Greetings, everyone. I'm Jim Berry, and I am Professor and Chair of Behavioral Medicine and Psychiatry at West Virginia University's Rockefeller Neuroscience Institute. It is my pleasure to be able to present a lecture to you today titled Bad Medicine, Mental Health and What the Opioid Epidemic Can Teach Us About Cannabis. As we begin, making sure that all disclosures are presented, and I do not have any disclosures or conflict of interest in regard to this presentation. A few organizations that I am a part of, one is that I serve on the West Virginia Medical Cannabis Advisory Board. I also serve on the West Virginia Governor's Council on Substance Abuse Prevention and Treatment. I and my department take part in a number of NIDA-sponsored neuromodulation studies, as well as some SAMHSA-related grants for treating and managing addiction within our population. I'm a consultant for Solero Systems Inc., which is a company that's looking at novel solutions for our overdose crisis. And then I am a consultant on the Advisory Board for the Addiction Policy Forum, Public Health Institute, and AHRQ's National Integration Academy Council. I will tell you at the forefront of this lecture that I am biased. And my bias is this, that I have been practicing here in the heart of Appalachia, in West Virginia, since the early days of the opioid pain pill epidemic. And I've had a front row seat since 2002 to what has transpired regarding a expansion of opioid pain pills and then the ensuing consequences and tragic consequences of what we find ourselves in today. And unfortunately, I see many parallels between what happened with the genesis of our opioid pain pill crisis and what I see occurring today with the cannabis industry. What are the objectives? There are three main objectives for this talk are to review the impact of cannabis on mental health, articulate what is meant by a medicine, recognize the similarities between the history of our opioid crisis in the current cannabis landscape. So some of you, or if not most of you, are familiar with the terminology death or diseases of despair. And this is a label that has been given to the phenomena that we United States have been experiencing over the last several years in the fact that our life expectancy has been declining. So the average age of death is going lower and lower than it used to be. And Case and Deaton, two economists have determined that or have named this as the deaths of despair. And there are three major factors that are driving this decrease in our life expectancy. It's not that older people are dying, but it's that people are dying at younger ages. And those three main factors are one suicide, two overdose and three liver failure and liver failure due of course, to the results of substance use disorders or substance misuse like alcohol and alcoholic liver disease, as well as infectious disease complications of hepatitis due to injection drug use. And the sad thing is that even adds more poignancy to this problem is that all of these diseases or all of these deaths are entirely preventable. And here is a study that a number of national colleagues and myself published a couple of years ago, uh, that can actually take you through, um, from 1999, uh, to 2017, 2018. And, uh, the, uh, rates of suicide and the rates of self-injury mortality and what this is, is a drug overdose. And you could see that the higher the, uh, or I'm sorry, that the darker blue and, uh, is a higher rate. And then the red is the highest rates. And you can see from, um, the early two thousands into the, uh, later part of the decade of the 2018 up to 2018, how, how much, uh, these problems have spread throughout our communities. And this has truly become a public health crisis. And a few points to make on this is, is one that, um, suicide and addiction, uh, go hand in hand. And sometimes it's hard to even tease out how many people, uh, actually intended to harm themselves, uh, voluntarily and how much, uh, overdose. And there's a lot of, uh, in between there as well, but, um, uh, we need to do a much better job of understanding mental illness and also not segregating, uh, substance use disorders or addiction from, uh, mental illness, uh, considerations and treatment. Uh, addiction is a mental health disorder, uh, just like suicide is. And you also see that substance use disorder goes hand in hand with other mental health disorders. And this is a national survey of drug use and health. I'll be presenting a lot of this data from, from the national survey of drug use and health, uh, for 2021, which is the most recent data that we have. This is an annual survey that is done, uh, across the country with large amounts of respondents and gives us a good understanding every year about, uh, what, what does the landscape of mental illness and, uh, other, uh, addictions look like. And in 2021, you can see that there were 82 million adults had either a substance use disorder or any mental illness. 44 of those had a substance use disorder. And of those almost half had any mental illness at 20 million and 6 million had what would be described as severe mental illness. Overdose has taken, uh, its toll on our communities. Uh, not the least of which has been my community here in West Virginia. Uh, sadly we lead the nation and have led the nation in overdose rates by far and away, uh, since the early days of the two thousands. It's the leading cause of injury death in the United States. Opioids make up the, the vast bulk of these overdose. There were over 107,000 deaths in 2021. 2022 looks like it is going to, uh, continue to, to grow from the, um, most recent data that we have. Uh, there was a 15% increase from 2020. And then of course, as you all are probably well aware, the COVID epidemic, uh, just exacerbated, uh, overdoses. And so nationally there was a 30% increase from 2019 to 2020 in overdoses. And in my state of West Virginia, there was a 50% increase. Then over 1 million deaths since 1999. And like I said, West Virginia is unfortunately, uh, been hot far and away the leading state, uh, through the last two decades in this horrible statistic, uh, to give you an idea, currently 92.5 per 100,000, at least in 2021, uh, of our citizens had died from overdose. One of the Southern most counties in our state called McDowell County, which is one of the Southern coal fields. Those rates, uh, shockingly are up to 228 per 100,000. Compare this to the number two, uh, region, which is, uh, Washington DC at 63 per 100,000. The average, uh, United States is 32.4. I believe Tennessee is the number two state. And here you can see that the types of substance have actually evolved, uh, since the early two thousands. And one of the points I try to make when I am speaking to various audiences is that, uh, it's important to look at this epidemic, not as necessarily an opioid epidemic, uh, but really to consider this as an addiction and mental health epidemic, the substances will change and they have changed. And you can see this, uh, in the early two thousands, what started at all was prescription pain pills. And that's this blue line you see here. However, in around 2014 is when, uh, the synthetic opioid fentanyl, which is incredibly potent entered our, uh, streets. And then we have a sharp increase in the number of opioid deaths, even as we had seen a plateauing of the, of the, um, uh, prescription pain pills during that time, there's a sharp increase in this, uh, green synthetic opioids, which is fentanyl and sometimes car fentanyl. Prior to that, uh, what many would consider the second wave after pain pills being the first wave is, is heroin. And this is what you see, uh, here. And then most recently, not only are we seeing this high, these high rates of fentanyl in our communities, but now we're also seeing a stimulant such as methamphetamine. We have a huge problem with methamphetamine in Appalachia. Anatomy of an epidemic. So this is, uh, I'm going to present to you a work, a piece by Dr. Wilson Compton, who is the deputy director of the National Institute of Drug Abuse, NIDA. And what he does is, is what he presents in this material is adds on to the classic disease triad of a host and agent and an environment in an epidemic. Uh, so in the host, right, you've got individual factors such as genetic and behavior. So in the opioid epidemic, you've got, um, uh, potential genetic factors that make one, uh, at risk for developing a opioid use disorder. You also have, um, uh, environmental factors. So if you've had adverse childhood experiences, if you are around, uh, peers who are using or family, then you are more likely to end up using opioids as well. And that's, you see that, and then the actual agent would be the opioid itself. But what he does is he adds to this classic, um, uh, frame, uh, the vector element. And in the vector element is it emphasizes the active role of purveyors of these substances in the genesis of an epidemic and the continuation and the flourishing of such an epidemic. So when it comes to opioid pain pills, uh, you see that the pharmaceutical industry had a outsized, um, influence and really, uh, convincing, uh, physicians that it was safe and even good to prescribe and recommend opioids, despite the fact that there was very little to no evidence to support that. And there had been decades of evidence to demonstrate the real harms. And so also in addition to that, to those two elements as a vector, uh, the pharmaceutical industry and the prescribers, you also have the dispensers. So, uh, pharmacies were at fault and you see a number of pharmacies that have been, uh, held responsible, uh, through many of these settlements for their role in the opioid pain pill problem. And then of course you have, uh, the, just your typical drug dealer, uh, people who are selling, who are both manufacturing and selling, uh, these substances and these products on, on the street. And so these vectors influence both the extent and how and where, um, uh, this epidemic spreads. And so, as mentioned earlier, it started with the pain prescription epidemic, but then the second wave was heroin. And why did that happen? It really, much of it was due to financial, um, uh, explanations that, that pain pills became and were, and still are, uh, very expensive. However, uh, heroin became dirt cheap. And for every $100 decrease in the price per gram of heroin, the number of heroin overdoses increased by nearly 3%. And so you see a lot of people turning to, uh, the much cheaper, uh, product of heroin. And then this was further complicated by, uh, several years ago, the introduction of a incredibly potent and incredibly inexpensive alternative to heroin, which is the synthetic fentanyl. And, uh, that's sadly where you see just a skyrocketing of these, of these, um, products. So physicians, uh, you know, most physicians were trying to do the right thing. They were reluctant to use opioids until they were convinced to do so based on the poor evidence. Uh, pain advocacy organizations sought regulatory changes, uh, to medical boards and other, other governing bodies to ensure that more opioids were prescribed. And it coincided with these business decisions that are truly fueled, uh, the increase. And, um, now most folks are well aware of what was happening within, uh, these pharmaceutical, um, um, C-suites and in determining, uh, the fate of, uh, many people and many families. So cannabis, what's the big deal? It won't kill you unless a bale of it falls on you. Willie Nelson. And so Mr. Nelson, uh, is not alone in this, um, perspective that marijuana is not really that harmful. It's, it's not like opioids where you were going to stop breathing and overdose and it's natural, it's benign, and some would even say it's good for you. So what's the big deal? Well, we better make sure that, uh, there isn't much of a deal with it at all, because there is a very consistent pattern, especially among our high school students, that when they perceive that the risk of cannabis or marijuana use is low, they are much more likely to use. And you can see this bore out in the Monitoring the Future, uh, graph, uh, here displayed for you between 1975 and 2019, that there is an inverse relationship between, uh, whether or not someone thinks it is harmful to use marijuana. If they do, they're less likely to use. So, um, initiatives to educate and explain the risk, uh, have truly had a positive impact in whether or not some, uh, someone will use. And here you see that, again, this is the NASDAQ survey for 2021, the most recent data we have, is that marijuana use is by far and away the most common illicit substance that is, um, used by our population in the United States. Over 52 and a half million people reported using, uh, marijuana or cannabis. That's a 75% increase since 2009. And I changed, uh, my slide recently from 2018 data, and it was 43 and a half million at that time. So you could see the increase even in a couple of years of how, how much that has increased. And so there are many, many more people using than they had in the past. And so we better do a good job. Those of us who are in, um, the medical field, those of us who are in public health of understanding, uh, the risk and what we're in for as more and more people are going to be using. You see historic levels of increase in use among high school students. In 2021, you saw record levels of use. There was a 13% increase from 2011 to 2021. 43% of high school students reported using in the past year, 30% in the past month, and 11% report daily use. I frequently look at my hometown newspaper online, which is Detroit, Michigan, and I would see pieces like this that are probably similar to pieces that you see in your hometown newspapers as well, all over the country. Warren medical middle school students get sick after consuming THC gummies, cookies. And this is what the, um, uh, superintendent said as in a letter in response to this, uh, large number of students who got sick from THC. Since marijuana became legal in Michigan, we have seen an increase in students vaping and eating edibles containing THC. Unfortunately it could come, it should come as no surprise because many children see marijuana use as normal and do not understand the effects or consequences of using it. And the other important point to take away from this presentation is that today's cannabis plant is much different than your grandfather's cannabis plant. There is a, such a greater degree, a higher degree of potency today than there was several decades ago, even in the mid nineties. And so you can see what happens here is from the early nineties, the THC, which is the main psychoactive component of cannabis and the component that most users are seeking because of the euphoric properties, uh, has been bred to increase over the last several decades. While the CBD component, which is considered to be a somewhat of a balancing chemical to these effects of the THC has remained rather steady or lowered. And so you have a much higher potency of product in today's cannabis than you do even a few decades ago. And we know with other substances that higher potency equals higher risk. A common beverage of choice here in this region is yingling and yingling, and there's a 12 and a half ounce can of yingling, it is 4.5% alcohol by volume or ABVs. Contrast that with wild turkey, which is 50 and a half percent ABVs. If you were to consume 12 and a half ounces of wild turkey, you would become fecal faced, you would become comatose. There is, and that has to do purely with the potency of the alcohol in that amount of beverage comparatively. You also see this difference in the risk of a higher potency opioid product. Here you have the lethal dose of heroin compared to the lethal dose of fentanyl. And of course the lethal dose of the even more potent synthetic opioid, the carfentanil. And this is what has been really driving those rates of overdose deaths as we've already mentioned. Getting back to the pain pills and potency between 1997 and 2007, the average dose of an opioid pain pill prescription increased from 100 to 700 MMEs per person per year. Do you think that had anything to do with the addiction and overdose problem that we found ourselves in that we are still trying to grapple with today? So you have the one element of increased potency but the way that the average user is consuming today is different than the frequency of consumption in the past. So the frequency of consumption several decades ago, 1990s and before was six to eight times a month which translated to most people who were using cannabis were using on the weekends. Nowadays, you can see here this red line in the graph is the number of daily or near daily smokers. And so now the most common and average user is using daily or multiple times a day and these numbers continue to grow. So you have a situation where there is increased frequency of using the product and an increase and a higher potency of the product. So pre-2000 average users were using about two nights a week as mentioned. So today with given the frequency and the potency that's about 70 times more THC than the pre-2000s. To give you a comparison in caffeine, here is a 20 ounce diet Coke with caffeine, compare that to 35 brand brandy cappuccinos in the amount of caffeine. And we also have demonstrated evidence of higher potency products associated with psychosis. Here is a very important study that was done in Europe. They looked at populations in five large European studies and they looked at first episode psychosis. And they determined that if somebody was using a THC product that was 10% or greater in potency, they had a three times greater risk of having a first episode psychosis compared to those who were not using THC or at least a lower potency of THC. If they were using daily that risk increased by five times. There was also a Denmark study that was done and here you see the graph that evaluated the relationship between cannabis use disorder or cannabis use or cannabis addiction and schizophrenia. And what they determined that as you had a greater frequency of use and higher potency products and availability in Denmark that the rates of schizophrenia increased significantly and that there was a four times greater risk of those with schizophrenia also having a cannabis use disorder. And this gives much more credence to the idea that it is not merely cause or casual but it is actually is causative. And here is data from the Drug Abuse Warning Network. And this is another annual survey that is done by a large amount of the United States population. And this looks at emergency departments and the substances that are attributable and linked with an emergency department visit. And what I wanna draw your attention to is that you see in 2022, the number of emergency department visits related to cannabis was almost equal, 12% compared to 12.7% of opioids. And you can see that the number of people with emergency department visits outpaced methamphetamine, cocaine and these other drugs. So really second or third, just barely to opioids and certainly alcohol remains the largest contributor to our emergency visits. The highest rates of emergency visits was for those between the 18 and 25 year old range. Males surpassed females and the largest proportion by ethnic demographic was the black population at 660 per 100,000 compared to whites that was 153 per 100,000. The largest numbers were between the 26 and 44 year olds which accounted for nearly half of the visits. And another point that I want you to come away from this talk is that using multiple substances together is very common. And so there are some advocates in industry and narratives out there that would try to suggest that using cannabis would be a substitute for using other substances. However, the data simply does not bear that out. And I can tell you that the personal experience as a psychiatrist and an addiction specialist for the last two decades is that it is more the norm that my patients who are using other substances are also using cannabis as opposed to not using cannabis. And here you can see that basically this is, when you look, these are the top two substances, alcohol and cannabis that are in emergency departments that are combined with other drugs. And the larger the box, the greater the proportion of other drugs with that drug. And so the big three for both alcohol and cannabis is using either one together in addition to cocaine and then also methamphetamine. And you could see the likelihood of how frequently that occurred in these studies. And again, overdose is not the only cause of concern when it comes to drug deaths. So motor vehicle accidents is a, also should be a pressing concern among public policy folks and communities. And so this is a relationship between cannabis related car fatalities and then also alcohol related fatalities. And you can see that by the blood alcohol concentration and cannabis involvement, here you just see just the cannabis and you see significant increase in the rates of fatalities with motor vehicle accidents. But what is also, well, and you see a doubling and almost doubling from 9% to 21% between 2000 and 2018. But you also see this phenomena that with cannabis, you see higher rates of higher blood alcohol concentrations in fatal accidents as well. So there is a direct relationship there. This is an incredibly important study that is probably the most well-funded and important study that's currently occurring in the United States to this day. It's called the ABCD study, Adolescent Brain Cognitive Development Study. A lot of attention, a lot of resources is going into this particular study and it's following a large number of children from childhood into adulthood and seeing what sort of relationships are there between certain behaviors and the development of various psychological, psychiatric and other cognitive problems and just develop them. And so this is an article that was published in 2022 that was a follow-up from a 2021 report that demonstrated that children who are born to women who are using cannabis have a much greater likelihood of developing psychotic episodes and behavioral problems in grade school, essentially. And what this study does, which came out last year, it actually adds longitudinal data to that baseline report that those changes or those problems, excuse me, unfortunately persisted into adolescence and they had greater increase of psychopathology which leads to greater risk of psychiatric disorders and substance use. And so the authors, again, conclude that this further cautions against cannabis use during pregnancy. So here you see the data that looks at the relationship between a particular substance and mental illness status. And you can see the red line is the, or the red box is severe mental illness. The blue box is any mental illness and the gray box or the rectangle is no mental illness. And you can see the high rates of a co-occurring mental illness, severe mental illness, 40%, 41% and use of marijuana higher than any of the other substances listed here, alcohol or tobacco, or even opioids. And for those of you who have been practicing in the mental health space, you can probably attest to what I can attest to is that a number of patients who come in are with severe mental illness are also coming in with cannabis use. And part of the challenge is helping them understand how their cannabis use is likely contributing to their mental illness and likely impairing the ability for effective treatment to occur. Here is a important article that was published in the American Journal of Psychiatry a few years back that actually looked at the risks and benefits of cannabis and cannabinoids in psychiatry. Many experts looking through the current information at the time and ultimately conclusion was is cannabinoids become more available and become more available. The need for an evidence base adequately evaluating their safety and efficacy is increasingly important. There is considerable evidence that cannabinoids have a potential for harm in vulnerable populations such as adolescents and those with psychotic disorders. The current evidence base is insufficient to support the prescription of cannabinoids for the treatment of psychiatric disorders. One thing that I did not mention in this talk is, and there should be another webinar to elucidate much of this data, is just the high evidence of association of cannabis and suicide, especially for our young people. And then the British in their psychiatric journal, The Lancet, had a great article, summary article on the data regarding the association of potency with mental illness and addiction, a systematic review. And they concluded that the findings from the systematic review highlight the potential for an increased risk of negative mental health outcomes and addiction with higher potency cannabis use. The findings support recommendations to discourage the use of higher potency cannabis products for low risk use. The recommendation should be incorporated into educational tools and then in the management of cannabis use in clinical settings. Policymakers should carefully consider cannabis potency when regulating cannabis in legal markets, such as through limits or taxes based on THC concentration. The other thing that I will tell you, well, I'll go on to this and then tell you about a patient experience that I had even this week. So this looks at, this was an article published in 2017 that should be a jaw dropping article for many of you. And what this did is it looked at a first episode psychosis or a substance induced psychosis. And if somebody had a first episode psychosis, their likelihood of developing a bipolar disorder or schizophrenia within three years for any substance was 32%. For cannabis, that likelihood almost reached 50% in the next three years. And the risk was highest for kids between the ages of 16 and 25 years old. And that brings me back to a consultation that I had even this week with a father of an 18 year old college student who reached out to me because unfortunately this college student had been admitted to a state psychiatric facility for severe and unremitting psychosis and suicidality. And he was using a THC vape pen. And it comes to turn out that was the only substance this poor fellow had been using. And unfortunately he, like many of those that we see in the data, then experienced severe psychotic episode. And one of the recommendations and the urgings that I gave the father was, as we are trying to get him help, is to do whatever is possible to get him help if he does have a cannabis use disorder, but to ensure that he does not continue to use cannabis and THC. And also you need to be on high alert over the next three years to make sure that he is well cared for, that he is followed closely and monitored for any signs of developing schizophrenia or a bipolar disorder. Folks, we are seeing an insane number of people who are being admitted to our psychiatric facility with THC related psychosis. It is not uncommon to see, and especially in our adolescent unit, the majority of those who are up there for a psychotic reason or severe mental illness that's directly related to their cannabis use. Here's a slide, a pretty good article that looks at the relationship between cannabis, the cannabinoid system, and our stress response. And it's a busy slide, but you got the information there. Suffice to say that endocannabinoids are, if you don't know this, our brain makes natural cannabinoids, a very, very low potency amount of these natural cannabinoids. And they are integrally important in neurodevelopment, inflammation, the pruning and the forming of various neurons, and among other processes. And they appear to have a role in actually mediating and regulating glucocorticoids, which are responsible for how we experience and what our body does during stress. And so this is really tied into our resilience. And what these authors conclude based on the data is that those who have a deficient endocannabinoid system may have an increased risk of having psychopathology and PTSD, a major depressive disorder. And that those who use then phyto or synthetic cannabinoids, meaning cannabinoids that come from the plant or cannabinoids that come from the lab, which are much higher potencies than what our natural system is used to, that can really affect to the negative to our stress response and our resiliency. And so they posit that stress and cannabis use likely have a bidirectional relationship such that stress likely promotes and maintains cannabis use while cannabis use likely alters stress responses both acutely and chronically in ways that may ultimately in the long-term increase perceived stress and risk for anxiety and depression. This indicates that cannabis deceptive perceptions to the contrary may not be an effective coping mechanism for stress. I think of another patient who was admitted to my dual diagnosis unit And she was using cannabis and had a severe anxiety. And I asked her just like I asked all of my patients or tried to. So why are you she was a big believer that cannabis was helping her excite. I said, Tell me what you mean that it is helping your anxiety. And she said, Listen, I'm incredibly stressed at work. I come home and I've got five kids who young kids who are probably all over me and wanting my attention. And I also have a mother in law at my home is constantly nagging at me. I want to just be able to sit on the couch and let my brain go long, long, long, long, long. And when I do that, when I use when I smoke marijuana, that's what my brain is able to do. And so what she's experiencing here is, again, what I would say is not treatment for your mental illness. And what that is, is it's a deception. It's it's Yes, it can make you be numb and dumb for a little while, but that is not truly helping your anxiety. And actually, it could be making your anxiety worse, and it could be driving you to more cannabis use. And the other thing I would would say when I told this patient, like I tell all of my patients is, listen, I am convinced that for most people, based on my experience, treating patients that if we can help you stop using cannabis, it's going to take a while and you have to trust me in this. But if we can help you stop to stop using cannabis, marijuana, that actually your anxiety, your depression and other mental health problems will get a lot better. And we may not even need to give you any medications for these problems that you may not need to have any medication. And there are so many patients that we treat where that is ends up becoming the case. And so here you see a bi directional framework. So of course, every person is going to have some predictors, non modifiable risk for stress and cannabis use such as genetics, such as early early life adversary or adverse adverse life experiences. And if you are born to a mother who is using cannabis, then that puts you at certain certain degree of risk as well as having problems. So you've got that baseline risk. Somebody will use cannabis acutely. And what will happen is for some people, they'll experience a sense of well being, some will actually feel much, much more anxious, and it's really a bad experience for them. But some will experience this sense of well being, they'll feel euphoria or a high, their perception of stress goes down when they are using. However, over time, what happens is with chronic cannabis use, it blunts that stress response, it blunts the reward response, which puts somebody at a greater risk for other addictions. And then you also experience a well known withdrawal phenomena, discontinuation from the cannabis. And that creates a lot of anxiety and other problems. And so then what happens is that drives the development of the cannabis use disorder. And then you have that bi directional problem with stress driving cannabis use and the cannabis use disorders driving the stress. The risk of addiction is about one in five risk of cannabis use disorder in any user. And the risk increases if that user started early and used more frequently, anywhere between 22 and 44%, the average being 33%. Here is a article published in JAMA a couple of years ago, that was a pretty slick article. And what they did was they took two groups, they took a group that was on a waiting list to get a medical marijuana card. And then they took a group that actually got the medical marijuana card, and they followed them for three months. And what they found at the end of those three months, that there was no improvement in pain, anxiety or depression among those who received the medical marijuana card, despite the fact that those three conditions are top, the top three conditions of medical indication by most states, that there was no improvement. However, there was a three time risk, greater risk of developing a cannabis use disorder or marijuana addiction. And here you see the past year substance use disorder among adults in 2021. And you can see that marijuana use disorder at 16.3 million, far and away surpassing opioid pain pill addiction, far and away surpassing methamphetamine use disorder or cocaine or even heroin use disorder, second only to alcohol, which continues to be the number one substance. So why is that? Oh, let me get back to this slide first, is marijuana use disorder. And this is broken down by age group. And this is something that is that everyone should be paying attention to because one of the demographics that I've noticed over the last several years, that has stood out like a sore thumb in many of these health indicators, substance use, suicide, anxiety, is this 18 to 25 year old age group, these, this is the age group, this is the population, this is demographic that is probably the most vulnerable demographic in the history of the United States. And so a lot of attention should be played to how do we help this particular age group minimize their risk of a host of these problems. But you can see how, how much greater they are represented in the rates of marijuana use disorder percent in the last year, 14.4%. Oh, gateway. So a lot, there's a lot of confusion regarding what is meant by gateway. And some people get really upset when you suggest that cannabis is a gateway drug. And what I think they're truly misunderstanding what is meant by gateway, gateway doesn't mean that you, if you use marijuana, you are automatically going to then be addicted to, or find yourself with a heroin addiction. That's not what gateway means that that's more like, like a portal. But what gateway means, and here's an illustration that I try to put together for this, this particular slide. So thought experiment. We have these beautiful, beautiful hills in West Virginia. It's currently fall right now here, and there is just an explosion of these gorgeous colors across our hills. So your very kind and elderly aunt is a West Virginia homesteader and she died. And in her will, she gave you an acre of land in these beautiful hills of West Virginia. And here's that acre. We also know in these beautiful hills of West Virginia, that we've got a bear, we've got black bear. And let's say that you've got this acre of land that your, your aunt has given you. And there is a fence along this whole acre of land. And your house is in the middle of this fence. And there is a gate that opens from your yard within this acre to the yard or to the, to the wilds outside in West Virginia. If you stay on this side of the fence, then you will not be at risk of, of a black bear attack. If however, you go through this gate automatically, then now you are at risk for being exposed to a black bear and potentially having harms related to a black bear. So that is what we mean by gateway. And so there are three substances that are well-known gateway substances, meaning that if you start as a young person with one of three substances, your likelihood of going on to use other substances is much greater than if you had not used those substances during childhood or young adulthood. And this looks at survey, the NASDA survey from 2004 to 2014 and self-reported first use. Okay. So this is a survey. These kids get a survey and they say, what is the first substance you use? And it could be marijuana, it could be tobacco, or it could be alcohol. Those are the three known gateway substances. Those who reported using marijuana first in 2004 was almost 5%. That rate doubled in 2014 to almost 9%. Contrast that with cigarettes. If they use cigarettes first, it actually dropped in 2014 from to 9% from 21%. So in 2004, if you, when you surveyed those, those kids 21% reported using tobacco first before they used any other substances. And then in 2014, that rate was about 9% alcohol. Again, remember this is the big substance it's readily available. It's legal. And that's always been the constant at around 30%. It is easy for kids to get alcohol using marijuana as their first drug. Okay. It increased odds of you developing a cannabis use disorder and heavy current marijuana use. And interestingly enough, because the rubric has typically been that the drug you start with is the one you're most likely to use. But what we found with cannabis was if you started with marijuana as your first substance, it was equal to starting with tobacco for developing a tobacco use disorder. As youth aged, the older they got, the more likely they were that their first drug would have been cannabis, marijuana compared to tobacco using marijuana or alcohol as the first substance, they were more likely to use other drugs. Here you see the first again, this is what is the first substance that you use? And this is the most recent data. And again, in 2021, the national survey of drug use and health, and you could see under alcohol, which is 4.1 million. So 4.1 million kids, 12 or older people, 12 or older would say that they use the first substance they ever used was alcohol. Contrast that again with tobacco at 1.2 million, and then marijuana at 2.6 million, far outpacing prescription pain pills, far outpacing any of these, far outpacing any of these other substances that you see here. Again, alcohol, cigarettes, and marijuana. Why did marijuana or why did cigarettes go at such a lower rate? You saw that it dropped from in the 20 percentile to like 9% or less. Well, there was a very strong public health campaign to demonstrate and to articulate and educate regarding the risks associated with using cigarettes. And that had a real effect. What we have today is the opposite with marijuana. There really isn't much of a educational campaign to help be honest regarding to the public regarding the harms associated with marijuana. And you see increasing rates of marijuana. With more legalization, there's going to be more access and you're going to find more and more people who first start using marijuana as a substance. And as mentioned earlier in the ED data, it is also very important to understand that co-use is very, very common, if not the norm. And what this graph looks at is this gray bar here, the dark gray bar is the lifetime prevalence of a substance. And right next to it is the mean number of other substances ever used. And to take alcohol as an example, 86% of Americans have reported that they had used alcohol at some point in their lifetime and report using almost two other substances as well. Contrast that with heroin at the other end of the spectrum, where 2% of the population have reported to using heroin at some point in their lifetime. However, those who did use the greater rates of the more likely to have used almost seven other substances if they have used heroin. Marijuana is pretty interesting because almost half of respondents reported that they had used at some point in their life. And the number of other substances they would use is about three. And so one would have to figure alcohol, cigarettes would probably be in there. And that means any one of these other substances likely used with marijuana. Here is some data that we published from our own team and looking at the co-occurring substances that were present in urine samples for patients admitted to our emergency department or our psychiatric facility. If they were positive for opioids, what other substances were in their urine? And 53% were cannabis. And at the time, this was also 57% of opioids. And this looked at data from 2009 to 2018. And in 2009, that was in the early days of the addiction or at mid time of the addiction problem. And a lot of doctors weren't as savvy to the reality that mixing benzodiazepines and opioids is a toxic combination. And so early on, we saw a lot of co-prescribing and also a lot of benzos be showing up with people who were using opioids. But actually, those numbers have declined over the last several years. But we continue to see really high rates of cannabis use. Which leads us to speak to the idea that somehow cannabis is the solution to our opioid crisis. This claim has been made. It was especially made very vociferously and loudly several years ago with some epidemiologic data that was ecological that suggested that possibly states that had lax medical or lax marijuana laws had decreased rates of overdose. However, really one should have made that claim with that particular data. And when that data then followed up to today, it actually with those same states and that population, actually the rates increased. And there was a 20% increase in overdoses in those states that had legalized cannabis. Here, the authors conclude that instead of supporting the marijuana protection hypothesis, and that's the idea that somehow for folks who are using marijuana, they won't be using opioids. The ecological associations on the national level suggest that marijuana legalization has contributed to the United States opioid epidemic in all races, ethnicities, and especially in the Black population. If so, the increased use of marijuana during the 2020 to 2022 pandemic, the COVID pandemic, may thereby worsen the country's opioid crisis. And here is a very comprehensive, thorough, probably the most comprehensive piece to date on the evidence related to cannabis and opioid overdose deaths. And this is in the Journal of Health Economics that was published this March in 2023. And what they found was that actually medical cannabis dispensaries in your communities raised opioid deaths by almost 30%, leading the authors to conclude that legal medical marijuana, particularly when available through retail dispensaries, is associated with higher opioid mortality. The results for recreational marijuana, while less reliable, also suggest that retail sales through dispensaries are associated with greater death rates relative to the counterfactual of no legal cannabis. We provide evidence that cannabis legalization leads to relatively large increases in deaths involving synthetic opioids, particularly during the current era of widespread illicit fentanyl. Policymakers, physicians, anybody who is concerned about the health of our communities needs to pay attention to this data. All right, bad medicine. I gave this lecture the provocative title of bad medicine. Here you have an elixir from the 1800s that one could purchase at your local apothecary. And what this elixir contained was alcohol, cannabis, chloroform, and morphia. I am absolutely certain that this provided relief to anyone who took this particular quote-unquote medicine. But the definition of medicine, bad medicine, according to Wiktionary, is any advice or treatment that has no value or exacerbates the problem. I would be willing to argue and bet that anybody who was taking this elixir had more problems after they took it than whatever problems they were trying to solve. Which leads us to the whole concept of medical marijuana. So our nation has been engaged through various states, I think 37 states to date and growing, that have legalized cannabis for medicinal purposes. And so we've been on this journey, this pathway of this grand experiment that is playing itself out naturally now, where we have unleashed a substance with known addictive and mental health properties as well as other potential health harms into the population without many safeguards or communication regarding what these harms could be. And not only that, but some would argue that it's actually good for you and that by placing the label of medicine on it, then it adds that patina of actually it's therapeutic. And so what is a physician to do, for instance, or a healthcare provider to do? On the one side of this path, they're told that this is a substance for medicinal purposes. On the other side is, well, we all know that this is a widely used recreational intoxicant. And even in some states where you have both medical and recreational legalized marijuana, you could go to the same dispensary and buy either product for medicinal purposes or quote unquote, or for recreational purposes. And what's the difference between those two products? Well, just the label. It's the same cannabis, but the way they are labeling it and the way they are taxing it is different. And it is incredibly important to know that it is not the halls of medicine that have designated cannabis as medicinal, rather it is legislators that have. And the American Medical Association, for instance, has stated, put out a statement. Cannabis for medicinal use should not be legalized through the state legislative ballot initiative or referendum process. And you have a whole host of other trade organizations, health organizations that have put out similar statements. And it is really more apt to call what we have in these medical dispensaries, not medical marijuana, but rather legislated marijuana, because that's truly what it is. It is not based on the evidence and the science for health benefits that is driving these dispensaries. So medicine, good medicine, what is a definition of a good medicine? And I found three definitions on the internet for what is a medicine. And then I developed one of my own. So a compound or preparation used for the treatment or prevention of disease. So that is one definition of medicine. Another, a substance such as a drug or potion used to treat something other than disease. Thirdly, a spell, charm, or fetish believed to have healing, protective, or other power. And then a definition that I developed myself, a label given to a substance used recreationally to decrease stigma and increase sales of the substance. If you are looking for what I would argue to be a very good definition of what is a good medicine or a true medicine, it's a compound or preparation used for the treatment or prevention of disease. And it would have to have these conditions in order to qualify for a medicine. It's rigorously tested for safety, efficacy, dosing, and purity. You need more than just a subjective experience in order to say it is a therapeutic medicine. The side effects, are they more impairing than the condition being treated? If so, you really need to examine whether or not this is a legitimate or a useful therapeutic. Does the long-term use lead to worse problems than the original condition? Are you developing an addiction? And is that addiction worse than whatever you were using the product for? Do alternative treatments exist already that are superior, even if subjectively less desirable? Can a compound be isolated or synthesized so to provide a quote unquote clean product? For example, we do not tell our patients to chew on the bark of the willow tree in order to get aspirin. We are doing the same with many of these cannabis products. And then finally, is there a risk to the population that truly outpaces the benefit to the individual And then decisions need to be made regarding what are the appropriate policies regarding that particular therapeutic. And this drives me then to what I alluded to early on in my assessment of what I am watching play out with cannabis in many of the same playbooks that I saw play out before me with the opioids, prescription opioids. So with prescription opioids, you had popular and unsubstantiated claims of benefit. That there were very scant evidence to truly recommend that this was safe to do. But however, there was a large groundswell of grassroots efforts to treat pain at all costs and to use opioids in order to do so. There was a minimization of harm. Those of us who were trying to sound the alarm at the time got labeled with names such as being opiophobic, that we were afraid of opioids. And this is really what the heart of how I understand the crux of the mistakes that were made, that there was truly a failure to understand the nature of addiction, the nature of chronic pain, and the nature of other mental illness, and how these have been compounded by the use of substances that are intoxicants, habit-forming, and cause other problems. And it was driven by strong financial motives. A lot of people making a lot of decisions, not in the best interest of patients, not in the best interest of communities, but in the best interest of their bank accounts. So we had big pharma. And then unfortunately, most physicians, even though they were probably trying to do the right thing, is that they lost their charge to first do no harm. Now fast forward to cannabis. Currently, today, you've got popular and unsubstantiated claims of benefit of all types of health benefit. You have a minimization of harm, that anyone who suggests that maybe there are severe and significant risks to consider regarding cannabis consumption are labeled cannibophobic. There's a failure to understand addiction, chronic pain, and mental illness. And instead of big pharma, P-H-A-R-M-A, now we have big pharma, F-A-R-M-A, again, a lot of decisions being made by people who are interested, not in the welfare of patients, but in the welfare of their pocketbooks. Again, physicians are neglecting to remember that their duty first is to do no harm, research, learn, and understand what is the true data, what is the evidence. And when you make a recommendation, is that, does it have the weight of the evidence behind it and what are the potential harms? Now what we have, which in the cannabis situation, which we did not have in the opioid situation is we have a large concentration of people who are very zealously advocating for legalizations for recreational purposes. We did not have that with the opioid problem. So this even further compounds this unclarity and the muddying of how we as physicians and healthcare providers are to understand cannabis as a potential therapeutic. So I described this triad of an iatrogenic epidemic with the opioid epidemic. As you know, iatrogenic means that it was an illness or a problem that was caused by medical examination or medical treatment. And what we had in the opioid crisis is you had an industry that was very powerful industry that was significantly influencing legislators to make laws and regulations to increase the likelihood of prescribing cannabis. And then you have these legislators in these industries who were also influencing medical accrediting boards to ensure that these purposes were carried out by the unwitting providers and mostly unwitting. And then, unfortunately, what we have today is the medical accrediting boards are completely out of this situation. So it's not like physicians are getting accredited through their medical boards to run these or to have any oversight of prescribing because you cannot prescribe a dispensed cannabis product. There are a couple of FDA approved medications that you could prescribe through pharmacies, but doctors are not allowed to prescribe cannabis products. They can certify and they can recommend. And so there is no regulation among the medical accrediting boards. But what is filling that spot is these dispensaries. And unlike the medical accrediting boards, which at least have a purported responsibility to protect the public, these cannabis dispensaries have no such charge and they exist to make a profit. Also, here is a picture of a dispensary that set up shop just a few miles from my office and my hospital where I am at giving this presentation. And when they built this shop, I was driving by and I noticed that there was a big neon sign of a motto in their lobby. And I thought to myself, what is that saying? So I drove up and a little closer. This is a medical dispensary, mind you. And you know what their motto was? A higher experience. Again, this is purported to be a medical therapeutic, a medical cannabis dispensary. And their motto was a higher experience. So as I mentioned at the beginning of this talk, I serve on the West Virginia Medical Cannabis Advisory Board. And there was an impassioned plea among one of the patient participants, colleagues on that medical advisory board that people are not using this substance, this product to get high. And the mere suggestion that there are people out there who are using this product, medical cannabis, for the sole purpose to get high was just unfair. However, the own dispensaries have this as their motto and their tagline. So a couple of questions I want to ask you and ask if this would make a difference in how you thought about medical marijuana. What if Anheuser-Busch sold medical beer? What if Philip Morris sold medical tobacco? Would it cause some degree of pause in thinking that this is a legitimate course of action? Well, Philip Morris, big tobacco is in the cannabis industry and also is big alcohol. And here's a website from another dispensary that is in the state of West Virginia and several other states. And I went on to their website when I knew that or when I learned that they were opening shop here in my community just to see what it was about. And so I'm going to read some of the advertisements here, but I'm going to change a word with each one of these. And I want you to think about, does this make you feel bad, uncomfortable? Something else is going on here. So Muse, everybody has a Muse. And for many, it's Xanax. Muse awakens creativity, giving you permission to let go. Sweet Talk, craveable confections infused with premium quality morphine. Get a taste of our delightful bites. You know you want some. And then these sales that they have, $35 vape carts and various products, Hayes, Headband, Blue Crush. Would you ever, in your right mind, as a clinician, recommend a medicine with the names of Headband or Red Hayes? But they always have this fine print, consult a certified physician to find out what dose works best for your condition. I would encourage any certified physician who is listening to this talk to show me and send me the evidence that you have to describe and delineate what is the right dose for a particular condition. And here is some pictures that a colleague sent to me from Florida, the Dr. Cannabis. And here you have a medical dispensary that is advertising in this fashion for their medical product. And selling such on St. Patrick's Day, you go into the bar, this particular bar, and you could book your cannabis card online. Again, a medical cannabis card online, St. Patrick's Day, go to the bar and get your medicine approved. And would we not have communities that are, and legislators and policymakers, just outraged if we had a Dr. Ritalin bus, for instance. Or we encourage those who are looking for methadone, go to your local bar and pick up your methadone dispension. Of course we wouldn't. But somehow we are allowing this to happen with cannabis. So in conclusion, what can we do? Well, the first thing I would say that we should do is try to have compassion and understanding on those who are currently using cannabis and those who are suffering from various mental illness and mental health disorders. And really try to understand why are they using, what is their, what kind of benefit are they receiving? Are they, what kind of harms? And really try to understand and try to help educate. Also not only educate the patients, but educate those people in your sphere of influence. I encourage you to read up on this, to really look for yourself. Am I saying what is true or am I being fanciful in what I've reported today? But look for yourself and with your education then, let your friends know, let your peers be somebody who can speak out to legislators and especially the media. You are the healthcare experts and you as the healthcare experts should be the one who are driving the conversation, not the industry. I would encourage you to advocate for stricter regulations in your states. So such as advocating for potency caps. This is one of the initiatives that I am trying to advance here in West Virginia. Also if you are going to have and designate cannabis as a medicine, then it should be a product just like any other controlled substance. It should be on your prescription drug monitoring program. So you should be able to, if you as a clinician are going to prescribe a controlled substance, to look and do a report and see if they are being prescribed or certified medical dispensed cannabis. Advocate for stricter regulations regarding commercialization and what commercialization does to increase and expand use, especially among our youth. Try to do whatever campaign is necessary to minimize pregnant women using cannabis or adolescents and children from using cannabis. Also let's do a better job of trying to study it. What are truly the, what are the efficacy of cannabinoids? What are the harms? What is the overdose data? What is the cannabis related to overdose data? What's the suicide rates? What are the emergency department visits? What are the hospitalizations that are associated with this, motor vehicle accidents? So really try to study this and then get this data out there. And so that we have a better understanding of how we wrap our heads around what to do regarding this in the future. And if you are a clinician, then I encourage you to be as specific as possible when you are taking your histories with a patient is ask and document what product are you using? What is the route? Do you know the potency? How frequently are you using? How old were you when you first started using? I want to give a couple of thanks to Elizabeth Stout, Keith Humphreys, and Stu Gitlow who have been very helpful for me as I've thought about a lot of these issues. And these are some of your colleagues. And then also want to put a plug in for Cannabis in Medicine, which is a very comprehensive evidence-based approach to Cannabis in Medicine by Ken Finn, who is the editor. Here also is an article that came out last year that I thought really resonated with much of my fears and what I've been seeing with Cannabis in relation to the opioid epidemic. And this is how we became the new Oxycontin in Tablet Magazine, August 30, 2022. It's a popular piece, but it's worth reading. And if you think it's of value, send it to those in your circles. So with that, I thank you and really appreciate the opportunity to share this information to you.

Mental Health

Opioid Epidemic

Cannabis

Medicine Qualification

Deaths of Despair

Substance Use Disorders

Opioid Crisis

Cannabis Potency

Mental Health Issues

Cannabis Classification

Stricter Policies