cbd oil status for marriage and family therapists

Cannabis-Friendly Psychotherapy

Even though cannabis is legal in California, the stigma remains, which can make it frustratingly difficult to find healthcare providers who are well informed about its benefits and risks.

As a licensed psychotherapist, I see individuals who use marijuana but worry about being judged or misunderstood by medical professionals.

From a well-informed and compassionate place, I can support you in navigating your relationship with cannabis.

Medical Marijuana

Cannabis has been for millennia used to treat a range of medical issues. For some people, cannabis takes the edge off of feelings of anxiety and depression. It can offer that “head-change” that nudges us out of unpleasant states. It can help with sleep and eliminate nightmares. It eases physical pain.

Some people also feel that cannabis opens them up to deeper levels of creativity, insight, sensation, and connection to nature and music.

Many of the psychological benefits of cannabis go unrecognized by mental healthcare providers. When used in a particular way, cannabis can actually amplify your internal experience, as opposed to numbing or dulling emotion. You can become more aware of tightness or soreness in your body. Emotions are heightened; senses are more acute. You may have access to thoughts, fears and feelings that are normally out of reach. You might even enter a trance-like state and “journey.” In these ways, cannabis can help deepen your connection to yourself. If you’d like to learn more about using cannabis in this way, please visit my article for Psychedelic Support Network here.

Maybe you like the effect cannabis has on you without knowing why; it just makes you feel better. In other cases, you may be choosing to use cannabis to manage a wide range of possible symptoms and conditions including:

Bookshelf

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

StatPearls [Internet].

Cannabis Use Disorder

Jason Patel ; Raman Marwaha .

Authors
Affiliations

Last Update: February 7, 2022 .

Continuing Education Activity

Cannabis use can cause intoxication, withdrawal, and biopsychosocial issues. This activity describes the evaluation and management of cannabis use disorder and highlights the role of the interprofessional team in improving care for patients with this condition.

Introduction

Cannabis is considered by the Food and Drug Administration as a Schedule I drug. (Other examples of Schedule I drugs include heroin and peyote.) It has no accepted medical purpose at the federal level and has a high potential for abuse. Most authorities disagree with this designation. Commonly prescribed drugs like opiates and stimulants are Schedule II drugs, meaning they have a high risk of abuse but are medically useful.[1] Benzodiazepines are Schedule IV substances, meaning they have a low potential for abuse and dependence. Despite federal regulations in the latter half of the 20th century, marijuana is still one the most commonly used drug in the United States.[2] The most common users are teenagers and adolescents, and usage tends to decline as these groups age into adulthood due to careers, marriage, cohabitation, and parenthood.[3][4]

Nevertheless, cannabis use has increased with the state-directed legislature turning the tide against federal regulation. State legalization of marijuana has increased cultivation demand, selective breeding for more potent strains, and competition in the marijuana dispensary industry. Expanding the use and legislation for the legalization of marijuana are propagated by potential health benefits and the absence of health concerns that are not well substantiated.

Cannabis abuse is a term describing the continued use of cannabis despite impairment in psychological, physical, or social functioning. It is an outdated medical definition formerly used in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), which divided substance use from substance dependence. The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) has revised the terms of cannabis use disorder defined by nine pathological patterns classified under impaired control, social impairment, risky behavior, or physiological adaptation. This activity will focus on cannabis misuse and related components – states of intoxication and withdrawal and cannabis use disorder.

Etiology

Cannabis use varies based on demographics. Research shows college students and young adults most commonly use cannabis to socially conform (42%), experiment (29%), and for enjoyment (24%).[5] Twelve percent primarily use the agent to manage stress or relax, consistent with other studies associating its use for depression, anxiety, social anxiety, and post-traumatic stress disorder.[5][6][7][8][9]

During pregnancy, mothers who reported using marijuana say they did so primarily to manage depression, anxiety, and stress (63%), pain (60%), nausea or vomiting (48%), and for recreational purposes (39%).[10]

Biologically speaking, impaired inhibition can predispose individuals to substance use disorders. However, healthcare professionals are unsure if this is true for marijuana.[11]

Epidemiology

Nearly four percent of the global population was using cannabis in 2015.[12] Amongst teenagers, eight percent in the US and 16% in Europe report use. Nine percent of all users experience addiction, of which nearly a fifth began to use in adolescence.[1] There is limited evidence for cannabis use among older patients. However, its consumption may be increasing as legal permission for its medical use may justify its use among former non-users. In the medical profession, first-year psychiatry residents are more likely to have Cannabis Use Disorder and seek out experiences to be disinhibited; these individuals also have a history of sedative use and anxiety.[13]

During pregnancy, four percent of mothers admit to using drugs, most commonly with cannabis.[10] A retrospective cohort study of more than 12 million pregnant women revealed nearly a tripling of cannabis abuse or dependence from 1999 through 2003 and a significant association for perinatal complications.[14] Thirty-five percent of mothers who have used marijuana have done so during pregnancy, and 18% used it while breastfeeding.[10] 

As consumption increases among adults, so does the unintended consequence of exposure to children. Between 2005 and 2009, 985 unintentional exposures to children (median age of 1.7 years) were reported. States legalizing marijuana have had a 20-fold increase in calls to poison centers and admissions to critical care units for its exposure.[15]

Overall, the trend for using cannabis is increasing over time for most, if not all demographics.

Pathophysiology

Researchers know that prolonged and heavy cannabis use can alter brain circuitry. However, the specific pathophysiological mechanisms are yet unclear. In terms of addiction, tetrahydrocannabinol (THC) is the primary molecule responsible for the reinforcing properties of marijuana.[16][17][18] Interestingly, despite the striatal dopamine system typically being involved with substances of abuse such as alcohol and opioids, meta-analysis reveals insufficient evidence at this time to support such a conclusion for cannabis. And also that dopamine receptors may not be involved.[19]

At a symptomatic level, heavy use modifies conscious experience by altering the brain’s network for self-awareness. By reducing anxiety and impairing memory, it also affects motivation and personal experience.[20] At a molecular level, the story is more complex.

The botanical provides over 500 different active chemical compounds, which interact with numerous molecular targets, thereby modulating the transmission of endocannabinoids, gamma-aminobutyric acid, glutamate, and serotonin. Psychoactive effects are primarily derived from tetrahydrocannabinol (THC) which binds cannabinoid receptors (CB)1 and CB2.[21] CB1 receptors are located throughout the central nervous system (CNS), lungs, liver, and kidneys. CB2 receptors predominate within the immune hematopoietic cells.[21] Binding these receptors modulates G-protein-coupled inhibition of cyclic adenosine monophosphate, thereby influencing pain, mood, appetite, nausea, and sexual activity.[21] CNS effects also appear to be mediated by glial cells, particularly microglia and astrocytes. In vitro studies show microglial to produce greater endocannabinoids than neurons, and astrocytes may play a role in signaling by regulating endocannabinoid turnover.[22][23]Thus an influence of the neuropil, not just the neurons, may better describe the CNS changes mediated by cannabis.

Toxicokinetics

Unlike synthetic substances and alcohol, cannabis is a more complex drug. Consumption or inhalation of the botanical exposes the user to hundreds of compounds, including cannabinoids (e.g., THC and cannabidiol) and non-cannabinoids (e.g., terpenes and flavonoids), many of which are bioactive compounds.[21] Compared to isolated pharmaceutical derivatives (e.g., dronabinol and cannabidiol), the sheer complexity of the plant makes a comparison between the two difficult. It is important to establish that what is currently known about marijuana is actually derived from studies of a single active constituent, tetrahydrocannabinol, and less so from the plant itself. This problem is primarily due to its Federal status as a schedule I substance and thus prohibition from federal research funds for its study.

Absorption, Distribution, and Metabolism

THC, the principal psychoactive and addictive component is most commonly smoked. It is rapidly absorbed by the lungs and distributed systemically via perfusion. The rapid influence on the brain contributes to its pleasure and abuse potential.[24] Oral ingestion typically follows a more gradual course and delays its peak blood concentration. It is extensively bound to lipoproteins with only 3% in the free state.[25][26] Metabolism through the liver can produce over 80 metabolites of delta-9-THC, with the most common pathway involving allylic hydroxylation at the 11-position followed by oxidation to a carboxy derivative.[27] Conjugation occurs with some metabolites, but it is not a major step.[27] Bioavailability varies greatly amongst and between individuals depending on their smoking topography, such as number, duration, and spacing of puffs, hold time, and inhalation volume.[28] It remains in the body for extended periods due to its lipophilic properties, allowing it to accumulate and slowly release from adipose tissue, along with its further processing via the enterohepatic circulation, which produces active metabolites as well.[27] 

Chronic daily smokers can produce detectable levels of THC and its metabolites one month after their last intake.[29] It is suggested that its lipophilic metabolites can form conjugates, allowing for greater stability, thereby prolonging its metabolism, and thus half-life, so that release from adipose tissue is the rate-limiting step of THC.[30][31][32] This high lipophilicity explains why withdrawal is a slow onset.

It is worth noting that the pharmacokinetics of THC is further complicated with multiple factors such as its physical/chemical form, route of administration, genetics, and concurrent consumption of alcohol.[27]

History and Physical

Upon evaluation, the patient history should investigate substance use, mental health, family history for substance use and mental health disorder, medical history, medications, substance use amongst social circles (particularly in adolescents), and environmental stressors.

The individual’s mental status is a critical part of the exam and can point at the phase of cannabis use. Intoxication can include euphoria, anxiety, uncontrollable laughter, increased appetite, inattentiveness, forgetfulness, restlessness, tachycardia, conjunctival injection, and dry mouth. And less commonly may include delusions, hallucinations, and derealization. Prolonged continuous use or withdrawal typically causes a depressed mood characterized by apathy, lack of motivation, irritability, loss of interest in typical activities, difficulty concentrating, and isolation. (Side note: Cognition can quickly be assessed by testing three-word recall, asking multi-step math problems, or recalling details from a brief fictional story as demonstrated on the St. Louis University Mental Status Exam.) This depressed mood can also include the differential persistent depressive disorder and major depressive disorder. Substance use and a mood or anxiety disorder are not necessarily mutually exclusive and frequently co-occur.  Even suicidality and homicidal tendency can result from dysregulated mood, a recent stressor, or substance use. Differentiation requires an understanding of the intensity and temporality of the symptoms; persistent symptoms during periods of sobriety can indicate a comorbid primary psychiatric disorder.

Classifying cannabis use in the US is dictated by the DSM-5. Generally, it can be understood as the acute and chronic effects. The acute phase includes intoxication and withdrawal states, along with secondary complications – delirium, psychosis, anxiety, and insomnia. Chronic regular use can be characterized by disordered behavior.