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

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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

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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

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BiggestmoQvaQonfortheiruseisPRICE(GDS2015)

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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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