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Dr Adam R Winstock Consultant Psychiatrist & Addic9on Medicine Specialist Honorary Reader University College London Founder & Director Global Drug Survey
Cannabis – and the waH of change Glasgow June 2016
DrAdamRWinstock2015
Loads of this stuff is on our
Lotsofthisstuff&dataisonourwebsitewww.globaldrugsurvey.com
andGDSYouTubeChannel
GLOBALDRUGSURVEY
• GDS2012:15,500• GDS2013:22,000• GDS2014:77,000• GDS2015:100,000• GDS2016:100,000• GDS22017:target250,000Ifyouwanttojoin…ask
Werunthebiggestdrugsurveyintheworld
DrAdamRWinstock2015
1. WinstockA,LynskeyM,BorschmannR,WaldronJRiskofseekingemergencymedicaltreatmentfollowingconsumpQonofcannabisorsyntheQccannabinoidsinalargeglobalsample.JPsychopharmacology2015
2. FreemanTP,WinstockAR.ExamingtheprofileofhighpotencycannabisanditsassociaQonwiththeseverityofdependencePsycholMed.2015Nov;45(15):3181-9.doi:10.1017/S0033291715001178.Epub2015Jul27.
3. WinstockANewhealthpromoQonforchemsexandγ-hydroxybutyrate(GHB)..BMJ.2015Nov25;351:h6281.doi:10.1136/bmj.h6281.Noabstractavailable.
4. Hindocha,Chandni,etal."Vapingcannabis(marijuana)hasthepotenQaltoreducetobaccosmokingincannabisusers."AddicQon111.2(2016):375-375.
5. Stevens,A.,Barrag,M.,Lenton,S.,Ridout,M.,&Winstock,A.(2015).SocialBiasinthePolicingofIllicitDrugUsersintheUKandAustralia:FindingsfromaSelf-ReportStudy.AvailableatSSRN2618393.
6. Shiner,Michael,andAdamWinstock."Druguseandsocialcontrol:ThenegoQaQonofmoralambivalence."SocialScience&Medicine138(2015):248-256.
7. Winstock,Adam."CannabisregulaQon:theneedtodevelopguidelinesonuse.BMJ348(2014).
8. WinstockAR,KaarS,BorschmannRDimethyltryptamine(DMT):prevalence,usercharacterisQcsandabuseliability.JPsychopharmacology2014
9. BarragMJ,FerrisJA,WinstockARTheuseoftheSilkroad,theonlinedrugmarketplace,intheUK,AustraliaandtheUSA.AddicQon2014
10. WinstockAR,BarragMJSyntheQccannabiscomparisonofpagernsofuseaneffectprofileswithnaturalcannabisDrugandAlcoholDependence2013
11. WinstockAR,BarragMJThe12monthprevalenceandnatureofadverseexperiencesresulQnginemergencymedicalpresentaQonsassociatedwiththeuseforsyntheQccannabisproducts.HumanPsychopharmacology2013Global Drug Survey GDS2015©
SomerecentpublicaIonderivedfromGDSresearch
Not to be reproduced without authors permission DrAdamRWinstock2015
What would the outcomes of successfully incorporated self regula9on look like? GDSwantstomakedrugusesaferregardlessofthelegalstatusofthe
drug
GLOBALDRUGSURVEY
Cannabis in Scotland – GDS2015 (n > 450 users)
Global Drug Survey GDS2015©
Not to be reproduced without authors permission
Days used in the last 12 months Method of use 2.3
19.9
19.3
17.8
40.6
1 2-10 11-50 51-100 Over1000 10 20 30 40 50 60 70 80 90
Blunt
Bucketbong
Food
Bong
Vapouriser
Pipe
Joint
Withtobacco Withouttobacco
DrAdamRWinstock2015
Most used 0.5-1gm /day; 3-4 joints /gm
DrAdamRWinstock2015
Cannabis – Sought Emergency Medical Treatment in Last 12 Months
Global Drug Survey GDS2015©
Not to be reproduced without authors permission
1.0
1.3
1.0
0.6
1.00.8
1.21.0
1.3
0.9
0.4
1.5
1.0
2.0
0.6
1.31.4
1.1
0.0
0.5
1.0
1.5
2.0
2.5
%Lasty
ear
users
Global EMT rate was 1.0%
DrAdamRWinstock2015
Cannabis – Global Emergency Medical Treatment Seekers (N=434)
Global Drug Survey GDS2015©
Not to be reproduced without authors permission
Preparation of cannabis used (%)
50.9 34.4
13.4
1.2 High-potency / hydroponic Herbal Resin / hash Butane hash oil
Symptoms presented with
0 10 20 30 40 50 60 70
Bladder/kidneyproblemsAggression
Seizures/fitsInabilitytotalk
AccidentAuditoryhallucinaQons
VisualhallucinaQonsNausea
ExtremesweaQngMoodproblems
ChestpainsAgitaQon
BreathingdifficulQesParanoia
FeelingscaredAnxiety
%
DrAdamRWinstock2015
1) So most people who use cannabis are pre_y OK with their cannabis – though most could use more safely 2) Quite a few cannabis users would like to use less, reduce their risk of harm and would benefit from a li_le support 3) 10-15% are probably dependent and would probably be be_er off using less / stopping though they might need a nudge to see this 4) 5-10% might benefit from a medically assisted detox 5) 10-20% may need some psychiatric/psychological support 6) Almost all could do with stopping smoking tobacco 7) For a minority can cause serious mental health harms
DrAdamRWinstock2015
Those with mental illness/young are different - vulnerable
UOK
Less Stop
Change
DrAdamRWinstock2015
HarmreducQon
• Saferusestrategies–mostacceptablewhereminimalimpactonpleasure/cost
DrAdamRWinstock2015
HarmreducQon
• Saferusestrategies–mostacceptablewhereminimalimpactonpleasure/cost
Reducinguse
• Cuongdown/reducinguse–amount/frequency/Qmestoned/increasenondrugacQviQes
DrAdamRWinstock2015
tobacco/vaporizer
amount/frequency‘tbreak’
hours/daynotstonedDrAdamRWinstock2015
HarmreducQon
• Saferusestrategies–mostacceptablewhereminimalimpactonpleasure/cost
Reducinguse
• Cuongdown/reducinguse–amount/frequency/Qmestoned/increasenondrugacQviQes
Stoppinguse
• PreparingforcessaQon/withdrawalmanagement/maintainingabsQnence/assessing/treaQngco-morbidcondiQons
DrAdamRWinstock2015
The waH of change
DrAdamRWinstock2015
• TheimpactofhigherpotencycannabiswilldependinpartontheTHC/CBDraQoandwhetherusersareableandwillingtoQtratetheirconsumpQonastheymightalcohol.
• EvidencesuggestuserswilluselessandinhalelessdeeplybutoverallstrongerpreparaQonsleadtohigherTHCconsumpQon….andproblems?
DrAdamRWinstock2015
Doeswhatyousmokemakeadifference?
DrAdamRWinstock2015
DrAdamRWinstock2015
• ROUTE• Routeofusemodifiesmanythings• Speedofonsetofeffect• DuraQonofeffect–abilitytoQtratedose• Bioavailability/waste• Oralvsmoking• Oral–nowastebutleadstoproducQonofsecondaryacQvemetabolitesandatwophasesequenceofintoxicaQon
• PassagethroughwatercoolssmokebutremovesTHCDrAdamRWinstock2015
Cannabis is the gateway drug
n Cannabis appears to increase tobacco use
n Cannabis use associated with poorer outcomes for tobacco smoking interven9ons
n Tobacco use associated with poorer substance abusing treatment outcomes*
n Worse withdrawal from both either alone
n Func9on , culture and economy – hard to challenge * Stuyt 1997 Am J Addict, Budney et al 2007
DrAdamRWinstock2015
Water pipes and bongs are not safer
• The use of water pipes or bongs which some believe are safer because they cool and filter smoke of toxins may be erroneous since they filter out more THC than they do tar resulting in greater tar delivery to the lungs (Gieringer 2001).
• If a person smokes the safest methods are either using a unfiltered joint without tobacco or a vapouriser which heats the plant material releasing the THC as a vapour but avoiding combustion (EMCDDA monograph 2008).
DrAdamRWinstock2015
DrAdamRWinstock2015
StarIngpoint- geOngstonedcanbenice
• EffecQveharmreducQonapproachesthatleadtochangeintherealworldneedtooccurthroughadialogue–andexchangeofideasandknowledgethatstartswithrespectforthechoicesofindividuals–someofwhomchoosetogethigh.
• Forthosewhogethigh,enjoygeonghighandconQnuetolivealifethey/othersarecontentwithouraimistominimizeriskofacuteandlongertermhealthharmsandpreventthelossofcontrolthatleadshappyusetodependent/problemaQcuse
• ForthoseforwhomcannabisisamajorproblemsorprobleminonepartoftheirlifeweneedtofocusmorebroadlyontheulQmateformofriskreducQon–cessaQon
DrAdamRWinstock2015
DrAdamRWinstock2015
Adam Winstock
ALREADYDOWNLOADEDOVER10,000TIMES
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DrAdamRWinstock2015
Harm ReducIon: suggestions
* Don’t mix with tobacco * Don’t hold smoke in lungs – don’t get more stoned but will increase tar and
carcinogens in contact with lungs * Don’t inhale too deeply – sucking on a bong or using a bucket may cool smoke but will
also force smoke deeper into lungs * Remove stalks, leaves etc * Don’t use a cigarette filter – will reduce cannabis/tar ratio 30% less cannabis; 60%
more tar * Don’t use too many papers (hemp v tree?) * Clean bong/pipes thoroughly * Don’t use plastic bottles/pipes/aluminium foil etc as can increase toxic fumes. * Buy a vapouriser DrAdamRWinstock2010
takenfromromthedrugsmeter
preparaQon
DiaryCutdownReducetobaccoNRTPsych-educaQonDealers/mates/$$Family
withdrawal
NightsedaQonAnxiolyQcs?SleephygieneTobacco–NRT
relapseprevenQon
Group1:1DiarySleephygieneTobacco–NRTMood/psychdisorders
QUITATTEMPTS/DETOX
DrAdamRWinstock2015
Firststepcutdown
• Smallerspliffs–smallerskins• Lesscannabis/spliff• Putthespiffout• LesscaffeinetopcompensateforsedaQon
• Limitaccess/Qmetosmoke–nonsmokingacQviQes
• DelayfirstQmetofirstspliff
DrAdamRWinstock2015
UnIlwehaveanevidencebaseandaccesstomeds..whatdowedotohelp?
• Does it ma_er……? • Psycho educa9on and CBT/MI first line • Consider abuse liability if meds are used • Timing and dura9on of treatment • Consequences of cessa9on on other diseases / prescribed
medica9ons efficacy/toxicity • Situa9onal factors • The role of in pa9ent
DrAdamRWinstock2015
Typicalregime
• 4-7days• Diazepam5mgt.i.d• or• Zopiclone7.5mgo.d• +/-NSIADs/paracetamol/anQ-emeQc• Caffeineavoidance• Sleephygiene• NRT
DrAdamRWinstock2015
Sleep
• Sleep hygiene • Rebound REM • Dreams • Caffeine • Alcohol subs9tu9on • Sleep management advice
DrAdamRWinstock2015
WithdrawalmanagementsummaryAdvise gradual reduc9on in amount used prior to cessa9on.
Suggest delaying first use 9ll later in the day
Suggest pa9ent considers use of NRT if planning to stop independent tobacco use at same 9me.
Advice on good sleep hygiene with avoidance of caffeine that may exacerbate irritability, restlessness and insomnia.
Relaxa9on, progressive muscular relaxa9on, distrac9on
Psycho-educa9on for user and family members as to nature, dura9on and severity of withdrawal.
Cue and trigger avoidance
Symptoma9c short term medica9on provision of analgesia and seda9on if required.
If irritability and restlessness marked consider limited provision of very low dose diazepam for 3-4 days
DrAdamRWinstock2015
ACUTE HARMS EASY TO UNDERSTAND AND QUITE POSSIBLE TO AVOID FOR MOST
DrAdamRWinstock2015
What % of people had sought emergency medical treatment following the use of drugs/alcohol in the last 12 months ? (global)
1.21
3.5
0.6
2.2
0.9
0.5
1.8
1.1 1
3.2
0.6
2.3
0.7
0.3
1.8
1.31.1
3.4
0.7
2
1.3
1
1.9
0
0.5
1
1.5
2
2.5
3
3.5
4
Alcohol Cannabis SyntheIcCannabis Cocaine Researchchemical MDMA/ecstasy Ketamine Anydrug
EMTlast12months Male Female
LASTYRUSERSN>90K>41K>1.2K>15K3.8K>23K>4.3K>100K
Global Drug Survey GDS2015©
Not to be reproduced without authors permission DrAdamRWinstock2015
Potency
• MostmanyQmesmorepotentfullreceptoragonistatCB1receptors–maymodulateothersystemse.g.opioid/serotonergic
• Some100sQmesmorepotentthanTHC• ImpactuponacQvityincludepsychoacQvity,analgesia,anQ-seizure,weight-loss,anQ-inflammatory,andanQ-cancergrowtheffects.
• VariableproductcomposiQonmeansonejointcanvaryfromthenextfromthebradedbatchbyafactorof10ormore
DrAdamRWinstock2015
FIGURE.NumberoftelephonecallstopoisoncentersreporQngadversehealtheffectsrelatedtosyntheQccannabinoiduse,byweek—NaQonalPoisonDataSystem,UnitedStates,January–May2014and2015
3,572callsrelatedtosyntheQccannabinoiduse,a229%increasefromthe1,085calls
M>>FMid20sSeveritygreaterwithincreasingagePolyuse
20%byingesQon
DrAdamRWinstock2015
What % of people had sought emergency medical treatment following the use of drugs/alcohol in the last 12 months ? (global)
1.21
3.5
0.6
2.2
0.9
0.5
1.8
1.1 1
3.2
0.6
2.3
0.7
0.3
1.8
1.31.1
3.4
0.7
2
1.3
1
1.9
0
0.5
1
1.5
2
2.5
3
3.5
4
Alcohol Cannabis SyntheIcCannabis Cocaine Researchchemical MDMA/ecstasy Ketamine Anydrug
EMTlast12months Male Female
LASTYRUSERSN>90K>41K>1.2K>15K3.8K>23K>4.3K>100K
Global Drug Survey GDS2015©
Not to be reproduced without authors permission DrAdamRWinstock2015
Symptom profile in emergency treatments seekers Winstock et al 2015
59.5
81
35.1
61.9
21.6
47.6
29.7
38.1
8.1
33.3
16.2
33.3
8.1
19
8.1 9.5
16.2
38.1
16.2
33.3
0
10
20
30
40
50
60
70
80
90
Cannabis SyntheIcC
ChartTitle
Panic/anxiety Paranoia AgitaQon Breathlessness Audhalls Visualhalls Fits Aggression SweaQng Chestpain
SCusersalsoreportedagreaternumberofsymptomsthancannabisusers,suggesQngincreasedsymptom-clustering.DrAdamRWinstock2015
CANNABIS SC
N % N %Hospitalised 18 48.7 10 47.6
TimetoRecovery6hours 15 40.5 10 47.6
12hours 5 13.5 1 4.824hours 6 16.2 2 9.548hours 2 5.4 0 0.072hours 1 2.7 0 0.096hours 1 2.7 2 9.51-2weeks 2 5.4 0 0.02-4weeks 1 2.7 1 4.8>4weeks 3 8.1 2 9.5Notyet 1 2.7 3 14.3
TOTAL 37 100 21 100
ODDLY For both cannabis and SCs no difference in the prevalence of EMT among those who had a mental health diagnosis (0.95%) and those who did not (and no difference was observed in EMT prevalence according to being in current receipt of a mental health prescription or not. Winstock et al 2015
DrAdamRWinstock2015
The risk of seeking emergency medical treatment is at least 30 x 9mes greater aHer taking synthe9c cannabis products than natural cannabis (Winstock et al J Psychopharmacology 2015)
DrAdamRWinstock2015
Common acute medical presenta9ons AgitaQonAnxiety/panicTachycardia/increaseBPChestpainShortnessofbreath/depressedbreathingDrowsinessorlethargyNausea&vomiQngMuscletwitchesHallucinaQons/paranoiaSeizuresSuicidalideaQonViolenceaggression
10%severe/life-threatening50%requiresomesortoftreatment40%mildtransient
DrAdamRWinstock2015
Acute management - control and minimize the risk
• SymptomaQcmanagementwithmedicaQons/behavioralcontrol• Seizures• Violence–riskofharmtoselfandothers• Labilebloodpressure• OverheaQng/vomiQng&dehydraQon• ConsidersyntheQccannabinoidwithdrawalandmanagingitinthoseadmiged
• Considerotherunderlyingmedical/psychiatriccondiQonsandothersubstances
• InvesQgaQons–sampleofthedrugforfutureanalysis,bloodsamplesforrenalandliverfuncQon
• Psychiatricadmissionandassessmentwhererequired• Followup–medicaQonreview,relapseprevenQon,behavioralsensaQon
DrAdamRWinstock2015
Fatali9es CardiacLiverKidneyTrauma
DrAdamRWinstock2015
DrAdamRWinstock2015
BiggestmoQvaQonfortheiruseisPRICE(GDS2015)
DrAdamRWinstock2015
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Global Drug Survey GDS2014©
Not to be reproduced without author’s permission
Drugs Meter
DrAdamRWinstock2015
Global Drug Survey GDS2014©
Not to be reproduced without author’s permission
Drugs Meter
DrAdamRWinstock2015
Global Drug Survey GDS2014©
Not to be reproduced without author’s permission
Drugs Meter
DrAdamRWinstock2015
Global Drug Survey GDS2014©
Not to be reproduced without author’s permission
Drugs Meter
DrAdamRWinstock2015
Global Drug Survey GDS2014©
Not to be reproduced without author’s permission
Drugs Meter
DrAdamRWinstock2015
Winstock A 2014DrAdamRWinstock2015
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