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Treating Patients Who Have Made Cannabis Their Medicine

August 19, 2020

By Andrew Penn, RN, MS, NP, CNS, APRN-BC
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“I tried trazodone, zolpidem, and quetiapine for sleep, but none of them really worked, or they left me hungover the next day. I found that a couple of puffs off a cannabis vape worked better for my insomnia than anything else and I am happy with that.”

“I tried gabapentin, pregabalin, and nortriptyline for my fibromyalgia and chronic headaches. None of them really worked, but I noticed when I started using a little cannabis tincture, my pain went down, and I had less problems with my IBS.”

“The escitalopram has helped with my anxiety, but I’m noticing the CBD gummies have really helped reduce the remaining anxiety symptoms.”

Have you had patients like this? I certainly have. As more and more states (42 at last count) have lifted some, if not all, restrictions on cannabis, and the federal government has removed some cannabidiol (CBD) products from Schedule I, more patients are exploring the medicinal aspects of cannabis for their psychiatric conditions. Many of these patients are presenting to their psychiatric providers already convinced of the benefits of their cannabinoid self-treatments.

This year at Psych Congress, I’ll be giving a talk called “When the Patient Has Decided That Cannabis Is Their Medicine” on this challenging clinical quandary. Some clinicians respond to patients by saying that cannabis is always a problematic drug. I will show them where they are likely wrong. Other clinicians think that cannabis is only beneficial. I’ll present evidence that highlights the patients most likely to be harmed by this drug.

Many colleagues have shared with me that while cannabis is one of the world’s most commonly used drugs, they have received very little education about the pharmacokinetics of cannabinoids and how they interact with the human endocannabinoid system. They have admitted to me that they know more about citalopram than they do about cannabis.

In my talk, I’ll review the fascinating role of the endocannabinoid system and how it helps to fine tune other neurotransmitter systems through retrograde signaling, as well as how exogenous cannabinoids like CBD and tetrahydrocannabinol (THC) interact with the cannabinoid receptors. I’ll review two cases drawn from my practice to look at how patients have used cannabis successfully, when the cannabis use has exacerbated their psychiatric issues, and how we can use shared decision-making, harm reduction, and motivational interviewing to help patients who are exhibiting problematic cannabis use. I’ll also examine cannabis dosing, drug interactions, and possible risks, to help attendees become the sophisticated clinicians that today’s patients need us to be.

When the Patient Has Decided That Cannabis Is Their Medicine” will be presented at 10 a.m. Sept. 13, 2020. Psych Congress 2020 is being held virtually Sept. 10 to 13, 2020, with a preconference Sept. 9, 2020.

Andrew Penn, RN, MS, NP, CNS, APRN-BC was trained as an adult nurse practitioner and psychiatric clinical nurse specialist at the University of California, San Francisco. He is board certified as an adult nurse practitioner and psychiatric nurse practitioner by the American Nurses Credentialing Center. He has completed extensive training in Psychedelic Assisted Psychotherapy at the California Institute for Integral Studies and recently published a book chapter on this modality in The Casebook of Positive Psychiatry, published by American Psychiatric Association Press. Currently, he serves as an Associate Clinical Professor at the University of California-San Francisco School of Nursing, where he teaches psychopharmacology, and is an Attending Nurse Practitioner at the San Francisco Veterans Administration. He has expertise in psychopharmacological treatment for adult patients and specializes in the treatment of affective disorders and PTSD. As a steering committee member for Psych Congress, he has been invited to present internationally on improving medication adherence, cannabis pharmacology, psychedelic assisted psychotherapy, grief psychotherapy, treatment-resistant depression, diagnosis and treatment of bipolar disorder, and the art and science of psychopharmacologic practice.

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