topic and now it looks introduce our featured speaker over there is dr kevin hill he's the director of addiction psychiatry at israel deaconess medical center and assistant professor of psychiatry at harvard medical school here a masters in health science at the robert wood johnson clinical scholars program at the yale school of medicine he treats patients with substance abuse disorders and a variety of cannabis and his book marijuana the unbiased truth about the world's most popular weed is a popular and valuable resource for he consults on cannabis related issues to policy makers and prominen all right well thanks for that welcome i appreciate it always great to be back in belmont spent a number of years working here so like the town quite a bit and it's great to be here and have such a good turnout so we're going to cover a lot of ground but i do want to make it clear that we're going to focus really on the science tonight so i know that in massachusetts obviously we have medical marijuana policies in place for over five years now i know that obviously recreational cannabis was legalized recently too and that's going to be implemented quite soon and so you have decisions to make about how your town is going to handle that but we want to focus today on really the risks and benefits what does the science say when it comes to the risks of using cannabis today of using cannabis in a regular way what are the benefits for cannabis in terms of medical you know what what are there are really reasons to use this and what is the evidence that there are so that's really going to focus on you have my contact information there obviously feel free to think of me as a resource moving forward on this terms or disclosures of been funded by the end i h the national institute on drug abuse which is a branch of the united states have a current grant from the world health organization to cover the therapeutic use of cannabis and then i have a book that you can check out it's been out for a number of years now on marijuana really i think it's important to state first and foremost that when you think about what you've heard about cannabis until this point a lot of what you heard frankly is either incomplete or just flat out untrue in the reason for that is because when you and about who you have heard information about can from these are folks that have political agendas so they have skin in the game for you to vote one way or another on these issues and so as a results we have really two distinct camps when you think about cannabis you have people who are strongly pro cannabis so they believe that there are this many medical indications for cannabis they often believe that more or less cannabis is a harmless drug and then on the other side you have people who probably well meaning but they essentially will relay the message that if you use cannabis you're doomed and so those are extreme views and neither of them are really accurate in many ways and so i would encourage you as we're going to talk about tonight to be evidence based and try to be balanced and be open minded to looking at the evidence on this issue i think that that's really critical to do that so i'm a clinician first and foremost so that's another piece when you think about who you hear about risks and benefits of can from think one question asked of me what type of experience does a person have in terms of making those statements making those judgments so i treat patients in a variety of settings i am the head of addictions cadre now at beth israel deaconess medical center in a division that was largely created in response to the opioid crisis so that's kind of another topic but you know again that's something that we don't want to you know but want to downplay in any way i mean we're in the state of an epidemic frankly in the commonwealth and across the country too and so one question that we could possibly address tonight if you wish to think about how cannabis might play a rule in that crisis i have a private practice i see a lot of patients i think everybody that treats addiction sees a lot of patients with opioid use disorder the whole used to sort of this point but i have a sort of a niche where i see a lot of relatively young folks who use cannabis a probably fifteen to twenty five parents or teachers find out if they're using or says spec that they're using they bring them in to see me and then finally if you're a sports fan you know that drugs in sport are ubiquitous and so i've worked with some local and some leagues local teams in leagues as well both treating patients who happen to be athletes but also helping some of these leagues make their cannabis policy the second boy at what i've spent a number of years doing is really trying to develop treatments for that subset of people so one of the things that we're going to see tonight is that most people who use cannabis never need to see somebody like me they never have an addictive disorder but for that group that does i really would like there to be a treatment that works at least one and so we'll talk about that so i spent a fair number of years trying to develop either pharmacotherapy zur behavioral interventions for that group and then finally the last bullet educational research we're doing here i'm a firm believer of that as a field and we in the medical profession really don't do a great job of  outreach unfortunately and so it's a very very difficult for those of us in the field to keep up with the latest research and the latest literature however when you think about a parent or a family that may be worried about their young person their child using cannabis or using opioids or any drug when you think about that type of scenario how would they ever know what to do when you when you think about all of the myriad options there are terms of treatment so i think we need to do a better job and i spent a lot of time over the last twelve years trying to do that particularly with cannabis there's a tremendous gap to bridge between what the science says and what the public perception is and that really shouldn't be that way so do work in schools  belmont high school before been all over the place middle schools high schools colleges that cetera and also try to influence policy makers where possible and sometimes is easier to do in certain states and countries than other play but  success in some you know some sometimes it's been a little bit more difficult but we certainly try so we think about canada's i think it's important to think about what the trends are and so i think you have a sense of being in a state a blue state that has all of these policies we have decriminalisation we have medical got legal cannabis at this point i think you have an idea of where the country is going and certainly the country when you think about cannabis use the enormous numbers of people using cannabis so over twenty two million in the last year that represents a doubling over the past decade or so and very very powerful messages again as i said at the top a lot of that has to do with the fact that people are trying to get you to think about this in one way or another to try to sway your your activity in the ballot box shall we say and so unfortunately when you think about that there are people who have the tendency to distort evidence you know so that's when we think about the policies that's one piece celebrities or another so as much as i'm grateful for all of you to come out tonight if justin bieber decides to say anything about cannabis tonight he's going to reach a lot more people than on going to so so that's a very powerful tide to come back in and i think it's worth doing because i think it's critical i think a lot of people out there really want to know is you do you want to know and perhaps have a sense for the idea that maybe all that we've heard isn't quite right because people are trying to get you to think about it one way or another this slide here i think is very important really for two reasons i think number one to have an idea about the relative addictive potential of cannabis compared to other substances that you're more familiar with and then number two to think about how i would advise you to think about talking about this if you were to talk with your child or somebody that you care about who may have a problem with cannabis so the reality is most people who use cannabis don't develop an addictive disorder so it's about nine percent of adults so one in ten more or less with young people the percentages are higher so that's one of the main take home points tonight there's a different level of risk for young people so your brains develop in your mid twenty's or so so about twenty five so for some of us you know there's still hope for the rest of us like me it's over you know but i think that it is very important to think about the difference of there because what you do when your brain is developing is it will see sort of under construction is one way to think about it what you do is so critically important and so when you think about that the percentages are higher for young people so about one six and so as i like to say if i had in the front row here we have a few seats still vailable six fifteen year old kids using cannabis only one of them will go on to develop an addiction to can or another substance but i can't tell you which one it's going to be so that predictive piece is really not available to us one of the things we've always tried to do in substance use disorders try to be able to better predict who's going to have a problem and we really can't do that with the level of granularity that we really would like to have at this point so as i say if you suspect that your teenager let's say is using or you fine paraphernalia and you know that they're using you need to bring the cavalry at that point because you can't predict for sure who's going to go on and just pass through a phase who's going to go on to do something in a more significant way than they might be already i also think it's critical to think about cannabis just to be thorough in to be balanced about it to understand this idea that cannabis probably not as addictive as other substances as we can see here if you look at fifteen percent or so heroin we've got all the way on the right so o ids heroin depending on which data you look at in the twenty's or thirty percent of users will develop an addictive disorder so that's much higher i also think that one thing that comes up a lot in these debates about cannabis is a comparison between cannabis and alcohol and then also opioids and so the way i like to think about this is i do welcome the comparison between cannabis and alcohol in particular and i think that as i've said a couple of times most people who use either of those substances don't develop a problem however i think the major difference between the two is that as a society we all recognize that alcohol is dangerous everyone of you knows the risks associated alcohol doesn't mean that you might not make a choice to use it or some people develop a problem with it but the main difference though is that if we were to have a group of young people hear their thoughts about cannabis would be far different their understanding of the wrists would not be to the level tha it is for alcohol we'll talk more about that in a minute i think that's a critical difference once we introduce opioids into this that's really the street people are dying every day and we actually have multiple people in our commonwealth dying every day as a result opioids so one thing that often comes up in this debate is this idea that cannabis is not as bad as these other substances so here's here's the truth about it when you think about the risk associated cannabis in these arguments are talking about extremes of talking about mortality dying overdose that sort of thing so when you hear people say no one's going to overdose on cannabis they're talking about they're not going to have a fatal overdose on khamis and that's actually true doesn't mean that you can't end up making bad choices you can't get in your car in a passing a fatal motor vehicle accident but you're not going to have an overdose related to the amount of cannabis that you ingest that day so that is actually a true statement and so one of the things that is a sort of controversial piece and some people disagree with me about who again are well meaning but trying to steer people away from cannabis i think it's ok to think about these three substances together so can alcohol and opioids so on the whole when we're talking about the extreme risk mortality cannabis on the whole is not as dangerous as alcohol is which in turn alcohol is not as dangerous as opioids where you can have a fatal overdose on any given day however i think it's fair to understand that while cannabis is not as dangerous as alcohol which in turn is not as dangerous as opioids doesn't mean that cannabis is not dangerous ok so that's kind of a subtle point that some people don't even want to engage in so deep some people who are opposing camps they don't even want to talk about that i think you have to i think you have to because kids know young people are are gaging in that kind of conversation it's one of the most common pro cannabis statements there is that you're not going to overdose and i think it's ok to acknowledge that while still acknowledging what the real risk is there is still real risk there and so that that kind of thought to me degrees of danger when you think about this in real terms another critical point when we think about the risk associated with cannabis as sort of where we stand right now as a society as we have twenty nine states and the district with medical cannabis policies we have eight states in d c with legalized recreational cannabis so in the context of that as we see here use among young people so here's another point that's often  distorted but use among young people is relatively flat so despite all these policies uses flat however the chilling piece to this is this focused as well as it could be let me know if you don't think it is but i might be a little bit close to it but this is important when you think about despite the fact that the use among young people is relatively flat this is survey data from the monitoring the future survey comes out anyway from the university of michigan but the the risk so perception of risk among young people is dramatically declining over the last several years so to me that puts us in a precarious scenario so we have more and more states sort of loosening their belts when it comes to canada's policy there's more permissive cannabis policy however you want to slice it that's going to continue we're going to have more and more states with these policies and as that is occurring i think it's essential for us to have our young people know exactly what the are so again doesn't mean they're not going to experiment doesn't mean they're not going to do this but they have to know what the risks are you have a question this is a national population yes another point that i like to make is we see the perception of risk declining when young people here in the march from the future date is that if we were to plot perception of risk for two other commonly use substances among young people nicotine and alcohol we wouldn't see this because all kids know that smoking is bad for them they all know that alcohol is a risky behavior doesn't mean that some of them are going to engage in these behaviors but to me that underscores this idea that we do a poor job of educating young people about cannabis largely because it's such a polarizing topic there's so much aspect of around it like we've heard right people are afraid like if root talk about this in real terms you know we might give kids the green light to use and so as a result a lot of the educational programs really end up a couple of things happen when you think about schools for the most part number one nothing happens so if people are worried about taking time away from preparing for the standardized testing for which schools are judged upon it's hard to take time to talk about substances although you know some schools do a lot of schools do and then sometimes when they do take that time they're using scare tactics that have been proven not to work frankly and so that people mean well but if you're not talking about this in a sensible way i don't think it's going to work out very well so if i were to have you know and i've been in many of these rooms if we have cup laundry of young people here and i'm railing against them talking about how if you use cannabis you're doomed five minutes later everybody's looking in their phones and it's all over right so you lose credibility so to me when you think about the idea that everyone's aware of the nicotine risk everyone's aware of alcohol risk in they don't for cannabis it just says that we can do better we've done it before we've educated well about these other substances but we're not doing a good job when it comes to educating young people about cannabis so i mentioned earlier a lot of aspects of the controversy why is that why why is it such a hot topic  think the first piece is that people are trying to make this black or white right i want you to vote for this i want you to vote against it and i'm going to make every single argument i can tell the total extreme anything that i say that might open the door for the other side is just hurting you know my agenda so that's part of it i think the american way is to try to oversimplify things right we we like things black or white good or bad that's not the way that it is with this all right you have to be comfortable in the middle when it comes to can issues a lot of the answers that we're getting with the research that we're doing they're not the answers that we expected good in me i mean what i've done studies published papers had hypotheses you know figured that cannabis would affect treatment in certain ways for other addictive disorders and it didn't turn out that way so i think you have to be open minded about it and i would ask you if you have people that you think are reliable as educators about cannabis i would ask you this that if a piece of evidence comes out in a journal that runs counter to what they believe are they would change their mind or are they going to try to poke holes in a paper that comes out in a major journal i think you really need to be careful when you think about that people are misguided by their own experiences so a lot of people out there have used cannabis obviously as we talked about before twenty two plus million americans a lot of them have used cannabis years ago when it's nothing like what is available today we'll talk about that and then finally math can be tricky right so we feel we've seen numbers tonight already talked about twenty two plus million americans doubling over the past ten years so if only nine percent of adults develop a can of this use disorder so as i like to say a small of a large number can be a large number and it is in this case so ninety nine percent of twenty four million we're talking about millions there are millions of americans who do need to see somebody like me there using cannabis every day multiple times a day to the detriment of key areas of their lives work school relationships those are the people that we actually see in a program like mine so math can be tricky when you think about that most people don't have those problems most people aren't aware that you can have those problems that is why i think that the numbers do stay a little lower than they probably would otherwise because let's face it if you're you know fresh out of college and you're living in allston let's say with a bunch of roommates and you're using cannabis regularly and you start to think well you know what maybe this is holding me back maybe i'm not doing as well as i should be doing but your other three roommates that you're with they're all smoking every day too and they don't think that it could be an addictive process you know that cannabis is not addictive of course then you're probably less likely to talk to them about it or anybody about it if you've you're not even sure if this could be a problem is this a fame is being addicted to can this really a thing patients have that happen i mean i've seen it many many many times so it's even harder for people who do have a cannabis use disorder to come out into the light nationally get treatment because of the way that we think about this drug as a society so as i mentioned there are many myths that are perpetuated for a variety of different reasons i like to think about really three of them not harmful not addictive no withdraw all you know so there are really three key pieces and so we talk about the harms we talk about what can happen to people when they use usually regulate but you can have problems today so you can again get your car have bad things happen you could have just your judgment impair by cannabis get in a situation that you would otherwise get into but most of the problems that we talk about with cancer talk to people who are chronically users using every day multiple times a day addictive i think we'll talk about that obviously it is addictive you know most people don't develop an addiction to it but it is addictive you have that potential and then withdraw that's another piece that is not talked about a lot is probably not as relevant for a group of  are not treating patients every day but the idea is that if you are using cannabis every day multiple times a day and you try to stop you actually have physical symptoms in those symptoms when we think about other drugs like nicotine or opioids those symptoms of withdrawal are what get people to continue to use that happens with cannabis as well but i think one of the things i was asked to talk about really the implications upon youth and so as i mentioned earlier brains are developing your mid twenty's so the level of risk is much more significant what happens in that period of development is so critical and i think that's something that a lot of stones and states have really tried to russell with this idea one receptor in particular is located in a variety of places but there are many stevie wonder steppers in the brain so when you think about cannabis and its effect upon the brain you have of variety different effects there so again your frontal lobes judgment is of is affected obviously if you're continuously using hippocampus has to do with memory so that's something that i think people are common with commonly associated with cannabis use that if you're you know if you used today your short term memory could be affected but certainly if you do that over time cerebellum has to do with balance so i mean the fight or flight response is fear so can this affects variety different pieces of the brain and so when we think about the long term effects there are many but i do want to say something that isn't often talked about when people talk about the adverse effects the harmful effects of cannabis one piece that is often not brought up because people feel like it's not going to help their cause is this idea that the dose really makes a difference how much you use over what period of time is critical there is a big difference between somebody who is using three times a day six days a week seven days a week and somebody that's using once a week once a month people don't want to talk about that these effects that we're going to talk about and second these are people who are using regularly in a lot of cannabis so most people who are using these days they're not using in this way i think it's just critical to be open and honest about that so a lot of bad things can occur if you do take it to his extreme at this point most people have not done that but there's a risk there so if you're using early in a regular fashion so generally starting and using regularly before sixteen you can have cognitive problems of some of the imaging studies that have been done more or less show that a healthy control not using cannabis compared to a young person using cannabis regularly that person is using cannabis will recruit different parts of their brain to get the same amount of work done essentially so that they need they need to work harder to do the same amount of work the analogy that i like to use if you're revving your car and high r p m is all the time it will get you here today it will get me to the temple today but it's probably not good for the long term life of my engine right and that has been born now that idea has been borne out in many key papers including the marilyn meier paper which came out in a major journal in two thousand and twelve and in that paper which is one of the more important papers that talks about the harms of cannabis they followed over a thousand people over time they did neuropsychological testing it to points what they found was that group of young people who started using early in a regular way in a harmful way they lost up to eight points of their i q over time so that's more than a standard deviation that's a significant last and if you were fortunate enough at some point to stop using you don't get that back you can stop the decline but once you lose it you know it's over at that point so that's critical this piece here from a clinical perspective i mean i've talked to more patients than i can count who use cannabis they tell me well i actually think it helps my anxiety and so that actually gets to one point to talk later about how do you treat a patient what should you do if somebody has a problem i think it's very very important initially to find out why they are using why are you doing this because again i have to figure out what at least the perceived benefit is if i'm going to get anywhere with the patient so that's another point so we give people who just say it's just you know crazy that you're doing this it's cetera or it's the greatest thing ever those people really are the room sitting with patients who are struggling with this issue so so i've seen it over and over again people say they use cannabis to treating as id i can understand that there are many things about this plant that are not intuitive so when you think about it if you're anxious and you use cannabis your anxiety is going to go down when the drug wears off your anxiety to go back up so this type of thing will happen over time people will be medicating their anxiety in many ways as they do that the baseline level of anxiety actually increases so using the plant to treat anxiety is not a good strategy however to be thorough and again a lot of people don't want to be thorough and these issues there are many different that are unique chemicals to the cannabis planted some of those can have annoyed or very promising to treat so we may ultimately see pieces of the plant certain canaveral is helpful in that way but if you just go out you know downtown here by or you go to a dispensary and you buy cannabis to treating zaya that's not a good strategy in my view we have other ways to treat it that are far better in my opinion worsening depression is also say so with cannabis use as you can imagine if you're a young person you're spending a lot of your time using you're not doing your homework let's say eventually it's going to catch up with you you're not going to feel good about it mean that type of thing in this piece here which is chilling this idea that if you have a family history of a psychotic disorder schizophrenia schizoaffective disorder bipolar disorder with psychotic features if you have a family history of one of those conditions you're more likely to express it if you are using cannabis at a young age so to be clear not saying that your use of cannabis will cause you to have schizophrenia but it makes it more likely that you're going to express it you know some of these papers and in this paper here the deformity paper which is inland it's tree from three years ago now time flies but it put the increased risk at about five times so that's a very very significant so really one of the other notions that we get into kind of foreshadowing talking about treating patients with cannabis use disorder treating any patient with addictions this idea that particularly young people that some people are dealt a bad hand they have a family history of addiction and it's very hard for them to deal with especially when you think about this idea that their friends can go out  a thursday or friday and or saturday or all three do whatever they want in the person that i'm talking with cancer and so it goes beyond trying to help them understand look these are the risks of your use but you also have to help them deal with these feelings of grief you know they'd like to be able to do with their friends are doing but they can't because of their own genetics and fortune and so there are a lot of pieces to really on the path and you talk about treating a patient with this type of addiction successful so i mention one of the myths was an addiction so not to get too technical and i'm not a neuroanatomist i know there are other people in the area that do this sort of thing but their brains on the left nucleus accumbens that's the pleasure center we i think we're familiar with this idea we use certain drugs you do certain things you have released a certain neurotransmitters dopamine is probably the most common neurotransmitter that anybody's ever talked about or chemical so i like this lie because when i do talks with other doctors of different disciplines they hear what i do a lot of times people say hey wait up in i didn't think it was physically addictive right psychologically to have well here's the truth however you want to think about addiction cannabis meets those criteria it's psychologically addictive it's physically addictive so i like this life for that reason we think about other substances or things that are reinforcing or addictive invented mean on the top stimulants cocaine adderall that type of thing got marijuana here cheesecake i'd say you know what i mean whatever your vice is the point is that process sees substances that you use that make you feel good cannabis does the same things as some of these other things that we're more familiar with so to be clear again the scales are different here scales are different but the process is the same so i mentioned earlier that i do like the comparison between alcohol and cannabis i don't like the notion of hard drugs versus soft drugs something that some people believe in this idea that look certain drugs are really dangerous other drugs are not so bad the reason why that's problematic is we see here  cocaine let's say another stimulant everybody agrees that that's a hard drug but here we are with the soft drug cording to people thinking about things in that way really doing the same type of thing so i don't like that comparison i would offer that you have to understand that people make choices about what their drug of choice is so in other words a patient will say to me look i don't like candace i don't like the way it makes me feel you know i don't i don't like to use i've used it i tried it i don't ever want to use that again or people may say look you know this is the greatest thing ever like if i'm going to come home just want to relax reward myself for a job well done weeds my thing right like that could happen similarly when you think about this for other drugs it's kind of the same story opioids you know they make these slow me down like that other people feel oh yeah you know this is a very old feeling so people are making these choices and so that is why at the end of the day when patients come in see me with a substance use disorder sometimes it's hard to distinguish between who may have a problem with cannabis or alcohol or opioids because they're at that point they've all developed problems in these key spears usually work school and relationships so so that's that's hard for people to appreciate that people can take their cannabis use and just go off in such a harmful extreme and i can tell you you know i've seen it happen many many times i've seen people lose their academic careers as seen people lose their marriages of seen people lose multimillion dollar finance careers or athletic careers many many times just because of cannabis and granted that's an extreme doesn't happen for most people but it can happen i think that's what one of the messages here is if you're going to do this you have to be aware of what the risks may be and then finally i mention this withdrawal piece the reason why i mention this is because when you think about treating patients like this who have cannabis problems i think it's critical to help them understand that work when you try to stop the next time they usually have tried before on their own because nobody wants to have to see somebody like me if i have to but when you're trying to help them stop the next time say look when you stop using a lot you stop you're probably going to have some physical symptoms so anxiety irritability difficulty sleeping things that we're familiar with we think about like nicotine withdrawal that's really the point of this slide a series of studies that show the similarities between nicotine withdrawal in withdrawal which is a think cannabis withdrawal syndrome is in our psychiatric diagnostic manual so i think that's critical to help patients be aware that you are probably going to have some physical symptoms when you try to stop in like i said we're more familiar with that with nicotine withdrawal or people you know paying attention the opioid epidemic you know those symptoms drive people to use it when you're dopesick you have chills sweats cramps similar things can happen with  i mention the difference between cannabis that people may have used years ago in today's cannabis that's important what is the difference between today's cannabis will first you have to know what camp is this what marijuana is so hundreds of chemicals in the plant hundreds of them and then there are over a hundred chemicals distinct to the cannabis plant over a hundred can have a as i say about one hundred six depending on where you look and just to give you a sense for the idea that we're side can make you psychotic on the other side of quite an extreme and then the hot one lately can beguile c b d so that is not psychoactive doesn't make you high it has something anti anxiety properties in anti psychotic properties of very promising compound i mentioned this earlier that there are can have been ones that have a lot of medical problems so that gets into this whole debate and how this is pretty pretty complex area right it's not so simple you can just say look the whole thing is  bad news let's get rid of the reason why you hear about these two together is because they actually compete for precursors at the plant levels so they're competing and that is why when you increase t h c you lower c b d that's something that is often talked about well you know this is a high c b a strain of cannabis etc that when it gets into a lot of issues that we could talk about if you have questions but i think the major point here is that if you had experience with cannabis yesteryear in the sixty's seventy's or eighty's you're using a cannabis that had a t h c content of probably three or four percent so if we were to  go down town here go down the park street let's say by some cannabis we're pretty easily going to be able to get the plant into the twenty's or thirty's so in terms of published data we're looking at twelve thirteen percent and twenty sixteen but we can get the plant in the twenty's or thirty's pretty easily so the potencies going up you know yesterday's campus is nothing like what you get today so the question becomes that hasn't been answered as well as we would like but i think we can kind of appreciate this idea that if bad things happened before and now we're increasing the potency well probably more likely to have bad things occur i think it's a one of the reasons one of the drums of it would be very loudly for quite some time that we need more research right we've got this many states and this many people using it we've got this much research and so that gets into questions of who should fund it and i assume ideas about that too just to mention quickly just to be thorough there are many different ways of people are using marijuana these days and these are these four pictures are really their own talks under their own but just a quick tour synthetic  so simply put these are things that people use when they think they're going to be drug tested so i normally be drug tested and i want to get high i may turn to synthetic can advise and so that's people who are on probation people who plant and so that's all you have c v d the other piece that again i mention the compete so that c b d actually buffers some of the negative effects of t h c you don't have that with synthetic contaminants so the worst stuff that could happen happens here and so if you're if you pay attention to sports you know there benson stories of people using these substances doing things that are a little unusual so they're very dangerous of the nurses bottom left this is a concentrate so when you hear about people talking the wax shatter dabbing we're talking about using a concentrated t h c substance so you know now because we've already talked about it that you can easily get the plant in the twenty's or thirty's but this is eighty to ninety percent t so serious serious stuff so more likely to become psychotic probably vomiting is something else that we see people using cannabis all the time they develop these cyclical vomiting syndromes definitely more likely to see that with concentrates and so what i've seen many times of patients who are pleased with the increased potency in the the plant but they're like hey if you know if i can get eighty or ninety percent to see concentrates and they have with that that i'm going to do that so people are transitioning to that and that's something that i think is worrisome in many ways i show east cigarettes here because it's been a hot topic in many schools lately so just you should know that the cigarettes not just nicotine in there you can buy liquid th c you can put your own materials in there and so there are a major problem in high schools and things you have people with these cigarettes that look like a pen essentially they're actually in class that's easier more easily done in a sort of served tissues manner edibles here really the poster child for the poor education about marijuana that we do so there's a couple different many different issues here with these obviously there's no reason that anybody should package a marijuana product like this so what happens is you have toddlers say oh there's a shiny product right that or you could have a seven year old say i like a cat i'm going to do that so that's an issue that has been an issue but many states ha thoughtfully addressed it come up with better packaging and that sort of thing childproof packaging but i think the bigger issue for me anyway is the fact that we still have adults end up in the e r after using edibles and to me it just underscores  notion that we just need to do a better job of educating people because the reality is if you go to nevada or colorado or soon massachusetts and you say hey look i want to try this what is are really talking about let's try this what often happens people by notable take a bite nothing happens take another bite nothing happens thirty minutes later you get four times the dose that you were in tears a painting and then you you might not feel so good so that's how people end up in the e r i mention things about cameras that are not intuitive this is one of them right is let you in on a little secret when i have a brownie i eat the whole thing you're not supposed to do that here so a brownie will probably have a hundred milligrams of t h c you should have a tenth of it i don't have a tenth of a brownie when i i don't know what you guys do and what your maybe a lot more willpower than i do but i am going to have a kick care and we have a brownie i mean the whole thing so to me we've got to do a better job if you're going to have these policies in place if you're going to have twenty two plus million people doing this let's educate them can we do that i think we can do a better job so quick side lights here into the science of medical cannabis medical marijuana just to briefly talk about that then we'll segue into talking about how to treat how do you identify somebody who might have a problem to do about it so quick tour of medical cannabis so i think it's important to talk about this in a realistic way in my view is somebody that's done some of this research and has paid very close attention to it for a number of years and i still do i think that the end of the day there is evidence for using cannabis for some medical indications there are a few of them will talk about it so there are some there's some evidence here for some medical conditions however you know we've got people using cannabis for this many things so that gets to part of the problem and i don't want to spend a lot of time talking about but that's where we have some of the problems states that have this idea you know this availability the potential to use something that can be very helpful for people that have serious medical conditions but the way in which it's done in these states is really lack so again if if you're interested in further reading in again any paper that i mention if you want to if i can help you get it just let me know happy to do that so i've written on this in a whole bunch of places these are getting to be a little old twenty fifteen so that was jama journal psychiatric practice i mean i think if you check with the jama paper and you know anybody can read it i think it's pretty accessible but you know it's an important paper what i said there but we'll get to it just a second so when you think about what the science says about medical cannabis as i mentioned earlier there is evidence supporting the use of cannabis for some medical conditions we think about what has been done in terms of research there has been a fair amount of research done already but we need a lot more so we really need to know definitively what cannabis is good for in we're not moving in that direction we're moving ahead with all these policies everywhere including the commonwealth but the research is leg sorely behind in my view when you think about this the best evidence is really for three things at this point in rice a good evidence of talk about multiple positive randomized controlled trials which are the gold standard chronic pain neuropathic pain which is kind of a burning sensation you get your nerves a certain neurological conditions and then muscle specificity associate with multiple sclerosis so we're talking about multiple positive randomized controlled trials for all three of these conditions so to me i think there is likely that we will have other canaveral is really up to f d a approved an amorous right now i think will have more commandments approved probably as soon as two years or so so that's my view but don't take my word for it's not just me so this was a report my paper came on twenty fifteen to twenty seventeen at the beginning of twenty seventeen this report came out from the national academies of science engineering medicine it's free it's available you can download it if you need help getting it i can help you get it but it's readily available and so they essentially supported what i had said more or less they pointed to chronic pain they point vomiting we already had an f d a indication and they also supported the idea of specificity so i didn't say that there was strong evidence for neuropathic pain but more or less they followed what i've said and there been some other papers too there is a growing body of literature in top generals supporting the use of cannabis for some of these conditions pediatric epilepsy is another one dr a syndrome is a particular kind so i think the best evidence is for the three things that i mentioned but there is other evidence that is coming out all the more reason as we have these promising compounds to really study them in a rigorous way and that hasn't occurred unfortunately i mention the regulations are not going to talk too much about it but medical marijuana in massachusetts hasn't gone terribly well for a variety of reasons one of them is this idea that as a physician i can certify somebody for use of medical cannabis for anything i want to so when we voted for this specify a loophole so at this time this is a few years old but at that time there about twenty five thousand certifications that had been written and when there was twenty five thousand written total twenty two thousand written for other so the level of specificity is just not what i think should be so on the whole our policies in in the commonwealth could be strengthened with that where i think that's to be kind some states are doing it better than we are but i think gears talk about treatment here and then we'll take some questions so what do you do how would you identify somebody who has a problem what would you do about it that's something that a lot of us face so typical case that i would see kristen fifteen year old young person high school student comes to me got suspended so most people who come see me for cannabis problems they don't come in on their own so i've never had i never had my phone ring pick it up and say hey doc i heard that i could lose up to eight points in my i q if i don't stop smoking weed can you help me out that that call hasn't happened yet probably not going to happen so she got to this is a true and to sum it up he just said look i'd rather be used a different verb here but that was really the core of it and that's what you have to do really when you're sitting with patients again they've been doing this every day multiple times a day they like it there's a reason why they do it they think it's helpful for some reason i got to figure out what their reason is and i got to figure out why they might be willing to change and so when you think about these things as a parent as a teacher as a coach i mean what are you looking for you have to be thinking about a lot of things this is hard to determine who might have a problem with cannabis is not the you know you're not going to have them nodding out like they're using opioids and going to overdose as we mentioned earlier rights is a little bit more difficult so what are you looking for you're looking for this one's kind of easy problems that may be caused by using so people getting in fights people not behaving like they normally would skipping out you know they're not showing up to class like they should be they're doing stuff during their free periods that they should be doing leaving campus et c giving up important activities so i've been in massachusetts now for seventeen years or so and one of the things that many things about it that impressed me or made me do a double take one of them is young people in there still are specialized in sport right so one of the things i've noticed is that you know kids at a super young age to everyone you know they're six years old they're playing travel stock right maybe it happens in belmont i think it does a matter of fact but giving up important activities to me this is that kid that has been playing soccer every year in all these leagues all the time now there are a sophomore in high school they're not playing anymore so just because you're not playing soccer as a softer more and you did it for ten years doesn't mean you've got a problem with cannabis but it might right so it's knowing what normal is in what's a deviation from the norm what is baseline what is different from that situations so that's really kids in cars with cannabis and i've seen that variation many many many times and bunch of kids using drive in you get pulled over or maybe they probably don't get much more than a slap on the wrist but you got to see somebody like me that type of thing and then this piece here is probably the most common referral that i get from other physicians this use of cannabis despite other physical or psychological problems so that an important piece using any drug if you're using any drug in a problematic way it's probably not be only thing that's going on you're probably not doing this in a vacuum there probably are other cycle social problems or other psychiatric problems depression anxiety a d h d the list goes on and on so this referral to me is a doc saying look i you know i have a fifteen year old kid treating for a d h he ran the third stimulant it's not working and now i find out he's smoking every day three times a day right or somebody selects so it's not working anymore now you realize that you know there's a lot of cannabis use going on so that's a very very common referral so it's a piece of the puzzle it's not the only thing it's not the primary driver but it's could be a reason why the other things aren't going as well as they would like and so then you kind of just a get used to maybe take a little bit of a tangent but then you can get into a conversation with somebody saying look i know you don't think that marijuana is a problem for you but your depression bothers you so if we can just have a limited period of time where we stop using marijuana perhaps your mood will get better  that's the type of negotiation that you get into it's not as simple as say hey look this is yours it is worth the papers you know eight points of i q just stop that doesn't work it's more of a very delicate dance that you have to do how do you have this conversation i think there's really four stages to this that will talk about very briefly i want to take too much time but to get somebody into treatment what has to happen really four phases that i see how i think about this preparation conversation evaluation and for also the first step preparation get a bill that before you need you got to be able to have a relationship with somebody a conversation with somebody so that they're willing to tell you about things that are important to one of my patients so the story kind of and i think about this when i was young person of my unique told me look my dad talks to me about two things the red sox and the weather and you know i come from a somewhat similar family a lot of you know a lot of baseball fans in my family but the end of the day that's not enough right you have to be willing i have two daughters i am always asking them what you do today tell me more what you learn tell me something that you learn teach me a little bit all the times they don't want to do that right they don't want to talk to me and i want to answer my questions on my time frame but you've got to ask the question you've got to express that interest so that way when something bad is going down they're going to feel like they can come to you and that's what you have to do here and i think when you do that when you talk to people when you're asking those questions in this day need you actually have some advantages because of the fact that so few people do it right so if you go out and you know you look you see a family a dinner at a restaurant you know everybody's in their phone doing this kind of thing nobody's talking so if you do that you can separate yourself a little bit you have an idea about what you want to say we'll talk about that in a minute and then have a plan so if somebody does need help what are you going to do i think again i'm not a big believer in hierarchy of degrees and that sort of thing to me there are great people great clinicians who are social workers psychologists doctors you know they're good good of any of those disciplines they're bad of any of those disciplines too so at the end of the day if there is a problem that's identified you've got to have somebody good that you're going to go to because the window of opportunity is not open very long the conversation pretty simple so i think you just say this look i'm concerned about you i think you need evaluation so you're not making a diagnosis you're not pretending to be a clinician you know which somebody might take offense to you saying look i worry here i don't know what's going on but i think when you talk to somebody and then when you think about this sort of what what you're thinking about here what i'm also trying to engage in when a patient gets to meet this idea that look yeah i understand they're probably not as interested in the harmful things that we talked about earlier but what are they interested in why would somebody who thinks it helps their anxiety thinks it helps them relax why would they change their use well by nature of them being by virtue of them being in my office the risks are probably outweighing the benefits and so at that point what is there for them to say and so for me i think about the more tangible things really look i want to go to dartmouth i want to play in the sectionals in three weeks i want to continue to drive the car those types of things those more tangible things that's what gets a kid and once i figure out what's one of those things or something like that that's important then i can i can handle the rest i'm trying to just figure out what the what the h is what could motivate them the evaluation itself again never worry alone you shouldn't really be even concerned about you should just more be thinking about look where am i going to go if i say if i say look i am i worried about you i you need evaluation if they say yes where do you go if they say no what do you do a lot of times you know if you're talking to sixteen seventeen year old boy you know you've got to be met with a wall resistance i don't want anything i don't even from you you do there a lot of times people just stop they don't know what to do and the just let things go things continue to build so you got to be ready for all of these eventualities like i said just get somebody who knows what they're doing hopefully and then it's a thorough evaluation it's a comprehensive piece because as i mentioned before there's more to it than just saying look why are you using what he using how you doing this right there are other issues going on most likely that need to be addressed at the same time besides the use of whatever whatever drug it is now so we're talking about marijuana so for me you know when i'm sitting with a patient this is kind of getting back to the tangible piece of the motivational interviewing so simply put for motivational interviewing their one reason why they may change their behavior their make change their use in this case is better than ten reasons that i could give careful history doesn't happen very much these days in medicine people are all pressed for time when you think about how much time you spend with your doctor but people are pressed for time and you're very busy people are busy but you have to really take it take time to figure out try to pull all these pieces out of this what else is going on what is your family history what else may be contributing to the presentation you're seeing today alliance to me that's the biggest thing that i can do so have done research with medication behavioral interventions public been fortune off the publishing things and have some grants but the biggest thing that i can do or that any clinician can do in the room with the patient is build the alliance it's let them know that you're interested right i had one of my first patients when i was a resident tell me look i don't care what you know until i know that you care and that doesn't happen very often so if you do that you can do that really in a couple ways pretty easily frankly number one by listening to a lot of people want to talk these days not a lot of people are very good at listening so let them talk a bit listen figure out when that's to give you a lot of clues and when you're doing that if you ask the right questions that number one let us know that you care about what's going on but then number two ideally lets them know a little bit that you kind of know a little bit about this topic  that they're concerned about i think that's those are the things that you could do to build an alliance at the end of an evaluation like this obviously want to make very clear recommendations about what should happen but i will let you in another secret most patients who come into me don't want to do what i think they should do right away so i will say look i think you need to see a therapist i think you might benefit from an anti depressant most of those patients they don't want to do that but if i did this well if i built this alliance with them and they feel like hey this guy is interested in how i do they will often call me back at some point and so that's why it's so critical to listen and try to build that alliance be clear about what you think is necessary so that when they change their mind they have an idea about what's going to happen so they call you back the hope is that they do that before they've lost everything because that's kind of what's at stake right we talked about this before it's work school relationships and that's why they're there so these things are in play when they're there and the hope is that they are able to motivate before anything happens what does treatment look like we'll talk about in a second referral piece for marijuana right residential treatments not going to happen very often so the show intervention on if anybody seen it i like it's going to show the first half is pretty good because what it shows is that people with addiction it effects more than just them it affects multiple areas of their lives so that's great for people to see that if they are fortunate they haven't had addiction in their family but the second half of the show is just not all that realistic and if you've seen it they do an intervention and if the patients willing to get treatment and they hop on a plane and fly out to malibu and they're out there for six months or whatever i mean that doesn't happen i don't know why you but it doesn't have a for most of us you know we've got blue cross or harvard pilgrim and those pay those those insurance companies are going to send you out there so they don't have to either i mean you don't have to do that the evidence based treatment is really more outpatient based so structured outpatient programs could be what we call partial program and again i want to get technical if you have questions i'm happy to do that but structured outpatient programs ultimately going to see a therapist most of us would benefit from seeing a therapist in groups sometimes so with cannabis with marijuana there are a couple different kinds you can have groups that have a leader that you meet every week same people or you can have these mutual help groups you're familiar with alcoholics anonymous perhaps or narcotics anonymous there's a group that's in the area marijuana anonymous it's excellence outstanding there are multiple meanings you can also do it online but i like the live meanings two of them meet in cambridge at the divinity school there's great you know i've sent many many patients to those groups and i think that again if you have a problem with marijuana it's sort of a special thing in many ways because of the biases that we've talked about the way that society thinks about it so if you have a problem with it i think it's great to sit with other people who've been there they've done that they've had the same problem with you rather than sitting with people who have a problem with alcohol if you can i mean it is better than nothing in this case but i like marijuana not less in terms of treatment as a couple a couple pieces we're not going to take too much time what is treatment look like for people with cannabis like i said you're not going to detox you're not going to fly away to meldrew like he said i think this is the most important thing just getting to somebody that knows what they're doing so that they can figure out what the right step is a lot of it is just kind of getting somebody ready to do the things they need to do while building that alliance so that when they're ready to do it they've got somewhere to go they have a feeling that somebody can help them so back to this case and then we'll wrap things up kristin who we mentioned earlier started weekly talk therapy to establish that limited period of absence that's what i'm about i think when i read meeting with patients when it comes to any of these drugs people or alcohol people are overwhelmed when they think about you know i've done this every day for a long time the thought of never doing it again i just overwhelming so i don't want to have that conversation i said look let's take that off the table let's say look we know that you've got the pressure and you've got to you're worried about that i think that if we're able to get a limited period of time without marijuana in this case maybe your antidepressants going to work better maybe whatever else you're doing to help your anxiety is going to work better so get that limited period of absence the therapy addressed coping mechanisms divot the difficulty in giving up an activity that gets back to the grief that we talked about you know it's unfortunate you can't do what your peers are doing and then this person again true story did well in the last two years and now is in the top you know very good universit so that's another take home point that i want to make that despite how bad these things can be we're talking about marijuana today but this holds true for all drugs of abuse is that no matter how bad it seems people do better it's very hard to tell who's going to do better but no matter how bad it is sometimes these people do better even people who've had multiple over opioid overdoses if they get the right treatment at the right time and they're ready for it there's a lot of variables there but they can't they absolutely can do better we see this happen a lot that's what drives us i mean a lot of people don't get better unfortunately but when they do you know it's very very rewarding so there's someone up on marijuana a lot of misinformation unfortunately because they're trying to get you to do certain things they want you to vote certain ways we've already done that to a large degree in massachusetts so we have these policies how are we going to implement them i think that's the next step for you to take and then as i mentioned earlier the rule with any kind of these these issues whether it's marijuana or whether it's alcohol opioids addiction treatment can work i think for the most part in my view i don't want to speak for everybody but a lot of the treatment out there isn't very good so i think that a lot of people have had treatment before maybe it's not the right treatment maybe it's not good treatment so if they have the opportunity to get the right treatment and of course they're ready to accept it which is critical it absolutely can work and i think that's a major point i think that unfortunately for a variety of reasons that we could talk about if you're interested you know it's very hard for people to access treatment for substance use disorders because there's so much stigma in so many different levels so just to thank former research  assistant my medical astro who helped a lot of early versions of this talking this some of the slides are a few years old matt is a medical student now at new york medical college so doing well and i'll take some questions that's a great question so when somebody is coming to me again with we talk about marijuana they're not coming in the room it's often it might be for somebody in the field for a parent for a coach for a teacher and they're trying to figure out if  marijuana is an issue when it comes to me it's kind of been identified as a possible issue so i want to talk to them and figure out tell me exactly what you're doing and how often you're doing it what what form you know we saw all these different ways that people can use cannabis so i want to know granular detail how many times what are you using if you know the potency yes i want to know that the data say that about half of the people who are using daily meet criteria for cannabis use disorder cannabis addiction i'd say it's probably a little higher than that but the published data is about half so so it's up to me to really figure out if they meet those criteria i would say that because it's so hard for these people to come in and seek treatment most of the time most of the time when somebody comes in to see me and somebody wants them to see me relative or marijuana use they do meet criteria and i would also say when they don't and that happens to sometimes you know a very vigilant parent will be you know they know that their son or daughter used to bring him in to meet their they don't meet criteria for cannabis use disorder most of the time when that occurs there probably is something else going on that requires some type of treatment so by the time the level of suspicion rises to the point where somebody is seeking treatment it's usually justified quest you know it's good good good question i mean i think so it was that the question is the definition of adolescence think we're usually talking twelve to seventeen twelve eighteen that sort of thing but with cannabis as i mention in the patients that i see really there are all ages you know anybody of any age can have problems cannabis probably the sweet spot is probably fifteen to twenty five i think it's a little bit unusual for somebody who used twelve thirteen now they may be starting to use but again it takes a while i think it's especially difficult to determine that someone's got an issue for a parent you know if you're twelve or thirteen might need to see somebody so but time to get to me is usually at least fifteen i would say fifteen or twenty absolutely absolutely there are many many kids who may have used talking about extending into college for the point of the television there so yes maybe they were in a community or a family where you know it wasn't easy for them to use they might have tried it a few times in high school but now they're in new york city and college and while they can do whatever they want there's not much structure i mean that is a scenario as you can imagine is pretty pretty common and it's not just marijuana obviously there's opportunities to have things go awry and in many ways when there's a newfound freedom less structure  yes so the question is on top of cannabis use disorder you often see suicidal ideation or suicide but not not often but you definitely do i think one of the points that i think is critical to make and unfortunately you know we see this happening level the risk for suicide goes up so i'm not i'm not by any stretch i'm not trying to tell you that there are a lot of people out there that have cannabis just sort of that are committing suicide but the look the risk goes up and there's impulsivity there i mean there  many things there i think that's an under recognized facet of all of these addictions is that there's a lot of risk of there and it's not just when you're using when you think about it when people get into this sort of cycle where i've been diagnosed with an addictive disorder i get treatment may or may not be good treatment doesn't work and now i'm back in the cycle or you try this thing again my family is worried about me i failed out of school i don't have a job you think about that when all those things continue to happen it's very easy for these people to become hopeless so people who you never would have ever suspected that before when they get into these cycles you know and we just we just you know this patient that  we recently saw with begin with opioid use to sort of put the the risk goes up in have to have an intent already in it just because it's cannabis which again is not as dangerous on the whole doesn't mean that there isn't a risk there so hopefully when you get somebody into treatment again you're looking at the whole picture and that's one that really needs to be teased out i think well that so that happens sometimes and that's chilling frankly i mean what'll happen is when i see somebody and so will ghana is part of my job you know i'll be in the medical center you will see patients on the medical floors or i have out patients that come to see me in my office and one of the things that i always want to do in any of these cases is we talked about as i'm trying to find something that makes them brighten a little bit you know do you have kids do you have grandkids you know what is your for your family in the area where you are you watching t v what do you like to watch anything i'm looking for anything and most of the time you can find something that people will brighten up sometimes they don't in when if you're if you are having your first evaluation of somebody in this happens this happens sometimes and again it's scary but if you're trying as hard as i tried to find something to make them brighter and they're not brightening then we're we're recognizing that we're documenting it and we're we're being very concerned about what they do what they might do in the so there's so many pieces to that if somebody presents that way they're very they're at high risk for harming themselves you also have to understand that if they start to take a medication and they're doing a little bit better you know maybe that energy might give them a little bit more room to do something you know to harm themselves so there's a lot of levels here i bad as everybody says i mean this were in a really really difficult spot with patients with all types of addictive disorders i said some people some patients do well and that's great but but but you know there's a lot to lose yes so i mean so first of all you know it's got to be it's got to be really hard i mean as i know it's hard for the family i mean i have patients like this and it's very very challenging a lot of times they don't feel like they need their medicine and when you talk about decreasing the dose you always get really concerned and i know for patients that have psychosis that marijuana is a big issue for them a lot of them really like to do it i want to be clear i do think that ultimately we may see i mean there are some papers that are not randomized controlled trials but there are some papers that suggest canada die all has anti psychotic properties but if for a patient that i'm treating i mean i know there are many anti psychotics and they have significant side effects i don't want to downplay that but those medicines in general work very well and i would be hesitant because of any point if somebody is not on their medicine they could end up in the hospital they could hurt themselves and so i would try to stick with those medicines if i could i have had conversations with patients who are in those predicaments about canada die i try to be honest about it just say i really don't these other things i mean i think we should be doing that and i think that the state and i think that others who are profiting from canada should be funding those trials in addition to the n h but i would say at this point for a patient like that i would really want them to stay on their medication for probably a lot longer than they want to that's a similar discussion and i'm in right now with a bunch of patients of mine you know want to i just want to make sure everything's going really well for a while and then gradually kind of lay in the plane there but i understand and i empathize i mean it's a very difficult i have several families that i work with that it's a been it's not easy for me either i don't want to see people you know have are well trained not as many of them are as well trained as i would like i mean i i i know i know i have not been shy to say i mean i think that the quality of mental health care in on the whole isn't what it should be there are many reasons for that  that you know i think that unfortunately if the patients that we're talking about here if they go in and see somebody you know there is there's a chance they could see somebody good there's a chance they may not and i think that's why i'm a little less worried about some patients than others who have had multiple treatment results right so i would frequently go in to see somebody that's using fenton ill and you know are told their you know they've had they been on these medicines before they've been all these programs and as a result a lot of people don't want to take it but for me i mean it's a clean slate like i want to talk to them see what's going on only give them a shot so i'm willing to give a lot of people shot just because a in my view my experience of it probably been doing this a little bit longer than you think i just in less confident with the care that is out there and i'd rather say hey let's look at this see if we can figure out what to do and then you know give somebody a fair shake rather than say well you had a chance already and it didn't go well i don't want to do that now i don't i don't think that's really the way that we should do it so you have a question ye good question gateway so the gateway question i don't like the term and i mention of the one of the said why is marijuana controversial i think one of the reasons it's controversial is because americans we tend to go to extremes americans when they think about gateway we think about what we call a causal relationship so if i'm thirteen and i use marijuana then i'm going to definitely go on to do these other things that are terrible and it doesn't work that way what happens is that a young person twelve thirteen fourteen if they're using marijuana or nicotine or alcohol that's what happens is usually one of those three things if they're doing that at twelve thirteen fourteen they've increased they have an increased risk so i'm worried about that i'm worried about that behavior but they're not doomed they're not it's not automatic i mean you all know everybody knows that gets to being sensible but we all know kids who started who had tried marijuana at thirteen and they turn out ok that's one of the things that they're going to deal with patients so you can't say all or nothing you know you can't draw these extremes because patients will say well you know i have a friend who's at harvard law and me smoke every day and they turn all right so for me the gateway piece is misleading in many ways i don't i don't think that it's a gateway drug as people are referring to it increased risk yes so if you're young you're using cannabis i'm concerned i want to know like we talked about here what how much you're using what are you using are there other things going on there's a lot to figure out there but by no means is use you know an on your do do this yeah yeah breathalyzer so our get into the good stuff so it's more of a policy issue so when i talk about the policies i like to truck about the difference between ideas and implementation right so we can have great and we're not going to do a lot of it today but we can have great discourse about the merits of medical marijuana of legalized recreational marijuana so those are the ideas we can have a good our debate about that i think legalization is really complex for relative to cannabis impairment so to me as i've said many many times in many places the policy in the commonwealth and other places is way out in front of the science so unfortunately we always people using and as they use we don't have the breathalyzer equivalent for alcohol so just a you guys may know this but just to be thorough if you're driving you have a breathalyzer point zero eight blood alcohol content so we have a very precise way that we've determined you know we've point zero eight blood alcohol content for most people means you can have this level of impairment we're driving you know they so all things together you know they have a very precise way to figure out so it's your b a c plus your field sobriety test and a sidelight in massachusetts even with this great technology for alcohol you have a decent chance of getting off so if you don't have that technology and we don't have it there's no breathalyzer for cannabis there's no equivalent point zero eight but alcohol content then we got some problems right so in massachusetts what we're going to do now is they're already doing is that you have people who are able to you know police officers who are trained to do field sobriety test and try to look at some other things but if you don't have that level of specificity then i think it's going to be very hard to hold those drivers accountable in so there are people working on a breathalyzer or something like that but it's not to the level as it really should be and i'll take you back to twenty sixteen i did a bunch of events with and again i catch a lot of flak from the pro people and the inside people but i did a bunch of events with them sitting between them i said over and over again and again maybe people will remember this but he said look you're about to spend each of you are about to spend four million bucks on advertising how about because they're both saying that yes we should have more science we need that we should have that breathalyzer that would be great you know both people said that and i just said look you take a quarter of what you're going to spend on ads and let's do the research people can do this research it's not you know we should be having the best and brightest developing this technology because we've got more than half the country with medical we've got more and more states with legal and i had nobody take me up on it and another thing that occurs is that while everybody says they want the research once you vote on these issues as we did in massachusetts nobody talks about anymore nobody wants and always talking more research to talk about who's getting a licenses where the stores are going to be you don't hear it the cannabis control commission so they requested seven point five million bucks from the gov for fiscal year eighteen how much did they ask for for research and body seventy thousand dollars so that's less than one percent and the only reason they did it and if they want to say something otherwise you know i'm not a hard guy to find the only reason they did it is because they're mandated to do it actually says it in the line item mandated research less than one percent of the budget so we have to understand that we're not moving the signs ahead as we should so we're having we're going to have all these stores everywhere you may have in belmont you guys are going to decide on that but we don't have technology to hold people accountable i'm personally i think adults should be able to do what they want to do as long as isn't hurt other people but that gets that breathalyzer piece right i want people held accountable if some result they're driving under the influence i want to be held accountable and i don't think you can do it very effectively without the technology and so that is one of the reasons for me i really would like the science to be advanced before you implement these policies great quest know great question confidentiality so are they a minor or not that's a big question so if you're a minor there's really not much confidentiality right i mean and i also i was a want to stress i  didn't really talk about this today because i don't want to go to great details but what i'm doing an evaluation if i have a fifteen year old kid or a twenty one year old you know i would like the parents to be there if at all possible so the twenty one year old maybe you may or may not a lot of times they are willing to come in you know the la times the parents do come if that happens deafened for the fifteen year old i'm going to sit there i'm going to meet with the patient usually for about forty five minutes read a lot to cover but then i want to bring the parents  and we spend a lot more time talking about the same stuff that we cover the risks the benefits what's going on with that young person but then getting into the recommendations they want everyone to be on the same page it is trickier so if you have an adult a young adults you know will have will have conversation about what i think should be shared and you know i may ask for their permission to share it on the whole again you know being a parent and a clinician i mean i push hard i want releases signs i mean that's one of the things i mean again i push pretty hard for it in the beginning i want to talk to the parents i want to talk to other clinicians kind of you not the not the question that you asked but i also think that idea is so critical here when you're talking about treating addiction you can't rely upon one source of information so if it let's say it's a twenty one year old adult still i need collateral information because someone's going to come in to you and if you're not getting information from other people they may say things are going great when they're not you're not drug tests things that you need to get multiple sources of information we're talking about substance use disorders it's part of the illness to misrepresent what's going on in me tell it they're going to tell you what you want to hear so it's a confidentiality is it a great thing i think certainly for a minor there's not a lot of it and certainly explain to them why that is and then for people who are above eighteen i mean i'm going to push hard and just say look they care about you they want they should know what's going on and it's part of them i think that's also important as your little bit more likely to be able to talk to parents because for can particular the young person is not seeking the treatment on their own like their common end so they may there's leverage there right if we're going to continue to pay for you to be at this college or if you're going to live in the house so these are all issues that oh yeah good question good question so so more want to put words but more of an exit strategy ok so very very important and i think it's really critical to be precise about these terms so i am and i again i've written on this and many places i think that there is a growing body of evidence that suggests in the states with these cannabis policies there are less negative outcomes from opi use so for example a very important paper in one of the best journals came out in twenty five fifteen now maybe twenty fourteen in the medical marijuana states fewer opioid overdoses and that's not alone there are multiple papers now probably about five or six so i don't think you kidding nor that and i would liken this kind of gets back to the op ed that was in the globe few weeks ago we have to be able to study this stuff right we're going to have recreational cannabis in massachusetts we have to have the infrastructure in place to find out could this be one of the answers people are dying every day as a part of you as a part of the opioid crisis maybe this is part of the answer not saying it's the only answer so i think we have to look at that from a clinical perspective though i think it's critical to point out the difference between a patient who has chronic pain and is prescribed opioids for that patient i think cannabis can be a very viable piece just more data there so people have published on that lucas said multiple positive randomized controlled trials so i think cannabis is not a first line treatments not a second line treatment but it could be a part of that puzzle the other piece that i think you're alluding to i'm a little more concerned about so somebody who has an opioid use disorder using fentanyl i wouldn't tell them hey here's your medical card do this instead of opioids because for opioids we have three f d a approved medications that work really well it's one of the secrets in massachusetts because for a variety of reasons we don't talk about that but what medications work for opiate use disorder so i would be hesitant to see somebody get a medical card and not pursue one of those for alcohol depends i had somebody asked me that question was it yesterday might have been i mean i'd like to know why they think it's going to be one or the other and like maybe we could have more of a conversation about that but on the whole i mean like i said i think that is you know people can drink themselves to death i mean it happens it's very unfortunate when it happens but it does happen so cannabis probably a little less dangerous in that way but i don't want to know more yes was so so the question is about the potency and the labeling in this sort of thing and so yes in the dispensaries now they're accurately labeled they're supposed to be tested i think that's occurring i don't think anybody's go misrepresent what's going on i think there could be more education so no one's going to die if they you know if i eat the whole brownie like i like to do you know i'm going to end up in the e r i'm going to i'm going to be in bad shape i'm probably not going to die you know so i do want to be clear about that i think the labeling is correct usually i think that sort of thing but i just think there is a lot more education that can be done in these places and i also think that the places that sell cannabis should own more of the liability so if i certify somebody for medical cannabis it's not the same thing where if i write them a script and they go and they get a certain drug a certain amount from the pharmacy you know if i write a certification for medical cannabis they go into a dispensary they talk to the bud tender and you know who knows what their end up getting so i think that unfortunate for a variety of reasons the level of rigor is not there the level of the standard of care is not what i would like it to be in that case i think they're going to have to be they're going to the labeling will be good you know i think there is a possibility i mean there are going to be high potency available concentrates will likely be available not one hundred percent sure on that but i would i would gather that they are so i think what is for sale will be accurately labeled and i hope that people particularly people who are naive to using cannabis will understand the difference between what that product may do for somebody who's experienced in using versus not is a big difference yes  questions greg yeah well i mean i think that you have to have people in your community or providers that you trust you know could be your next door neighbor who might be a physician say who do you go to who would you recommend in you if you have people that you trust in the community you know could be the department of health you know they have people that they may rely upon but it's hard it really is hard i think if you it's hard to you know if if you call your insurance company and get a list you know i'm not that hopeful about it i do think i mean i think it's fair to say that there is a wide variability in the in the quality of care and  there are good places and places that aren't as good and there are sometimes people at some of these good places that aren't quite as good so you know there could be differences in providers at various institutions so it's very challenging and that's part of the reason why i like to do this because i you know we have bend down some of these roads and you know i have a family history of addiction and so i think it's very difficult for people to navigate this and know where to go and so i think it's a great question so talking about experience in just sometimes physicians just writing the scripts and that says there's not a lot of follow up not a lot of talking that happens a lot i mean i think that that's the way that medicine is kind of moving you know in psychiatry or addiction medicine the prescribe are often times doesn't spend a lot of time with the patient sometimes they are you know there are clinics where people just have to come certain number you know every couple weeks or you know whatever to get refills and i think it's a mistake and i think unfortunately that's what i'm talking about i think that if that's what somebody experiences ben they may have gone through that cycle a few times and i'm hopeful that if they do it the right way that things can still go better i definitely can appreciate patient patients are wary of medications they may have taken you know medicine that did make them feel you know again sometimes there is trial and error that's that's necessary but if you feel like you don't have an alliance with your doctor and they don't really listen to me they didn't really listen to me they just wrote out a script and sent me out of there i couldn't understand why there might not be a lot of confidence in the medicine you know i was in there for five minutes so it's difficult it does that doesn't happen everywhere i mean there are places that do more care careful evaluation and spend more time with patients hard to find those places certainly but they are out there all right thanks appreciate it