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Cannabis: The Good, The Bad, & The Mad

September 2, 2020
All Points North Lodge

Cannabis: The Good, The Bad, and The Mad - Dr. Shahla Modir, MD (Chief Medical Officer at APN Lodge) interviewed by iCAAD

Video Transcript


iCAAD: Hello, it gives me great pleasure to introduce to you today - Dr. Shahla Modir. Dr. Modir is a leading expert in addiction medicine and integrative psychiatry and currently works as Chief Medical Officer at All Points North Lodge. Dr. Modir, it's an absolute pleasure to have you here.

Dr. Modir: Thank you.

iCAAD: Could you tell me a little bit about your role at All Points North Lodge?

Dr. Modir: Yes. At All Points North Lodge, I'm the Chief Medical Officer. As the Chief Medical Officer, I helped to develop all of the admissions guidelines. I helped develop all of the acute withdrawal management guidelines as far as when we take clients in, if we're going to withdrawal them from substances of abuse, what will those guidelines be? What will they look like? They're all evidence-based guidelines based on the research that's been shown to help take people off substances in a very safe and effective way. I also help to do some of the training of the medical staff that's on-site, as well as serve as a high-level supervisor if they're struggling in a case and they need a higher level of expertise to give them some guidance, especially in the psychiatric conditions because I've done this for 20 years, they'll also rely on me for that.

I've also done a lot of the hiring of our medical staff and reviewing. We have our own staff meetings, so I help monitor everything that's going on onsite and problem-solve. I helped develop our COVID policies and manage them. So it's a pretty far-reaching role, a broad overview role, with some direct involvement in terms of supervision of the medical staff.

iCAAD: Amazing. Thank you. And I'm just, I'm really interested in the fact that you're an expert in not only addiction medicine, but also in integrative psychiatry. I think that's a relatively new field of expertise. Certainly for me, it's new, but it's something that I am absolutely passionate about and truly believe in. But I wonder if you could tell me a little bit more about what integrative psychiatry is and what it means.

Dr. Modir: Yeah, so integrative psychiatry is an approach towards psychiatry that takes into account a number of different dimensions of the whole person. We try and look at the person from multiple vantage points to help them arrive at what might be the best way to help them manage their condition. So we'll look biologically at what might be happening, right? So we'll make sure that they don't have a thyroid problem or B12 problem. We'll look at all of their labs and make sure they don't have a history of head trauma. We're not missing anything there. From the psychological point of view, what is their relationship and their childhood. Have they had difficult relationships with their parents from the attachment point of view, what's their trauma?

We look at environmental. Where do they live? Do they live in a city? Do they live in the country? How much exposure do they have to the outdoors? We might look at their microbiome in terms of like, do they take probiotics? What is their diet like? Is their diet something that would be conducive to maintaining stable levels of blood glucose or do they only eat sugar and have no protein? But also, where does the microbiome fit into what they're eating? And is there another approach we could use that might help them balance some of their good bacteria that we know affect mood?

We also look at them spiritually, if they have a spiritual practice. You don't have to be religious, but spiritual practices have been shown to give people meaning and improve psychological health. So we look to see if people have any spirituality in their life. And under that domain, you would combine body approaches in terms of people learning meditation or breathing activities or yoga or Tai Chi - finding ways to feel more connected and in their body. Because what we often find is that people are not in their bodies a lot. They're in their mind a lot, and that can be a huge problem. Or sometimes they are too in their body. And they're so obsessed with their body that they're not in the environment anymore.

So in that psychosocial, environmental, nutritional, and mind-body approach, we're able to kind of uncover where people might be stuck and address that from a number of different vantage points.

iCAAD: I honestly think it's fascinating. And I think, especially in addiction recovery, it's absolutely vital to look at all those points. You mentioned meditation and some sort of spiritual practice, and I know that by doing something like that, it can reduce levels of cortisol, which obviously is a stress hormone. And that can obviously have impact on your mental health. And it's all so connected. You know, I think it's really, really, really fascinating.

But anyway, when you were deciding on a topic to discuss today, you came up with cannabis. And the title of this presentation was "The Good, The Bad, and The Mad." Could you tell me what inspired this choice of topic?

Dr. Modir: Yeah, because I think that cannabis is a very interesting plant, and it has a number of different ways it can also be seen, right? So, you know, it's not all good or all bad. It's not like cocaine which maybe we would deem an anesthetic, but the risk of harm is so high. Here, you have so many different domains where it could be seen as something that's positive, something that creates addiction, and something that might actually cause psychosis or other mental disorders.

So I was trying to help people in this, we do a grand rounds talk at All Points North on this to understand the different domains. So the first domain we talk about is the good. And that's where we talk about, you know, how cannabis might help pain, how cannabidiol might help pain. In the bad, we talk about addiction, adolescent use that can lead to people having decreases in their IQ or predisposing them to other psychiatric disorders, what the addiction rates are, how they co-occur with so many other addictions. And then the mad is just a little bit more of a focus on psychosis and how cannabis can be connected and correlated to higher rates of psychosis, especially with increasing levels of THC.

iCAAD: I mean, there are some so many different views. Right now, especially it's such a hot topic. Because obviously, I mean, from what I've heard when I was growing up, it was the sort of the gateway drug. If you smoke weed, you know, you're going to end up on harder drugs and blah, blah, blah. And that possibly even was my experience in a way. But at the same time now, as I've got older, and in today's modern world, we see so much about CBD oil. And we see about, as you said, cannabis for pain.

And from the little research I've done, I've also heard that the cannabinoid system is the widest-reaching system in the body, wider than the nervous system and stuff, and it can actually really help. So if you take sort of CBD oil, and I don't know about cannabis itself as a plant (smoked or in any other way), but certainly the CBD oil that everyone seems to be using these days, it can really help pain. I mean, do you think that that is right?

Dr. Modir: Yeah. So there's a lot of newer information that's coming out about CBD. So in the cannabis plant, there are two major ingredients. One is delta-9 T.H.C., and that's the part of the drug that exerts the psychoactive effect. And then the other part of the plant is cannabidiol, and cannabidiol is actually an antagonist of THC. It blocks THC, right? And it has more anti-inflammatory properties and antinociceptive properties. So when they do research on pain, most of their research is coming from looking at the FDA-approved forms (Sativex or Marinol) when they're studying if marijuana or cannabis help with pain.

So they're not going to a dispensary and just grabbing marijuana and then studying it because the variability there is very high. So in the studies that they've done, they found that yes, marijuana, which includes both THC and CBD, does help with glaucoma. It does increase appetite in people who have AIDS wasting syndromes or are on some cancer chemotherapeutics and have lost their appetite. It helps nausea. It also helps the appetite itself. It's also been shown to help muscle spasticity in multiple sclerosis and a number of other conditions. And it helps nerve pain.

That's probably like a summary of like a hundred papers of what it actually does create benefit for. I think the anti-inflammatory effects of CBD are very new. We have Epidiolex that just got approved in 2018, and that is a whole leaf extract of CBD. And it's meant for the seizures, Dravet syndrome and Lennox-Gastaut seizures. That's what it has FDA approval for. But there are probably a number of different conditions that this whole plant leaf extract of CBD could be beneficial for. But right now, the only evidence we have that they've done formal studies for and an FDA approval for are these two difficult-to-treat seizure disorders.

So from the CBD standpoint, I think we're a little bit in our infancy. From the marijuana as a whole, they have studied it for a number of different conditions. And the summary of what it's good for is mostly what I described. There may be more conditions, but muscle spasms, nerve pain, glaucoma, cataracts, nausea, and improving appetite. Everywhere else becomes gray - some studies say it helps, some studies say it doesn't help. It's harder to define, but I think it's really a new idea to just study CBD, to see if CBD itself, since it's safer and doesn't carry the same risks of psychosis and potentiating mania if it's less harmful, might be beneficial for arthritis and other inflammatory conditions.

iCAAD: Do you think that with the relatively new push to legalize sort of cannabis, especially, I think it's mainly over in the States more than anywhere else, do you think that this is a positive move or a negative move for, I suppose, the addiction world?

Dr. Modir: Yeah. I think for the addiction world, it is complicated. There have been increases in the amount of use, especially in younger children and adolescents than was previous to states legalizing. We think we have 13 States where it's legalized recreationally and 33 for medicinal purposes. I think JAMA Psychiatry in November 2019, they looked at half a million people and they just had them anonymously describe their cannabis use habits. And they basically found that teens, who were from ages 12 to 17, have had problematic increases in their THC use by 25% in states where it was legalized. So you have a younger population that's already up by 25%.

They also found in adults 26 and older, in rates of cannabis use disorder went up by 26%, and problematic use, which means you don't quite meet criteria for cannabis use disorder, but you're moving towards it - it was up by 37%. So the legalization has led to consequences of people using more and there is more problematic use in both adolescents and in 26 and older.

They interestingly didn't find an increase in age 21 to 25, but I think that's a ceiling effect because they were already using it anyway. You know, it didn't change their habits because they were already the primary users, but in the younger kids, they've done studies that showed a perceived risk of marijuana is less because it's legal and all the marketing and branding that goes on there where they use dreamy and unicorns and all these very like childlike images - that makes it seem like it's safe and cartoony. When in that population, it's actually the most dangerous, right? Not only because it is a gateway drug, and so are nicotine and alcohol, and marijuana is a gateway drug to much stronger drugs, but it affects brain development, it increases the likelihood of someone developing a psychotic disorder, the onset of bipolar disorder.

So there are a lot more far-reaching implications if you start using cannabis when you're under 25-years-old while the brain is still developing than after. And some of those are irreversible once you turn the gene on. And it goes back to what you said, it's because we have these cb1 and cb2 receptors all over our brain. That's why it can do so much, but it's also why it can harm so much because it's not just acting in the mesolimbic dopamine reward system. It's acting in multiple areas of the brain. It has modulatory activity, and it can upregulate and downregulate in so many different areas - turn genes on and turn genes off. If you have a genetic predisposition, you might turn on a schizophrenia gene. You're five times more likely to do that if you start smoking pot as adolescents, things like that.

So that's why I think legalization is...we need to regulate it better. We need to discuss what the implications are, and we need to make changes to the law that help people become aware of what the ramifications are and what they're doing.

iCAAD: And that's what I was going to ask. I was going to ask, do you think there is enough education around it? It's the fact that in a developing brain, it causes so many possible negative consequences. And I don't think that the general public is aware of that. I mean, cannabis use, from the age of about 12 to 18, it's a rite of passage, isn't it? It's just a normal thing that people do. But I don't think they understand or that the general layperson would know that actually what they are doing could cause so much damage to their developing brain.

Dr. Modir: In ways that are difficult to reverse, you know, in ways that are difficult to reverse. If you've had a cannabis-induced psychotic episode, within two years, between schizophrenia and Schizoaffective disorder, almost 50% of the people who have had a cannabis-induced psychotic episode can develop schizophrenia and Schizoaffective disorder together - 50%. 27% for one and then you get a little less for the other. But I mean, that's really alarming, especially if it's during the critical development period of the brain when you're under 20.

So I think if adolescents understood that they could turn on a gene they didn't even know could be possible, and the higher amount of THC you use, the more likely you are to become psychotic. Just if you have a family history of schizophrenia, you're more likely to turn that gene on. You're five times more likely. If your risk is one in ten based on your family history of developing schizophrenia, if you use marijuana, it's one in five.

iCAAD: That's crazy. See, I didn't even know that.

Dr. Modir: That's right. And the higher THC is what's pushing people. You know, back in the day 20 years ago or even 30 years ago, the average THC potency was 4%. Even in 2008, it was like 9%. And now, it's like 17%. When they done studies and they've found the average on the street right now, it's about 17%. That's really high. Still not nearly as high as resins and waxes and hash, you know, those oils that get to 70%, 80%, right? You're just raising. And then studies have shown over and over, you have an increased likelihood of having a psychotic episode when you've used stronger and stronger THC. There are a number of factors.

iCAAD: Do you know if there's been any stats or papers done since they legalized cannabis in those 13/33 states as to whether the rate of psychosis in adolescents or even adults has increased or not?

Dr. Modir: Yeah. I think they show more emergency department visits in all of those states for psychosis. In those states, emergency department visits related to cannabis-induced psychosis are much higher, 25-30% higher. So they are having more episodes. They are presenting in an emergency situation to an ED and requiring intervention. Andthere was a recent study in the Lancet in March, 2019. And they looked at 900 patients who were diagnosed with first episode of psychosis. And they found that one in five were due to marijuana use. And they found that if you smoke pot daily, you are three times more likely to have a first time episode of psychosis, especially if you started before age 15. You were five times more likely to have a psychotic episode if it was high-potency THC, and they defined that as 10%.

iCAAD: Wow. And now you're saying the average potency is 17%.

Dr. Modir: Yeah from the recent study in 2017. So I guess it depends what state you're in, but yeah.

iCAAD: That's really scary, isn't? It's really scary. When I was researching these questions, I was looking at concerns that Americans have had since the legalization of marijuana. And one of the concerns among the American population was that traffic accidents would increase due to legalization. And have you seen any results of this?

Dr. Modir: Yeah, there have actually been a couple of studies that have come out, because obviously it's new, right? But there are some states that have had legalized recreational marijuana for longer. Colorado is one of them. And British Medical Journal came out in 2019 with a study, and they found that there was a 10% increase in car accidents since the legalization in Colorado. They also found that overdoses from opiates and other substances and alcohol abuse went up by 5%.

JAMA came out the study just this last year where they looked at the NTSB data, and they calculated a number of different predictive factors, and they found that there was an excess of about 75 deaths per year from 2014 to 2017 in states that had legalized marijuana for recreational use. In 2020, in Washington state, AAA did a study, and they looked at what percent of fatal car accidents did people have THC in their blood? And they found that it increased by 50%. One in five of those fatal accidents had THC in their blood. And there's a big argument about, well, how valid is that? Because marijuana can stay in your system for a month, just measuring it in the blood doesn't mean that they were high at the time. And so there's a lot of debate about how to try and look at this.

There's even debate about how are you going to really be able to like assess people like on the spot. You have to take them back. You have to get a blood test. And that gets complicated for chronic users, but it does appear that there is a net increase. The Insurance Institute of Safety and Loss also did a study recently, and they concluded that there was an increase about 6% in cases due to THC-related car accidents.

So it does seem that legalization has increased the number of car accidents. And they've actually done studies to look at people's perceptions around, "Is it okay for me to drive if I've used marijuana or not?" And alarmingly, many more people think it's okay to drive your car when you're stoned than drive your car when you're drunk. And they don't really understand that it impairs memory, coordination, attention, and you are more likely to have a car accident.

iCAAD: That's crazy. Yeah. Well, that's the thing. And I wonder, I mean, obviously drinking and driving has been a thing that's been drilled into all of our minds for so many years. You know, alcohol has been around. I mean, I suppose marijuana has been around forever, but it's the idea of legalizing. Alcohol being the legal recreational drug that has come with warning signs on it since, you know, basically the dawn of time, whereas marijuana seems to have come... And I might be wrong, maybe at the beginning of when alcohol was in use recreationally, there weren't any warning signs. You know, it probably didn't come with a "Careful, don't drink and drive" sticker on it or whatever, but...

Dr. Modir: We should have that. Just as we should have, for higher potency THC, we should have warnings about the possibility that you could cause psychosis, you could cause a panic attack, you could cause a manic episode. When they look at people using marijuana for depression, they find that people are more depressed, get hospitalized more, and have more suicidal thoughts. So when people say, "I smoke pot for my depression," there's no evidence in favor of that, you know? Anxiety seems to be a bit mixed, but there are so many people who are highly sensitive to it that end up more anxious and having panic attacks than actually get benefit. CBD is more beneficial for anxiety, right? And CBD blocks THC. So it would make sense the THC could cause more anxiety because the blocker actually helps it.

iCAAD: Yeah. I mean, it is fascinating, and you're right. It is all about education. It's about putting those warning signs on. Because I do believe in freedom of choice and doing whatever, but you need to be well-informed in order to be able to make those choices. And at the moment, you've got the companies that are making millions and millions of dollars advertising with these, as you say, these sort of childish logos and names and really enticing these young kids in. But who is doing the job of the warning? Who is?

Dr. Modir: Yeah, the states are not regulating, and there's no national warning. I work in Los Angeles, and I find like so many teenagers whose parents have no idea. They let their kids smoke pot every night. They don't understand the impact on memory and learning, that you can slow down pruning. So your brain is pruning during that stage. It's basically like pulling the weeds on information you don't use anymore to make space for all the new information you're learning.

And when you're smoking pot regularly, your brain doesn't prune. So when they do neuropsychological tests on teenagers who are smoking pot every day, they find that it takes more of their brain and takes them longer to arrive at the answer than people aren't smoking pot. And when they do scans, they can see that it requires so much more of their brain to work around all those unpruned weeds to find the answer.

iCAAD: So interesting. I didn't know that.

Dr. Modir: I tell parents that had no idea. And that you can lose a standard deviation in your IQ as a regular pot smoker who starts in their teens by the age of 25. They have no idea. The rise in the incidents of schizophrenia, psychosis, bipolar. They have no idea. It does cause sensitization of the dopamine pathway. It does cause cross-tolerance so that teenagers will seek out worrywart. You'remore likely to seek out cocaine and other drugs because you are sensitizing and priming the reward center for more reward. That's known and understood. It's also true for nicotine. I'm not saying it's just cannabis, but it's not not cannabis the way people like to say there is no gateway. That's not true. It's just not unique to cannabis alone.

iCAAD: We were talking about gateways, and you're saying they're more likely to seek out cocaine. And do you think there's a link between marijuana and opiate use?

Dr. Modir: There's also a link between marijuana and opiate use. And there are a lot of people who thought that if we legalized cannabis, especially for pain, that we would have a reduction in the amount of opiates being used, right? Here's a new way to treat pain that won't kill you. And it's got some mixed data that is moving towards the idea that it's not really a substitution drug. It's a companion drug.

That's kind of what the evidence is starting to show. I think a few years ago they were doing studies, and they showed that the number of opiate pills prescribed in states where there was legalized marijuana went down. So there were like 2 million less Vicodin pills out there when there was legalization. And in the beginning they thought (way back in like 2014 or 2015) there was some reduction in number of overdoses. And now, then they pull the data out. Are there less overdoses in states where people have legalized marijuana? No, there's not. There's more. So when they pull the data out to 2018 in states where marijuana is legalized, there are more drug overdoses, not less. And if less pills would lead to less overdoses, that should not be the case.

They've also done a study where they looked at 43,000 people from 2001 to 2005. If they were smoking marijuana at their initial interview, and these were people who had chronic pain and were on opiates, they found that you had 2.2 times the odds ratio likelihood of abusing your opiates by 2005, if you're a pot smoker. They also showed that you had 2.6 increase in the odds of becoming a person who had an opiate use disorder. So if you were smoking pot at your baseline and you were on opiates, you were twice as likely to become someone who became addicted to opiates. Two times the risk. So there's a lot of evidence mounting.

And then they just did a study in 2018 that looked at chronic non-cancer pain and people who are on opiates for their pain and were given access to marijuana in states where it was legal and they found they were more likely to abuse their opiate pain pill prescriptions, not less likely. And that's kind of why I say it's more likely to be a companion drug and not a substitute, but we're still trying to tease out the data. What looked like it was initially beneficial as we played it out more and in more studies has been looking more like people are more likely to just abuse both.

iCAAD: Yeah. And to be honest, I mean, if you look at historical data with, I don't know, methadone, for example. I mean certainly in the UK. I used to work in a methadone clinic, and I know that all the guys or girls who came in for their prescription, they would use them side by side. The meth would be the thing that they got off the government for free, and then they would go and use the street heroin that they would go and then buy. And they would just be able to save some money and not have to buy double the amount of heroin because they got it for free on the state.

And I suppose in a way, that's probably what could be happening with marijuana. And that's why the pills wouldn't go down. The Vicodin didn't go down because they're prescribing marijuana instead of Vicodin, but that doesn't stop... You know, the same amount of street drugs are going to be bought if not more because they're not getting the Vicodin. So they still want that. So they're doubling that on the street.

Dr. Modir: Yeah. And overdose rates are just, they're only going higher. It's 67 or 68,000 people. They're not less. So the hope that it was going to be like a substitution drug for pain and decrease the amount of people who were abusing opiates or had overdoses - so far and with more recent data, that has not played out to be true. It just seems to be that people who are going to abuse opiates already abuse cannabis.

iCAAD: So I think I know the answer to this, but for the audience and whoever's watching this, is CBD then completely different? We're talking about something that is totally and utterly different? When we're talking about marijuana being not such an effective or medicinal drug because it becomes a companion drug or a gateway drug, CBD on the other hand, is that something, as I said, beneficial and potentially effective and helpful?

Dr. Modir: Yeah. And it's not to say that marijuana isn't helpful. It's helpful for muscle spasms, increasing appetite and wasting. It's helpful for glaucoma, right? But it carries risks that have to be weighed that are greater than for cannabidiol. So when you take the marijuana plant, you have delta-9 THC which creates the addiction and the psychotomimetic effects of the drug. And you have CBD, which is a blocker of THC.

So it's kind of fascinating because in the plants itself, before people started extracting out all the CBD to make the drug more and more potent, it was pretty balanced. You would have the blocker CBD inside the same plant as the agonist. And so it would bring down the potency. So it was safer, right? And that's why you saw THC levels were lower, CBD levels were higher, and the drug was more balanced and the risk was less for all these negative outcomes.

But what happened is over time, people are like, "No, let's get rid of the CBD - more and more THC." People want to get higher and higher, and there's no evidence that you're getting higher. You can only get so high. Oh, by the way, you damage your dopamine receptors so that your ability to have joy and novelty moving forward also get damaged. So you're only going to get a little bit higher, and you're going to have less ability to enjoy regular life because you're damaging your reward center over time. And CBD, which is the blocker, has been shown to help with anxiety. It has anti-psychotic effects, which makes sense because if THC causes psychosis, then bblocking it and all the mechanisms in the endocannabinoid system can help improve psychosis. And that's true at very high doses.

In multiple studies, CBD has been shown to have anti-psychotic activity. It has been shown to have anti-anxiety activity. On the pain level, it's anti-inflammatory. So for a lot of inflammatory kinds of pain, it can be beneficial. And I think it's just in its infancy. So it's sort of like the safer version, but with people who have multiple sclerosis or have glaucoma or you know, have a lot of nausea, they might need some THC. But what's out in the dispensaries has a high, high level THC and low level of or almost no CBD. That isn't going to help most people's pain. And it's going to raise the risk of them having a psychotic episode, even if they don't have a family history of schizophrenia.

iCAAD: So I don't know this, but in medicinal marijuana, do they remove a lot of the CBD as well in that?

Dr. Modir: Well, yeah. You can go to the dispensary, and it just depends what you're getting. If you're going with what the FDA has, FDA has Marinol and Cesamet, and they control the amount of THC. And so every single pill has the same amount. But it's not from the plant. So nobody's extracting anything. It's really just THC in a medical form of it that's standardized. Epidiolex is the whole plant extract of CBD. Right?

And I feel like that's kind of in its infancy. And there, you know what you're getting because it's standardized and it's an extract that is routine out there. And the dispensaries, you have to believe them when they tell you there's this much THC or this much CBD. And now they have to be pain experts and say, "Well, you know, CBD will help this kind of pain, but not that kind of pain. Marijuana is not really going to help your this kind of pain or that pain."

And the reality is that they're not pain doctors and they don't know what the evidence shows. So they might give you a really high potency form of THC and tell you you need that. But actually you need low. 4% helps muscle spasticity. 4%. You don't need 17% to help muscle spasms. You need 4-6%.

iCAAD: So why are they telling people that they need really high potency? Is that because it's more expensive?

Dr. Modir: It's more expensive because they have to extract it. They are hybrids. It's more likely to create addiction. And then now that you have addiction, you have people coming back more. And to some degree, they don't even know because they're not pain doctors, they just work at a dispensary, and they're probably high themselves. "Dude, you should really try this." Right?

iCAAD: It's so scary.

Dr. Modir: It is. There's so much misinformation because there's not a standardized way of approaching it. "I got a prescription. So I'm going to get this." But really you walk in there and get whatever you want.

iCAAD: But why don't they make it standard? I don't understand. Why don't they make it standardized?

Dr. Modir: Well, I guess because it started as compassionate use. The Compassionate Use law for glaucoma, for nausea, for HIV wasting, it started way back in early 2000. And also because we made it a Schedule 1 drug, we were not really studying it except at very specific institutes because Schedule 1 drugs have no medicinal use. And so therefore, it slowed down the amount of research that was done on it in a way that could be beneficial to people. Even CBD. I think it was 2018 or 2019, hemp was brought down from Schedule 1ne. So that's why you see CBD at CVS, at the regular pharmacy.

But before that, you couldn't use hemp to derive CBD because it was considered Schedule 1. It was the Farm Bill that passed in 2018 where they put in there that hemp be taken off of Schedule 1 so that they could use hemp to make CBD so that people could use it, generally. But that's why the research is so far behind because the legislation and the laws really prevented there being a standard approach towards the research until the last four or five years, when the laws have been changing. And that's allowing people to do more of the studies to look at what kind of pain is benefitted, what kind isn't. CBD in 2018 from the Farm Bill, finally becoming something people can use, now they're studying it for pain, but our Schedule 1 really slowed down the amount of research for pain and other conditions.

iCAAD: You said at the beginning of this conversation that it was really complex. And it is. It's so complex and so difficult to know what's right, what's wrong, what should be done, what shouldn't be done in terms of everything - in terms of lore, in terms of education. What I'm getting from this really, what we've talked about is that education needs to increase.

Dr. Modir: Absolutely. The public needs to be informed in an educated way about the risks of THC, the risks of having higher amounts of THC? No, you're not getting higher. You're just going to get crazy. How was that fun? They study it - like who are the high potency users? They have anxiety disorders. They have depressive disorders. They are more likely to be male.

You know, they're sort of just zoned and spaced out. There are better ways to address an anxiety disorder than put yourself at five times the risk of having a psychotic episode by using high potency THC.

iCAAD: Do you see a lot of people come through All Points North Lodge who are addicted to marijuana? Do they come presenting with an addiction to marijuana or is it just generally something you find as you peel back all the layers of problems that they come with?

Dr. Modir: Well, I've been working in residential treatment since 2005. So I can kind of compare 2005 to 2020 across residential treatments. You know, I worked in Malibu in residential treatment, and I still do. I work in behavioral and mental health residential in Malibu also. So I can look across the populations. So what I have noticed is that I would say in the last five years, there's a much higher amount of cannabis-induced psychosis, cannabis-induced manic and psychotic episodes presenting. I would say this last February in Malibu, you can have six people and four out of six where cannabis induced psychosis - of all ages, 18, 25, 55, 45, all ages. And none of them knew.

And some of them took a long time to get better because they were trying to hide their psychosis, or no one really knew quite what was wrong. "They'rejust smoking pot." But it wasn't going away or symptoms were staying. And three of them were hospitalized psychiatrically first for a month before they came. And they still weren't better. I got them all better because I've done it for so long and I've had to treat so much cannabis-induced psychosis. The longer you leave it, it's harder to treat. It takes longer to treat, in a lot of cases, if you're showing up at residential. Maybe if you show up at an emergency room, and it's very early onset and you just smoked a little weed and you got paranoid for a minute, but these are people where for a month or two months or three months, they were resisting going to the hospital, they just wanted to keep smoking pot.

You know, they say it's not deadly. You can't overdose. But you know what? You can have a psychotic episode and in that psychotic episode, you can hear voices to kill yourself or to kill other people. You can believe that people are against you. You can be so miserable from these voices that you kill yourself. And I have seen that happen several times of people who have had drug-induced psychosis from marijuana that resulted in them killing themselves eventually. They would leave treatment. They would be better. They have aftercare plan for three or six months. "It's just pot, Mom and Dad. It's just pot. I just had that one episode." They start smoking pot again. They have another episode. Again, they go into that deep episode, maybe they disappear and no one can find them. And then they find them in a psychotic episode, they leave, then they ended up dying.

It's not a direct cause, but the downstream effects of having a psychotic episode from it can lead people to kill themselves. And in that regard, it's very dangerous. I mean, the people who were hospitalized for psychosis - one, he had a massive psychotic episode. He absolutely destroyed his room. I don't even know how they got him back there, but he's throwing things, breaking things. I mean, this is dangerous, right? It's not minor. The other girl, she's thinking that people are after her. She's just taping up all of the windows so that no one can look in and screaming at her parents and fighting and throwing things. And these aren't minor episodes where people are feeling like everyone's kind of looking at them funny. No, these are very serious episodes with ramifications that can lead to death if they're not intervened on.

So while marijuana itself might not cause you to die, if it gives you multiple psychotic episodes, if you get schizophrenia because you turn the gene on two years later, then secondarily you could raise your risk of death. So I think it's simplistic and dangerous to say that, "Oh, it's just a safe drug."

It's not a safe drug. It hits receptors all over your brain. It's not a clean drug. It's a dirty drug. And in the developing brain, it can cause you to have changes to your biochemical makeup in your brain that could last you forever. Now they're finding there are some genetic links. There's at least two genes that are linked to people having psychotic episodes on marijuana - the copS gene and the AKT1 gene. They have shown that if you have mutations in these genes, you have seven to ten times higher risk of having a psychotic episode on marijuana.

So they're trying to find out like, what is it? And they've also found that when they look at psychosis and people who've had psychosis from marijuana, it's a little bit different of a mechanism. It's not the same as like methamphetamine or cocaine. Different areas of the brain are involved, which is interesting. And that leads back to what you said because it affects so many different receptors. You have cannabinoid receptors all over your brain. They're not just in the reward system - that you can create a psychotic episode that may evolve in the next two years to schizoaffective or schizophrenia because you've now affected and primed so many different areas of your brain.

iCAAD: I mean, I'm going to leave this conversation really scared, honestly. Like, I mean, I know a little bit about the field and I understood the information that you've given us today has scared me. I mean, I find it really interesting, but I really, really hope that the rest of the world can hear this. What you're saying is so important because, and as we've said, I don't want to repeat myself, but so many people, so many young kids think it's a rite of passage and think it's okay and think that's what we should do when we hit thirteen.

Dr. Modir: They think it's harmless, right? But it's not that way anymore. It's not 4% anymore. And the approach towards it isn't like at a party or once. It becomes, "Oh, I use it for sleep every night. I use it for anxiety. I use it for ADHD." All these false claims where actually it's the opposite in most cases, and the amount of damage neurodevelopmentally you're causing psychiatrically you could be causing for the rest of your life.

And they have no idea, and their parents have no idea, and they think it's fine. And no one told them. They say, "Well, it's just a little pot every night that my 16-year-old is using to sleep." But it's not that way.

iCAAD: Well, I mean, thank you so much for the information you've given us. It's been fascinating. And is there anything else that you would like to add before we leave today?

Dr. Modir: Yeah. I'm just hoping that states who have created legalization pathways are going to create pathways to regulate use, regulate who uses, help educate them on the risks and the dangers - especially for the adolescent population and also for anyone in mental health who suffers from mental health problems, who's using it to treat their mental health problems. There's just not enough information out there about how it can worsen so many mental health problems, not improve them.

And then again, with the rising THC, the higher incidences of psychosis that occur, all of those risks and dangers need to be outlined so that people know what they're getting into and they're not surprised that they had this psychotic episode for four months and they don't understand why they're still not better.

"Like what happened and how could that have happened? It's just pot. I don't understand." I mean, I feel like I've had that conversation almost every week with somebody. "What do you mean marijuana can cause a psychotic episode in my 21-year-old?" And some of these cases, I'm telling you, it's not simple. It takes four to six months, and it takes high levels of medication and complex regimens were used. Some supplements have been shown to improve brain recovery. Some neural anti-inflammatories with the anti-psychotics all together to help people improve and a lot of education so that people don't walk away thinking, "I just had one psychotic episode. I can smoke pot again." Like, no, you've just primed your brain to have it happen again. If you keep doing it, your brain won't recover. And in two years, you're talking about between schizoaffective and schizophrenia, almost 50% of those cases going on to develop a long-term psychotic disorder. Serious.

iCAAD: Thank you so much. Sobering, but it's very true. Thank you so much, Doctor.


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