04/29/12 Chris Fitchner

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Patients out of Time Conference on Cannabis Therapeutics in Tucson with Dr. Chris Fitchner, Psychiatrist at Riverside CA mental health clinic

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Transcript

Century of Lies / April 29, 2012

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DEAN BECKER: The failure of Drug War is glaringly obvious to judges, cops, wardens, prosecutors and millions more. Now calling for decriminalization, legalization, the end of prohibition. Let us investigate the Century of Lies.

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DEAN BECKER: Thank you for joining us on this edition of Century of Lies. Today we’re reporting from Tucson, Arizona. I’m attending the Patients Out Of Time Cannabis Therapeutics conference. This week’s Cultural Baggage also features additional coverage from the Patients Out Of Time conference.

Here, speaking on the connection between cannabis and schizophrenia, Dr. Chris Fitchner.

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CHRIS FITCHNER: This is my first time at this conference. I’m actually a relative newcomer to this community. I’ll tell you a little bit about my background.

I’m a psychiatrist. I started my career in the VA initially running a clinic for post-traumatic stress disorder and later became a service chief in the VA. I went on to work for Illinois government. I was Chief Psychiatrist of the Illinois of the state hospital system for about 7 years. I spent a couple years as mental health director for the state.

It was during that time when I was looking at the interface of the criminal justice system and the mental health system – the overlap of the populations in the psychiatric hospitals and the jails and prisons, in particular the jails. That’s when I ran across data that showed there were more people arrested for marijuana-related crimes than for all other controlled substances combined.

At the same time it was a period when advocates in Illinois were working really hard to pass a newer-generation medical marijuana law. They do have an older one from the 70s but it’s never been implemented, never been activated. They were trying to pass a law modeled after California or Colorado. They never did pass that law. They’ve come close several times.

It was really in that context that my interest in drug policy generally and medical marijuana in particular developed. I spent most of my career in Illinois. About 4 years ago I came back to California where I’m originally from. I’ve been working full-time as a clinician, as a psychiatrist treating patients with severe and persistent mental illness in a county run clinic in the county mental health system in Riverside County.

The clinic that I work in…and this is where I am full-time treating persons with mental illness and I do mainly medication management. The clinic offers a number of recovery orientated services. It has a substance abuse program. My role as a psychiatrist is mainly using medications for treating patients. Of course I council them about general health-related issues frequently.

So I’ve been working full-time clinically. The county does not have a policy that supports doing medical cannabis recommendations so that’s not something that we do in the clinic but I do talk frequently with those patients who do have recommendations- those who are using it for therapeutic purposes and want to get recommendations. I typically advise them to have that kind of protection even though I can’t give them the recommendation in the clinic there. I have done a number of them privately outside but I don’t do them in the clinic.

But, nonetheless, we do talk about the potential hazards and benefits of cannabis use. It within that context that the thoughts I’m going to share with you today grow out of.

First I want to set up a dichotomy that is a lot like what Amanda just did in some respects. A central theme here is are we conceptualizing herbal cannabis. I’m just going to use that broadly at this point in time. We’ll drill down and talk a little more specifics from a substance abuse perspective and from a therapeutics perspective.

Just to cite Weil and Rosen from Andrew Weil’s book in 2004, any substance can be either good or bad. Relationships with drugs can be either good or bad. The drug in of itself depends on the relationship that the user has with it.

I think there’s an overwhelming bias within the mental health field and within the psychiatry field in particular to view marijuana as a substance of abuse. In fact there’s a sub-specialty within psychiatry in substance abuse disorders.

I want to skip through here very quickly because this has been covered in far more detail than I could possibly cover it in already. But I wanted to give you the flavor that if you approach this in clinical practice and you’re working in partnership with substance abuse programs who are working with people who have dual diagnosis conditions. That is they may have depression. They may have schizophrenia, post-traumatic stress disorder also they have co-morbid substance abuse problems. Most often alcohol but could be any other substance as well.

If you approach it from the standpoint of cannabis is a substance of abuse period the focus is going to be on looking for the persistent negative consequences. Of course there’s lots of money that’s been pumped into research showing exactly that.

Looking at whether people are able to stop use when they want to stop use. Looking at questions of addiction. That’s been addressed really well over the last two talks. Actually addiction is not a term that occurs in the DSM, in the psychiatric nomenclature. The diagnosis that we use are substance dependence – not addiction.

I really like in the talk before last the summary demonstrating cannabis addiction. With all the resources that NIDA has put into it have really been reduced to these facilitated or forced addiction paradigms where you have very high doses and then you slam somebody into withdrawal – or an animal model forced withdrawal by administrating an antagonist.

You have to go through extraordinary machinations to produce a cannabis withdrawal syndrome. In fact, it is NIDA’s view that marijuana is addictive largely because they’re able to demonstrate cannabis withdrawal syndromes in experimental models.

When you are looking at substance of abuse you are interested in the dual diagnosis from the course of illness both on the effects of primary symptoms and its secondary mental and physical effects.

From a therapeutics context you are going to be asking entirely different questions.- questions of clinical efficacy. Drugs when they are approved for use in schizophrenia – say when an antipsychotic drug is used. It has to first go through safety protocols and then is approved by the FDA and really very short term experimental designs where the effects of drugs are looked at for only 8,10, 12 weeks. They may have extended follow up designs but most of the randomized clinical trials are going to be short term.

Contrasting that with medical effectiveness studies which are much longer term studies that look at aspects of real-world practice. They’re not quite as tightly controlled. What’s the likelihood that patients would be able to get access to the medicine if it’s released in the system. How is it used when somebody’s on a multi-drug regiment. Real-world studies look at all the other variables that shape whether their patients would be able to adhere to their treatment - including things such as side effects and adverse incidents.

Drug safety I’ve already mentioned. Indications and specificity. Tomorrow I’ll be talking about post-traumatic stress disorder. We’ll have more to say about that later but that’s a disorder in which there is only two drugs, two medications that are FDA-approved for the treatment of that.

The vast majority of the medicines that are prescribed are prescribed off-label when someone’s doing medication management for that condition. I think that fundamentally changes the nature of the discussion around what’s the difference between being on solid ground with FDA-approved medications for a specific medication versus using medications off-label.

The more you get into difficult to treat patients who are treatment resistant where you’re using not just one or two medications but possibly a cocktail of three or four. You may follow professional guidelines that have been put together by the American Psychiatric Association or other organizations that may be more empirical or based on professional, clinical judgment. But, nonetheless, you are further away from the strict, narrow FDA map.

Also need to look at things like contraindications or relative contraindications to drugs. For example, in just a bit we’re going to say about cannabis and psychosis and all the literature that’s look at how cannabis is associated with a poor long term outcome in patients with schizophrenia - we’ll get to that in just a second.

Even medications that are approved, for example antidepressants, can worsen the symptoms of schizophrenia so any activating or stimulating medicine can make paranoia, auditory or visual hallucinations worse.

Let me just say a little bit about diagnosis in schizophrenia. If you look in the DSM there are a number of subtypes – paranoid schizophrenia, residual, undifferentiated, catatonic...Really the big picture is it doesn’t appear to be a single entity. If we are going to make a generalization schizophrenia really entails two classes of symptoms. The positive symptoms which are things that are additions to the premorbid personality which are usually things like hallucinations, delusions, ideas of reference. That is feeling that people are talking to a person or saying something to them when they’re not, talking about them. Fearful paranoid voices that may either be command-hallucinations – telling them to do things – or they may be detached conversations about the person’s behavior.

That contrasts with the negative symptoms which are things that are subtracted from the premorbid conditions. Things like apathy, impoverishment of thought, speech, social deficits – an inability to engage.

Now I want to look at the perceived wisdom from mainstream research. Let me just mention that I have a number of references at the end of this presentation which you’ll get when you get a copy of it. Unfortunately I didn’t turn it in in advance but you’ll get a copy. Once of the bibliographies that’s probably the biggest that I know of amassed on this issue of cannabis and psychosis or marijuana and psychosis is called the Cork bibliography. It was put together by the Royal College of Psychiatrists in Great Britain.

The number of meta-analyses that have pointed out that pot smoking teens are at higher risk of developing schizophrenia in their 20s than those who don’t smoke pot. That’s true. It’s true no matter how you look at it. Whether it’s a causal relationship or not is still open to question. But it is true that those who are using marijuana in their teens are at higher risk of developing schizophrenia later.

Now just to put that in perspective. It’s not a strong affect. It’s actually a weak affect. It’s weaker than the early childhood exposure to viruses that effect the central nervous system. There are three or four of them that are shown to be associated with higher incidence of schizophrenia.

The only psychiatrist who has publically tried to make the case that that is an important causal factor in schizophrenia was E. Fuller Tory. The community, in general, has rejected that notion. Yes, there is an affect but it’s not an important affect. The genetics are far more important. Maybe stress of early environmental experiences is a participant but nobody has accepted the idea, in the psychiatric community, that exposure to viral infections that attack the central nervous system in early childhood is an important driving factor in whether or not someone has schizophrenia later in adulthood or not. And yet that’s a stronger affect than the effect of cannabis use in adolescence.

There’s also some data, a number of studies showing that earlier use increases the risk even more. So those who use it earlier are more likely to develop symptoms in their 20s - kids in the range of 14 to 15 as opposed to the age of 16, 17 or 18.

There are studies that show that cannabis use can exacerbate symptoms in patients with schizophrenia. Also studies that show both herbal cannabis and THC administered experimentally can create transient psychotic symptoms in non-patients. So that’s led to speculation about an endocannabinoid disregulation theory about schizophrenia. It’s been quite some time since that was posed but these discussions are becoming increasingly sophisticated as we look at more research that’s coming out.

So THC exacerbates symptoms in experimental context and there’s always the question of transient and lingering cognitive deficits. We know that short-term memory can be impaired acutely from use but the question of importance of lingering deficits after long-term, heavy use is still an open question. Even though studies that have shown deficits don’t look very important clinically – even for those who have used it long-term – after they have discontinued use. You are able to show differences that are statistical significant in certain aspects of memory but it is not clear if all of those are clinically significant.

To counter everything that I have just said or offer sort of a critical or alternative perspectives. There certainly are plenty of patient reports of benefit from herbal cannabis use even for those patients who have schizophrenia.

My experience in practicing with patients is that those who find it makes their symptoms worse tend to stop it. They tend not to use it. They tend to use it if it makes their symptoms better. Some of them have outright told me that it makes hallucinations go away. That they feel less paranoid when they use it.

One of the things that becomes important is to have discussions for those who are using it regularly about how important is their reliability of access to consistent products because there may be people who are getting cannabis out in the street that their source is unreliable, that they don’t have a medical recommendation. Even with the recommendation that gets them into the best places to get access to medicine that’s labeled – this whole field is still evolving in such a way that the vast majority of users are not getting access to products that are consistent.

I think the more we can do that…I think that’s one of the reasons the California Medical Association, back in October, came out in favor of legalization. They want doctors to be able to understand what it is their patients are getting so that there’s some regulation and some labeling.

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DEAN BECKER: You are tuning in to Century of Lies on Pacifica Radio and the Drug Truth Network. We’re reporting from the Patients Out of Time Cannabis Therapeutics conference in Tucson, Arizona. The speaker, Dr. Chris Fitchner.

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CHRIS FITCHNER: There, of course, have been clinical case reports for a number of years out of the group in Brazil. Then, more recently, controlled research in Germany looking at CBD as an anti-psychotic. In one study in Germany comparing it to an approved established anti-psychotic found that patients with schizophrenia relieve their symptoms just as well as the established anti-psychotic but without as many side effects.

It’s tempting to then say can we have this dichotomy. Of course I’m aware that herbal cannabis is far more complex than that. Many cannabinoids we are beginning to understand some of them better than others. There’s a lot of research to be done but it’s tempting, at least initially, to say we have this anti-psychotic CBD so maybe those who have psychotic disorders, if they are going to use cannabis as medicine, maybe they need something that is higher in CBD with that anti-psychotic effect and maybe lower in THC which can exacerbate paranoia as we’ve seen in experimental paradigms.

And yet there’s also a clinical case series, a small one from the east coast, that was published just a couple years ago with half a dozen patients. These were people who were hospitalized with serious…they had schizophrenia. They had, at various points, been treatment resistant. At least several of them were on two anti-psychotics. At least one, I believe, was on Closopene which is for treatment resistant schizophrenia.

In this study the investigators added just molecular THC – that is Marinol or Dranabinol – to the regiment. In four out of the six cases they saw improvement. In three out of those six cases they were pretty sure that it was a specific anti-psychotic effect - the fourth one being possibly just a general calming effect.

So that’s a small series. That’s not much but it still becomes part of this discussion that now provides a published example of at least a handful of people that would confirm some of the reports that we hear when people say, “It seems to help me.”

In all the research to date the cause and effect relationship remains unclear. Certainly there are articles that claim to show in their analyses of data that cannabis is the causative factor that’s precipitating the emergence of the first episode of psychosis or is slowing the recovery from mental illness and causing it to be more problematic.

Probably the best research to date suggests that it is bi-directional. Sicker patients get, who have psychosis, the more likely they are to use cannabis if they are cannabis-using and the more cannabis they use the sicker they’re likely to get. That’s probably the best research shows.

But, again, these studies are evolving. As far as showing a clear cause and effect relationship really remains to be seen. There do, however, appear to be vulnerable subsets of patients and there’s some genetic polymorphism in research in terms of receptor studies and enzyme studies as well that suggests that certain patients are more vulnerable to the psychoticgenic effects of cannabinoids.

More recently there’s been studies…actually published online about two years ago but it just came out in Schizophrenic Bulletin in hard copy that shows that there is a subset…actually, what it shows broadly is that those who have schizophrenia who have a history of cannabis use actually have superior cognitive functioning. What I mean by cognitive functioning here is tests of memory and discrimination – sort of the more intellectual cognitive tasks making that separate from the question of hallucinations and delusions.

What they found was that this appeared to accounted for by a younger subset. Those who used it at an earlier age seemed to have the better cognitive functioning and it seemed to be accounted for by a subset of patients who started using it at an earlier age.

I think we get an idea of what we are up against in terms of the politics and the reigning values here when you look at how the discussion and the conclusions were presented in that article. Their hypothesis was that the most likely explanation was not a self-medication - that maybe they’re getting some therapeutic value, maybe the cannabis is actually helping them – but rather that these are people that because of their superior intellectual profile would not have developed schizophrenia if they hadn’t started using it at such an early age.

So what you typically find in reading the literature is the findings presented…there’s a statistical association…they say we can’t really claim to say that marijuana causes schizophrenia or it precipitates the break but once they’ve laid out all their disclaimers it’ll say how can we reduce the use of this substance so we can reduce the number of cases of schizophrenia. It always ends that way. Dozens of articles that are like that.

I think they are probably written that way in order to make it easier to get grant funding. Nonetheless they tend to take back what they grant in terms of what we actually know about the hazards associated with cannabis use for persons with schizophrenia.

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DEAN BECKER: This is Dean Becker interrupting to remind you that you are listening to Century of Lies and the speaker is Dr. Chris Fitchner. He’s clinical professor of psychiatry at the Southern Illinois School of Medicine. This was recorded in Tucson, Arizona at the Patients Out Of Time Cannabis Therapeutics conference.

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CHRIS FITCHNER: In real-world practice…just want to sort of give you a peek into that. Multi-drug regiments are common. I wish that they weren’t but I have patients whose voices and paranoia do not go away with one anti-psychotic at maximum doses. Certainly we try other things. I have patients in recovery programs having them look at wellness issues, nutritional issues. I put a lot of my patients on omega 3 fatty acids because of their brain protective properties. A lot of them are on fish oil which is particularly good for mood stabilization. Mood disorders are also relatively common in schizophrenia. A lot of my patients are diagnosed with schizoaffective disorder which means they’re meeting criteria for both schizophrenia and major depression or bipolar disorder.

Antidepressants in these folks, as I already mentioned, are relatively contraindicative but many of them are on it anyway because they do get depressed in the course of being treated for schizophrenia for a variety of reasons. Any stimulating medication whether it’s a stimulant or an antidepressant can make psychosis worse and I’ve certainly inherited patients from other doctors where they were on a regiment and still having break through psychotic symptoms and the key to getting those psychotic symptoms reduced was to lower the dose of their antidepressant.

Medications are often remarkably effective. There are some people whose symptoms will be controlled with just a single medication and have minimum side effects. But there are many others where that is not the case and they’ll end up on multidrug regiments.

Increasingly we are aware in psychiatry of the degree in which our newer agents, newer antipsychotic drugs were developed to minimize the likelihood of developing movement disorders as we used to see with the older antipsychotics. With the newer ones now what we’re seeing is metabolic syndrome. Increasingly patients gaining weight, becoming obese, increased blood sugar with non-insulin dependent diabetes and increased cholesterol – in short, developing metabolic syndrome. So it’s important for us to look at other modalities. It’s important for us to do everything we can to minimize the medication burden especially when we’re using these medications that do have substantial side effects.

We’re becoming more medical and we need to look at overall health and risks of treatment. I guess within that context what I would like to suggest is that we clearly have an herbal cannabis substance that can be bred and processed and turned into a lot of different types of products some of which, at least at this phase, at least in California , they are beginning to be labeled in terms of their CBD concentrations, in terms of their THC concentrations.

I would like to suggest that based on what we know to date about THC and CBD that there’s a good chance that herbal cannabis may become – especially a very high CBD strain with just a small amount of THC – may become the next generation antipsychotic because it may be that the THC which is going to be a more stimulating and maybe better for negative symptoms maybe just what’s needed to make CBD an even better antipsychotic than it’s been shown to be in the research that’s been done with it as a single molecule.

I think it’s very important that as we think about the potential therapeutic properties of cannabis in persons with mental illness that we be open to the idea that we need to be looking at a model that considers it as a whole plant, that considers that it may have multiple compounds that have different, overlapping therapeutic effects and to approach things in that direction may offer treatment possibilities that our current pharmacological strategies don’t. And, in fact, ones that lead us to have people on multiple drugs because we’re prescribing different things to target different symptom complexes.

So I think that herbal cannabis may have the potential to be a single substance, if you will, comprised of multiple compounds that can be developed into products that can be more useful persons with psychotic disorders as well as things like anxiety disorders and depression.

Thank you.

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DOUG McVAY: The federal government and several state Attorneys General are sounding the alarm over heroin use and prescription pain killer addiction. Their approach is more of the same. More law enforcement, more drug testing and more propaganda.

Outside the U.S. more enlightened approaches are proving effective. The research overall shows substitution treatment with methadone or buprenorphine to be highly effective for those dependent on opiates. Availability of methadone maintenance treatment must be expanded.

Still there are hard-core addicts for whom even methadone fails. What do we do about them? One possible answer – supervised injectable heroin treatment. It’s controversial yet the evidence of its effectiveness in all areas continues to mount.

The European Union’s Drug Agency, the European Monitoring Center on Drugs and Drug Addiction recently published a review with literature around heroin treatment. Overall they concluded,

“Over the past 15 years 6 randomized control trials have been conducted involving more than 1,500 patients and they provide strong evidence both individually and collectively in support of the efficacy of treatment with fully-supervised, self-administered injectable heroin when compared with oral methadone treatment for long-term refractory heroin-dependent individuals.”

Among other things they found that,

“Across the trials major reductions in the continued use of street heroin occurred in those receiving supervised injectable heroin compared with control groups most often receiving active methadone treatment.”

And,

“Reductions in the criminal activity of supervised injectable heroin patients were evident and were substantially greater when compared with patients under controlled conditions.”

Most importantly,

“Finally, countries that have conducted longer term – up to 6 years – follow up studies have seen a high retention in supervised injectable heroin: 55% at 2 years and 40% at 6 years, with patients sustaining gains in reduced street heroin use and marked improvements in social functioning. For example, stable housing, drug-free social contacts and increased rate of employment.”

In the U.S. where methadone is still considered controversial in some communities and treatment availability is thus quite limited, supervised injectable heroin treatment will seem like a radical approach yet it works.

The question is how long do we keep doing more of the same and failing before we try a different way?

For the Drug Truth Network this is Doug McVay with Common Sense for Drug Policy.

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DEAN BECKER: Thanks Doug and the website for Common Sense for Drug Policy is http://www.csdp.org

We’ll have lots more for you next week on Cultural Baggage and Century of Lies from the Patients Out Of Time Cannabis Therapeutics Conference in Tucson, Arizona.

As always I remind you there’s no truth, justice, no reason for this drug war to exist. Please visit our website http://endprohibition.org. Do it for the children. Prohibido istac evilesco!

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For the Drug Truth Network, this is Dean Becker asking you to examine our policy of Drug Prohibition.

The Century of Lies.

This show produced at the Pacifica Studios of KPFT, Houston.

Transcript provided by: Jo-D Harrison of www.DrugSense.org

Century of Lies / April 29, 2012

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DEAN BECKER: The failure of Drug War is glaringly obvious to judges, cops, wardens, prosecutors and millions more. Now calling for decriminalization, legalization, the end of prohibition. Let us investigate the Century of Lies.

-----------------------

DEAN BECKER: Thank you for joining us on this edition of Century of Lies. Today we’re reporting from Tucson, Arizona. I’m attending the Patients Out Of Time Cannabis Therapeutics conference. This week’s Cultural Baggage also features additional coverage from the Patients Out Of Time conference.

Here, speaking on the connection between cannabis and schizophrenia, Dr. Chris Fitchner.

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CHRIS FITCHNER: This is my first time at this conference. I’m actually a relative newcomer to this community. I’ll tell you a little bit about my background.

I’m a psychiatrist. I started my career in the VA initially running a clinic for post-traumatic stress disorder and later became a service chief in the VA. I went on to work for Illinois government. I was Chief Psychiatrist of the Illinois of the state hospital system for about 7 years. I spent a couple years as mental health director for the state.

It was during that time when I was looking at the interface of the criminal justice system and the mental health system – the overlap of the populations in the psychiatric hospitals and the jails and prisons, in particular the jails. That’s when I ran across data that showed there were more people arrested for marijuana-related crimes than for all other controlled substances combined.

At the same time it was a period when advocates in Illinois were working really hard to pass a newer-generation medical marijuana law. They do have an older one from the 70s but it’s never been implemented, never been activated. They were trying to pass a law modeled after California or Colorado. They never did pass that law. They’ve come close several times.

It was really in that context that my interest in drug policy generally and medical marijuana in particular developed. I spent most of my career in Illinois. About 4 years ago I came back to California where I’m originally from. I’ve been working full-time as a clinician, as a psychiatrist treating patients with severe and persistent mental illness in a county run clinic in the county mental health system in Riverside County.

The clinic that I work in…and this is where I am full-time treating persons with mental illness and I do mainly medication management. The clinic offers a number of recovery orientated services. It has a substance abuse program. My role as a psychiatrist is mainly using medications for treating patients. Of course I council them about general health-related issues frequently.

So I’ve been working full-time clinically. The county does not have a policy that supports doing medical cannabis recommendations so that’s not something that we do in the clinic but I do talk frequently with those patients who do have recommendations- those who are using it for therapeutic purposes and want to get recommendations. I typically advise them to have that kind of protection even though I can’t give them the recommendation in the clinic there. I have done a number of them privately outside but I don’t do them in the clinic.

But, nonetheless, we do talk about the potential hazards and benefits of cannabis use. It within that context that the thoughts I’m going to share with you today grow out of.

First I want to set up a dichotomy that is a lot like what Amanda just did in some respects. A central theme here is are we conceptualizing herbal cannabis. I’m just going to use that broadly at this point in time. We’ll drill down and talk a little more specifics from a substance abuse perspective and from a therapeutics perspective.

Just to cite Weil and Rosen from Andrew Weil’s book in 2004, any substance can be either good or bad. Relationships with drugs can be either good or bad. The drug in of itself depends on the relationship that the user has with it.

I think there’s an overwhelming bias within the mental health field and within the psychiatry field in particular to view marijuana as a substance of abuse. In fact there’s a sub-specialty within psychiatry in substance abuse disorders.

I want to skip through here very quickly because this has been covered in far more detail than I could possibly cover it in already. But I wanted to give you the flavor that if you approach this in clinical practice and you’re working in partnership with substance abuse programs who are working with people who have dual diagnosis conditions. That is they may have depression. They may have schizophrenia, post-traumatic stress disorder also they have co-morbid substance abuse problems. Most often alcohol but could be any other substance as well.

If you approach it from the standpoint of cannabis is a substance of abuse period the focus is going to be on looking for the persistent negative consequences. Of course there’s lots of money that’s been pumped into research showing exactly that.

Looking at whether people are able to stop use when they want to stop use. Looking at questions of addiction. That’s been addressed really well over the last two talks. Actually addiction is not a term that occurs in the DSM, in the psychiatric nomenclature. The diagnosis that we use are substance dependence – not addiction.

I really like in the talk before last the summary demonstrating cannabis addiction. With all the resources that NIDA has put into it have really been reduced to these facilitated or forced addiction paradigms where you have very high doses and then you slam somebody into withdrawal – or an animal model forced withdrawal by administrating an antagonist.

You have to go through extraordinary machinations to produce a cannabis withdrawal syndrome. In fact, it is NIDA’s view that marijuana is addictive largely because they’re able to demonstrate cannabis withdrawal syndromes in experimental models.

When you are looking at substance of abuse you are interested in the dual diagnosis from the course of illness both on the effects of primary symptoms and its secondary mental and physical effects.

From a therapeutics context you are going to be asking entirely different questions.- questions of clinical efficacy. Drugs when they are approved for use in schizophrenia – say when an antipsychotic drug is used. It has to first go through safety protocols and then is approved by the FDA and really very short term experimental designs where the effects of drugs are looked at for only 8,10, 12 weeks. They may have extended follow up designs but most of the randomized clinical trials are going to be short term.

Contrasting that with medical effectiveness studies which are much longer term studies that look at aspects of real-world practice. They’re not quite as tightly controlled. What’s the likelihood that patients would be able to get access to the medicine if it’s released in the system. How is it used when somebody’s on a multi-drug regiment. Real-world studies look at all the other variables that shape whether their patients would be able to adhere to their treatment - including things such as side effects and adverse incidents.

Drug safety I’ve already mentioned. Indications and specificity. Tomorrow I’ll be talking about post-traumatic stress disorder. We’ll have more to say about that later but that’s a disorder in which there is only two drugs, two medications that are FDA-approved for the treatment of that.

The vast majority of the medicines that are prescribed are prescribed off-label when someone’s doing medication management for that condition. I think that fundamentally changes the nature of the discussion around what’s the difference between being on solid ground with FDA-approved medications for a specific medication versus using medications off-label.

The more you get into difficult to treat patients who are treatment resistant where you’re using not just one or two medications but possibly a cocktail of three or four. You may follow professional guidelines that have been put together by the American Psychiatric Association or other organizations that may be more empirical or based on professional, clinical judgment. But, nonetheless, you are further away from the strict, narrow FDA map.

Also need to look at things like contraindications or relative contraindications to drugs. For example, in just a bit we’re going to say about cannabis and psychosis and all the literature that’s look at how cannabis is associated with a poor long term outcome in patients with schizophrenia - we’ll get to that in just a second.

Even medications that are approved, for example antidepressants, can worsen the symptoms of schizophrenia so any activating or stimulating medicine can make paranoia, auditory or visual hallucinations worse.

Let me just say a little bit about diagnosis in schizophrenia. If you look in the DSM there are a number of subtypes – paranoid schizophrenia, residual, undifferentiated, catatonic...Really the big picture is it doesn’t appear to be a single entity. If we are going to make a generalization schizophrenia really entails two classes of symptoms. The positive symptoms which are things that are additions to the premorbid personality which are usually things like hallucinations, delusions, ideas of reference. That is feeling that people are talking to a person or saying something to them when they’re not, talking about them. Fearful paranoid voices that may either be command-hallucinations – telling them to do things – or they may be detached conversations about the person’s behavior.

That contrasts with the negative symptoms which are things that are subtracted from the premorbid conditions. Things like apathy, impoverishment of thought, speech, social deficits – an inability to engage.

Now I want to look at the perceived wisdom from mainstream research. Let me just mention that I have a number of references at the end of this presentation which you’ll get when you get a copy of it. Unfortunately I didn’t turn it in in advance but you’ll get a copy. Once of the bibliographies that’s probably the biggest that I know of amassed on this issue of cannabis and psychosis or marijuana and psychosis is called the Cork bibliography. It was put together by the Royal College of Psychiatrists in Great Britain.

The number of meta-analyses that have pointed out that pot smoking teens are at higher risk of developing schizophrenia in their 20s than those who don’t smoke pot. That’s true. It’s true no matter how you look at it. Whether it’s a causal relationship or not is still open to question. But it is true that those who are using marijuana in their teens are at higher risk of developing schizophrenia later.

Now just to put that in perspective. It’s not a strong affect. It’s actually a weak affect. It’s weaker than the early childhood exposure to viruses that effect the central nervous system. There are three or four of them that are shown to be associated with higher incidence of schizophrenia.

The only psychiatrist who has publically tried to make the case that that is an important causal factor in schizophrenia was E. Fuller Tory. The community, in general, has rejected that notion. Yes, there is an affect but it’s not an important affect. The genetics are far more important. Maybe stress of early environmental experiences is a participant but nobody has accepted the idea, in the psychiatric community, that exposure to viral infections that attack the central nervous system in early childhood is an important driving factor in whether or not someone has schizophrenia later in adulthood or not. And yet that’s a stronger affect than the effect of cannabis use in adolescence.

There’s also some data, a number of studies showing that earlier use increases the risk even more. So those who use it earlier are more likely to develop symptoms in their 20s - kids in the range of 14 to 15 as opposed to the age of 16, 17 or 18.

There are studies that show that cannabis use can exacerbate symptoms in patients with schizophrenia. Also studies that show both herbal cannabis and THC administered experimentally can create transient psychotic symptoms in non-patients. So that’s led to speculation about an endocannabinoid disregulation theory about schizophrenia. It’s been quite some time since that was posed but these discussions are becoming increasingly sophisticated as we look at more research that’s coming out.

So THC exacerbates symptoms in experimental context and there’s always the question of transient and lingering cognitive deficits. We know that short-term memory can be impaired acutely from use but the question of importance of lingering deficits after long-term, heavy use is still an open question. Even though studies that have shown deficits don’t look very important clinically – even for those who have used it long-term – after they have discontinued use. You are able to show differences that are statistical significant in certain aspects of memory but it is not clear if all of those are clinically significant.

To counter everything that I have just said or offer sort of a critical or alternative perspectives. There certainly are plenty of patient reports of benefit from herbal cannabis use even for those patients who have schizophrenia.

My experience in practicing with patients is that those who find it makes their symptoms worse tend to stop it. They tend not to use it. They tend to use it if it makes their symptoms better. Some of them have outright told me that it makes hallucinations go away. That they feel less paranoid when they use it.

One of the things that becomes important is to have discussions for those who are using it regularly about how important is their reliability of access to consistent products because there may be people who are getting cannabis out in the street that their source is unreliable, that they don’t have a medical recommendation. Even with the recommendation that gets them into the best places to get access to medicine that’s labeled – this whole field is still evolving in such a way that the vast majority of users are not getting access to products that are consistent.

I think the more we can do that…I think that’s one of the reasons the California Medical Association, back in October, came out in favor of legalization. They want doctors to be able to understand what it is their patients are getting so that there’s some regulation and some labeling.

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DEAN BECKER: You are tuning in to Century of Lies on Pacifica Radio and the Drug Truth Network. We’re reporting from the Patients Out of Time Cannabis Therapeutics conference in Tucson, Arizona. The speaker, Dr. Chris Fitchner.

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CHRIS FITCHNER: There, of course, have been clinical case reports for a number of years out of the group in Brazil. Then, more recently, controlled research in Germany looking at CBD as an anti-psychotic. In one study in Germany comparing it to an approved established anti-psychotic found that patients with schizophrenia relieve their symptoms just as well as the established anti-psychotic but without as many side effects.

It’s tempting to then say can we have this dichotomy. Of course I’m aware that herbal cannabis is far more complex than that. Many cannabinoids we are beginning to understand some of them better than others. There’s a lot of research to be done but it’s tempting, at least initially, to say we have this anti-psychotic CBD so maybe those who have psychotic disorders, if they are going to use cannabis as medicine, maybe they need something that is higher in CBD with that anti-psychotic effect and maybe lower in THC which can exacerbate paranoia as we’ve seen in experimental paradigms.

And yet there’s also a clinical case series, a small one from the east coast, that was published just a couple years ago with half a dozen patients. These were people who were hospitalized with serious…they had schizophrenia. They had, at various points, been treatment resistant. At least several of them were on two anti-psychotics. At least one, I believe, was on Closopene which is for treatment resistant schizophrenia.

In this study the investigators added just molecular THC – that is Marinol or Dranabinol – to the regiment. In four out of the six cases they saw improvement. In three out of those six cases they were pretty sure that it was a specific anti-psychotic effect - the fourth one being possibly just a general calming effect.

So that’s a small series. That’s not much but it still becomes part of this discussion that now provides a published example of at least a handful of people that would confirm some of the reports that we hear when people say, “It seems to help me.”

In all the research to date the cause and effect relationship remains unclear. Certainly there are articles that claim to show in their analyses of data that cannabis is the causative factor that’s precipitating the emergence of the first episode of psychosis or is slowing the recovery from mental illness and causing it to be more problematic.

Probably the best research to date suggests that it is bi-directional. Sicker patients get, who have psychosis, the more likely they are to use cannabis if they are cannabis-using and the more cannabis they use the sicker they’re likely to get. That’s probably the best research shows.

But, again, these studies are evolving. As far as showing a clear cause and effect relationship really remains to be seen. There do, however, appear to be vulnerable subsets of patients and there’s some genetic polymorphism in research in terms of receptor studies and enzyme studies as well that suggests that certain patients are more vulnerable to the psychoticgenic effects of cannabinoids.

More recently there’s been studies…actually published online about two years ago but it just came out in Schizophrenic Bulletin in hard copy that shows that there is a subset…actually, what it shows broadly is that those who have schizophrenia who have a history of cannabis use actually have superior cognitive functioning. What I mean by cognitive functioning here is tests of memory and discrimination – sort of the more intellectual cognitive tasks making that separate from the question of hallucinations and delusions.

What they found was that this appeared to accounted for by a younger subset. Those who used it at an earlier age seemed to have the better cognitive functioning and it seemed to be accounted for by a subset of patients who started using it at an earlier age.

I think we get an idea of what we are up against in terms of the politics and the reigning values here when you look at how the discussion and the conclusions were presented in that article. Their hypothesis was that the most likely explanation was not a self-medication - that maybe they’re getting some therapeutic value, maybe the cannabis is actually helping them – but rather that these are people that because of their superior intellectual profile would not have developed schizophrenia if they hadn’t started using it at such an early age.

So what you typically find in reading the literature is the findings presented…there’s a statistical association…they say we can’t really claim to say that marijuana causes schizophrenia or it precipitates the break but once they’ve laid out all their disclaimers it’ll say how can we reduce the use of this substance so we can reduce the number of cases of schizophrenia. It always ends that way. Dozens of articles that are like that.

I think they are probably written that way in order to make it easier to get grant funding. Nonetheless they tend to take back what they grant in terms of what we actually know about the hazards associated with cannabis use for persons with schizophrenia.

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DEAN BECKER: This is Dean Becker interrupting to remind you that you are listening to Century of Lies and the speaker is Dr. Chris Fitchner. He’s clinical professor of psychiatry at the Southern Illinois School of Medicine. This was recorded in Tucson, Arizona at the Patients Out Of Time Cannabis Therapeutics conference.

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CHRIS FITCHNER: In real-world practice…just want to sort of give you a peek into that. Multi-drug regiments are common. I wish that they weren’t but I have patients whose voices and paranoia do not go away with one anti-psychotic at maximum doses. Certainly we try other things. I have patients in recovery programs having them look at wellness issues, nutritional issues. I put a lot of my patients on omega 3 fatty acids because of their brain protective properties. A lot of them are on fish oil which is particularly good for mood stabilization. Mood disorders are also relatively common in schizophrenia. A lot of my patients are diagnosed with schizoaffective disorder which means they’re meeting criteria for both schizophrenia and major depression or bipolar disorder.

Antidepressants in these folks, as I already mentioned, are relatively contraindicative but many of them are on it anyway because they do get depressed in the course of being treated for schizophrenia for a variety of reasons. Any stimulating medication whether it’s a stimulant or an antidepressant can make psychosis worse and I’ve certainly inherited patients from other doctors where they were on a regiment and still having break through psychotic symptoms and the key to getting those psychotic symptoms reduced was to lower the dose of their antidepressant.

Medications are often remarkably effective. There are some people whose symptoms will be controlled with just a single medication and have minimum side effects. But there are many others where that is not the case and they’ll end up on multidrug regiments.

Increasingly we are aware in psychiatry of the degree in which our newer agents, newer antipsychotic drugs were developed to minimize the likelihood of developing movement disorders as we used to see with the older antipsychotics. With the newer ones now what we’re seeing is metabolic syndrome. Increasingly patients gaining weight, becoming obese, increased blood sugar with non-insulin dependent diabetes and increased cholesterol – in short, developing metabolic syndrome. So it’s important for us to look at other modalities. It’s important for us to do everything we can to minimize the medication burden especially when we’re using these medications that do have substantial side effects.

We’re becoming more medical and we need to look at overall health and risks of treatment. I guess within that context what I would like to suggest is that we clearly have an herbal cannabis substance that can be bred and processed and turned into a lot of different types of products some of which, at least at this phase, at least in California , they are beginning to be labeled in terms of their CBD concentrations, in terms of their THC concentrations.

I would like to suggest that based on what we know to date about THC and CBD that there’s a good chance that herbal cannabis may become – especially a very high CBD strain with just a small amount of THC – may become the next generation antipsychotic because it may be that the THC which is going to be a more stimulating and maybe better for negative symptoms maybe just what’s needed to make CBD an even better antipsychotic than it’s been shown to be in the research that’s been done with it as a single molecule.

I think it’s very important that as we think about the potential therapeutic properties of cannabis in persons with mental illness that we be open to the idea that we need to be looking at a model that considers it as a whole plant, that considers that it may have multiple compounds that have different, overlapping therapeutic effects and to approach things in that direction may offer treatment possibilities that our current pharmacological strategies don’t. And, in fact, ones that lead us to have people on multiple drugs because we’re prescribing different things to target different symptom complexes.

So I think that herbal cannabis may have the potential to be a single substance, if you will, comprised of multiple compounds that can be developed into products that can be more useful persons with psychotic disorders as well as things like anxiety disorders and depression.

Thank you.

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DOUG McVAY: The federal government and several state Attorneys General are sounding the alarm over heroin use and prescription pain killer addiction. Their approach is more of the same. More law enforcement, more drug testing and more propaganda.

Outside the U.S. more enlightened approaches are proving effective. The research overall shows substitution treatment with methadone or buprenorphine to be highly effective for those dependent on opiates. Availability of methadone maintenance treatment must be expanded.

Still there are hard-core addicts for whom even methadone fails. What do we do about them? One possible answer – supervised injectable heroin treatment. It’s controversial yet the evidence of its effectiveness in all areas continues to mount.

The European Union’s Drug Agency, the European Monitoring Center on Drugs and Drug Addiction recently published a review with literature around heroin treatment. Overall they concluded,

“Over the past 15 years 6 randomized control trials have been conducted involving more than 1,500 patients and they provide strong evidence both individually and collectively in support of the efficacy of treatment with fully-supervised, self-administered injectable heroin when compared with oral methadone treatment for long-term refractory heroin-dependent individuals.”

Among other things they found that,

“Across the trials major reductions in the continued use of street heroin occurred in those receiving supervised injectable heroin compared with control groups most often receiving active methadone treatment.”

And,

“Reductions in the criminal activity of supervised injectable heroin patients were evident and were substantially greater when compared with patients under controlled conditions.”

Most importantly,

“Finally, countries that have conducted longer term – up to 6 years – follow up studies have seen a high retention in supervised injectable heroin: 55% at 2 years and 40% at 6 years, with patients sustaining gains in reduced street heroin use and marked improvements in social functioning. For example, stable housing, drug-free social contacts and increased rate of employment.”

In the U.S. where methadone is still considered controversial in some communities and treatment availability is thus quite limited, supervised injectable heroin treatment will seem like a radical approach yet it works.

The question is how long do we keep doing more of the same and failing before we try a different way?

For the Drug Truth Network this is Doug McVay with Common Sense for Drug Policy.

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DEAN BECKER: Thanks Doug and the website for Common Sense for Drug Policy is http://www.csdp.org

We’ll have lots more for you next week on Cultural Baggage and Century of Lies from the Patients Out Of Time Cannabis Therapeutics Conference in Tucson, Arizona.

As always I remind you there’s no truth, justice, no reason for this drug war to exist. Please visit our website http://endprohibition.org. Do it for the children. Prohibido istac evilesco!

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For the Drug Truth Network, this is Dean Becker asking you to examine our policy of Drug Prohibition.

The Century of Lies.

This show produced at the Pacifica Studios of KPFT, Houston.

Transcript provided by: Jo-D Harrison of www.DrugSense.org