s healing mission. Can the nurse working within spiritual consciousnes help other human beings experience healing and their own spiritual consciousness in order to transcend suffering of psychic, physical, social, existential, and emotional pain? I believe so.

Within the nursing context, I view spiritual consciousness as the unfolding of loving energy and various modalities of integrating nature and meaning whereby nurses facilitate healing. The nurse’s spiritual consciousness soothes worries and brings healing to others when they are in fear, pain, or suffering. Spiritual consciousness illuminates the universal need for humanization in nursing situations whereby dehumanizing circumstances deny or strip human beings of their dignity and humanity. Spiritual consciousness is the loving consciousness and healing energy that human beings tap into to restore harmony in times of disharmony.

Spiritual consciousness is evolved consciousness for nursing. It can be cultivated by nurses worldwide to facilitate healing. The nurse, in spiritual consciousness, being loving toward another during moments of the other’s suffering, brings healing energy to the situation. Spiritual consciousness is characterized by spaciousness and lightness. It provides a glimpse into the goodness and beauty of the universe, and the freedom not to get bogged down or trapped in mere physical and limiting aspects of being. I believe it is central to nursing’s healing mission. Thus, the notion of spiritual consciousness challenges each of us in nursing to experience this loving energy and to discuss it for better understanding the usefulness and limits of spiritual consciousness for facilitating healing. images

The human mind’s binding capacity can be warded off by shifting into spiritual consciousness. Spiritual consciousness does not include limited and bounded views such as hatred, sense of division, greed and power over others, malice, or separation between us, other human beings, earth, plants, animals, rocks, trees, rivers, stars, and the moon. In spiritual consciousness, we are all universal one.

As nurses gain experience sensing into their own spiritual consciousness, nursing will be better poised to meet its social mandate. Working from within spiritual consciousness, nurses are provided with multiple pathways for healings to occur. As nursing and society evolve, ideas related to spiritual consciousness and healing need further development.

Nurses and Global Peace


This blog posting will be a bit different from others I have written, but I believe the NurseManifest page is a place where we can open our hearts and souls to the essence of nursing, which is healing, caring, love, and compassion. In a world seemingly torn asunder from fear, violence, and anger, nurses are called forth to support healing on a local and global level. The call comes from something beyond ourselves, and if you stop and listen closely, I believe you will hear that calling. You are a nurse and there is a reason you were drawn to nursing: to support healing through loving kindness and caring.

A few nights before the recent violence spread around the world, from Beruit to Paris, I lay in bed cuddling my 7 year old daughter close. Every night I am blessed to be able to spend some time reading to my daughters and cuddling as they drift off to dreamland. For a few moments that evening, I found myself floating in a space where I felt like the mother of the universe was whispering to me, not in words, but through a deep felt intuitive process. I knew the goodness, the light, and the powerful strength of peace as they came through clearly to me, carrying with them the message that the mother of all, the earth as a complex system, will heal itself. After the moment of certainty passed, I was left with the usual feelings of uncertainty: how will the good and the light prevail in these times of darkness? Who will help make this happen? What is my role in this process?

Then tragedy struck, and violence and war continue to grow. The feelings of uncertainty have not dissipated, so I sit with those, but I also do remain strongly rooted in the belief that as nurses, we can support global peace and healing through our own efforts of creating local peace and healing. And that local peace starts at the place closest to us all, right from our hearts.

As we practice our own healing, creating our own peace and loving-healing processes, we can begin to spread that healing, peace, and love to others. A practice I try and do daily is called loving kindness meditation. I feel on many levels this practice is about my own healing and self-care so that I can be a better nurse, wife, and mother… and it is also about bringing that healing into the world.

I start with focusing on myself, in my heart space, and intending for myself healing through the following words:

May I know peace, joy, love, and ease. May my heart be full. May I be safe, healthy, and happy.

I than send this intention to the loved ones in my life, wishing them all love, peace, ease, happiness, health, and safety: family, friends, pets, students, and colleagues. As the circle of intention spreads outward, I send the intention and feelings of love and peace out to my “enemies” and challengers, and I end with the whole planet, with every being being sent the intention of peace, love, and healing.  The process takes  5-10 minutes.

As nurses supporting healing, we can think and act both locally and globally. Imagine if every nurse sent out an intention, a prayer, a positive thought for healing and peace for the entire mother earth and all of the beings living here. Consciousness studies show that our thoughts and intentions impact our environment and reality.  I think of Jean Watson’s call for us to practice loving kindness and  Martha Rogers’ concept of Unitary Beings. We can reflect the patterns before us, we can create shifts in consciousness to support healing.

Despite the medical system’s over-emphasis on technology-cure-illness management, I still believe that nurses are truly called toward the healing that all beings are capable of experiencing. If you have been called to be a nurse, can you return to that calling, can you spare a few moments to consider the global situation, and what you can do as a nurse to support healing from the truly local level (yourself) and on to the global level?

I would love to hear from nurses and how they are supporting peace and healing around the globe. The call has been made, how will you answer?

 

peace-signs-clip-art-peace-signs-clip-art-10h call has been made… how will you respond?

 

 

Renewal


Renewal

by Wendy Marks, DNS, ANP-BC

Renewal

Spring is a time of renewal in nature. Flowers and leaves bud and bloom, birds busy to make their nests, eggs are laid, warmed and hatched, bees make hives, migratory birds fly back to northern homes.

Humans shed winter coats and boots and migrate outdoors to take in the warm breezes, air and sun.

The Unitary-Transformative paradigm informs nursing practice that humans and nature are symbiotic. External environments affect body-mind-spirit. Fresh air, the aesthetics of flowers, birds, and nature sounds affect our feeling tones by soothing our senses. Internal environments are harmonized with rest, nutrition, hydration, and happy thoughts.

Kolcaba’s Comfort Theory (2003) can be used as a guide to understand how patients, families and nurses engage in behaviors to promote physical, psychospiritual, and environmental wellbeing by providing relief, ease, and transcendence towards improved health or peaceful death.

Several Comfort Scales are available to help evaluate comfort in different settings.

Here’s a comfort scale designed for nurses:

http://www.thecomfortline.com/resources/cqs/NursesComfort%20Questionnaire.pdf

You might take the test and then ask yourself where you need to seek renewal for yourself as a human in need of caring and comfort.

What are you doing to renew yourself? Are you going to take a walk outside? Smell and feel the warm, fragrant breezes? Hear the chirp of birds and see the new flowers, leaves and bees? Will you surround yourself with others who value peace, kindness, and love?

Make your values as a nurse healer visible and explicitly engage in health seeking behaviors, free yourself from the burdens of heavy coats and boots. Set sail in the Spring time breezes and feel the sun on your face as you enter a new day and transcend all that no longer serves you.

Reference

Kolcaba, K. (2003). Comfort Theory and Practice. NY, NY: Springer. www.thecomfortline.com

Dreaming in nursing


I woke up at 0430 this morning with my heart pounding. Occasionally this happens, I have a “nightmare” about nursing.

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In this particular dream, I was working a night shift and at the end of the shift I was chatting with the nurses. I was getting ready for report, and I couldn’t remember seeing any of my patients; no names, no faces, no recollection at all. I began to feel anxious and I asked one of my fellow nurses, “Gee I hope I finished my charting” and she replied, “No I don’t think you closed out your charts.”

In a panic I ran to the charts. Of course in the dream they were not electronic, they were huge paper charts, perhaps as big as they could be about 6 inches thick, with hand written notes. I was trying to decipher the handwriting and figure out what was going on with a particular patient. As I read through the chart I realized I had not assessed this patient. I must have slept through entire shift. How could that be? Clearly from the diagnosis this patient would have needed pain medication, turning, toileting, and so on. Who was caring for this patient? I had nothing to chart and I realized that I would, at this last hour, have to go and check on all of my patients, assess them, check their meds, and then chart. My 5-year-old daughter arrived in the dream and wanted to play and I had to tell her no.

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Somehow, I woke up and had to convince myself it was just a dream, nobody was harmed, I was safe in my bed. For the record, I haven’t work the floor since the late 1990’s, though I worked as a hospice nurse and taught clinical in the hospital until 2005. Around that time, I finished my PhD, and began to focus on just honing my skills as an educator while I had two babies and raised them into young children.

I have this type of dream several times a year. I suppose I could do a dream analysis, look for the Jungian archetypes, or focus on my own life-anxiety and how it is related to my work. But I am really wondering about here is the dreams that nurses have: the good, the bad, the sleep time dreams, and the awakened dreams.

What is it that our hearts desire in our practice? What are we “dreaming of” in nursing practice and education… and how do we get there? Do we find reward in a broken healthcare system and as the largest providers of healthcare in the nation, how do we take back our practices of caring and compassion? How do we partner with others to create change? How can we use the Nurse Manifesto created by Peggy Chinn, Richard Cowling, and Sue Hagedorn to our benefit?

I would love to hear nurses’ stories about what they desire. I myself wrote a story about what nurses experiencing versus what we desire and you can read about that here: https://nursemanifest.com/research_reports/2002_study/nurse65x89.htm

This story was recently published in Creative Nursing journal. I am also presenting this story and supporting nurses in creating a personal plan of action at the American Holistic Nurses Association Annual Conference in Virginia Beach, VA this June. I hope to see you there!