Mini Symposium: Emerging Cannabis Research and Treatment for Psychiatric and Other Priority Populations-Emerging Cannabis Research and Treatment for Psychiatric and Other Priority Populations

Emerging Cannabis Research and Treatment for Psychiatric and Other Priority Populations
Video Transcription
Actually, we have this new session this year, we will have two mini-symposia. As I mentioned earlier, we had such a high quality submissions that we wanted to include  as many as possible. So we came up with this format of mini-symposia, and I'm so excited to introduce one of our youngest symposia chair ever, Dana Rubinstein.  She's a medical student at Duke University. She is completing a concurrent master's of health science and clinical research through NIH TL1 grant.  Prior to medical school, she received her bachelor's in public health and Latin American and Caribbean studies. She is passionate about cannabis and tobacco research.  She's also interested in pain, disability, health equity, and policy, a lot of good interest. Her recent work uses epidemiologic techniques to analyze national survey data.  She also works on clinical trials and human lab studies in these areas. She will be applying for psych residency, hopefully, in fall of 2024, and aspires to  be an addiction psychiatrist. So she will introduce her panel, who is going to be discussing emerging cannabis research and treatment for psychiatric and other priority populations.  So here you go, Dana. All the best.  Hi, everyone. Thank you so much for coming to our first mini-symposium. I'm excited to present emerging cannabis research and treatment for psychiatric and  other priority populations. And I'll introduce, we have disclosures, no disclosures for us, basically. Someone added that slide in, I think.  So these are the speakers for today's panel. I'll be speaking first. I'm a medical student at Duke University School of Medicine.  We're glad to have Dr. Tony George afterwards, and he's a professor at the University of Toronto and CAMH, and he is also the co-chair of the symposium and has been wonderful in  supporting me as I put this together. And then lastly, we'll have Dr. Howard Padua, who is a research scientist at the UCLA Integrated Substance Abuse Programs.  So to go right into the first presentation, my presentation here, I'll be presenting trends  in cannabis use and cannabis and tobacco co-use among U.S. racial ethnic minoritized adults with serious psychological distress. We have a few objectives for this talk.  The first one is to understand potential effects of cannabis and tobacco co-use. The second is to describe trends in cannabis use and cannabis and tobacco co-use from 2008 to 2019.  And the third is to then examine these trends stratified by race, ethnicity, and serious psychological distress.  To start by defining some variables that we'll be using here, tobacco and cannabis co-use we're defining in the past 30 days, and cannabis use, when we talk about that, will also be  past 30 days. There are a few different types of co-use patterns that you can see. The first one is sequential use.  So this might consist of chasing a joint with a cigarette or vice versa, doing one right after the other. You can also have simultaneous use.  So this would be co-administration of tobacco and cannabis in a single product, like a blunt or a spliff, or some type of electronic vaping product.  And then the third is concurrent use. So this is using tobacco and cannabis product in a temporal time period such that their effects overlap.  So those are a few specific patterns we can see. But people can also be considered individuals who co-use tobacco and cannabis if they simply  use both tobacco and cannabis, even on separate occasions. This has significant effects. We know the deleterious effects that tobacco can have.  And we also know that cannabis use can have especially negative consequences in terms of psychiatric symptoms.  So when using both of these together, individuals with co-use experience additive psychiatric, psychosocial, and toxicological risks.  Individuals who co-use tobacco and cannabis also have an increased risk of initiation and dependence on both of those substances.  There's not much updated data on co-use trends over time. But here we see that we have a study from 2002 to 2014 using data from the National  Survey on Drug Use and Health, which I'll call NSDUH. This is tracking daily cannabis use over time and linear time trends by cigarette smoking status.  So the upper two lines, the red and blue, represent people who smoke daily and non-daily. And those individuals have significantly higher prevalence of daily cannabis use throughout  the whole study from 2002 to 2014. Additionally, the slopes of those lines are steeper, so they have a faster increase in daily cannabis use over time.  Looking at this another way, a different study also used NSDUH data from 2003 to 2012 and found that during this time period, exclusive tobacco use significantly decreased while  exclusive cannabis use increased and co-use of tobacco and cannabis increased. So based on those studies, I was interested in seeing the role of serious psychological  distress given the important role of mental health conditions and cannabis. And I was also interested in looking at race ethnicity.  So the panel on the left displays daily smoking trends in NSDUH from 2008 to 2019 in people  who smoke daily with serious psychological—showing the rate of people who smoke daily and people with serious psychological distress.  And the one on the right is for those without serious psychological distress. So importantly, we found that over time, people all four racial ethnic categories without  serious psychological distress decreased their cigarette smoking from 2008 to 2019, which is what we'd hope and expect.  And also individuals reporting non-Hispanic white race ethnicity with serious psychological distress decreased their smoking over time.  However, concerningly, those three overlapping lines on the bottom left, we see that those  are—those are closer to flat and individuals reporting non-Hispanic black ethnicity, Hispanic  race ethnicity, or non-Hispanic other race ethnicity had a stagnant daily smoking prevalence.  So there was no significant change in their smoking since 2008, which is a major problem.  Given these differences, I was further interested in seeing the role of cannabis use and whether  there might be differences in cannabis use by race ethnicity and serious psychological distress.  So again, I used the NSDUH data from 2008 to 2019 with a sample size of nearly 700,000 individuals, and this is a sample that's representative of the country.  For statistical analysis, I use a technique called joint point regression to analyze trends, which looks at not only the overall trend in time, but it looks for whether there are  inflection points when the trend or the slope of that line changes. The outcomes, again, the first one will just be past 30-day cannabis use, and then we have  past 30-day co-use, and these trends will be stratified by race ethnicity, as in the  previous slides, and non-Hispanic white, non-Hispanic black, Hispanic, and non-Hispanic other, which  unfortunately some of these other categories were too small to analyze themselves or collapse  into this group, and past month serious psychological distress was defined as scoring greater than 13 out of 24 on the Kessler Psychological Distress Scale, or the K6.  Results of this study, first we have overall prevalence in the US general population for cannabis use and cannabis and tobacco co-use from 2008 to 2019, showing the most recent  estimates of these trends. They both increased significantly since 2008. Cannabis use increases faster than tobacco and cannabis co-use to the extent that cannabis  use prevalence in the US population reaches nearly 12% in 2019, and is likely still increasing. Tobacco and cannabis co-use in our endpoint of 2019 ended at around 6%.  Now looking at these trends stratified by serious psychological distress, first looking  at past 30-day cannabis use, again the left side is those with serious psychological distress, and the right is those without serious psychological distress.  We see major differences here, such that all four groups with serious psychological distress  have much greater prevalences throughout the entire time period, including ending in 2019,  where some of those groups with serious psychological distress have up to two or three times the  prevalence of cannabis use as their counterparts without serious psychological distress. We also see that the increase in cannabis use and that rate of change is faster for  individuals with versus without serious psychological distress in all four categories.  Looking at cannabis and tobacco co-use prevalence, this is pretty similar, although we find that for all groups with serious psychological distress, again the prevalence is greater  throughout the study, and the slope is greater, so the increase is faster. That's true for all groups except for the non-Hispanic other race, ethnicity.  The prevalence is greater throughout for that group, however the slope wasn't significantly different.  So to wrap up these slides, cannabis use and cannabis and tobacco co-use have become significantly  more prevalent in the U.S. since 2008, as I said, reaching up to 12% and 6% for the prevalence.  Additionally, cannabis use and co-use had greater increases among individuals with serious  psychological distress across all racial ethnic categories, except for co-use among individuals  reporting non-Hispanic other race, ethnicity, and furthermore, the cannabis use prevalence was higher throughout the whole time period for all groups with serious psychological  distress versus without, for both cannabis use and cannabis and tobacco co-use. Limitations of the study include that NSDUH is a cross-sectional, is a repeated cross-sectional  study, so we can't follow individual trajectories. Additionally, serious psychological distress might approximate serious mental illness,  but shouldn't be used as a diagnostic measure. And looking towards what this means for the future, we need more research to better understand  the reasons for and consequences of cannabis use and co-use among priority populations. And one of the most important takeaways here is that the largest differences were between  individuals with versus without serious psychological distress. We know that cannabis can both increase the onset of psychiatric symptoms and worsening  for individuals who might already have some type of psychiatric condition or psychiatric symptoms, so it's especially important to continue monitoring this and screen for them  in clinic and continue working in this area. Thank you so much for listening to the presentation. Up next, we'll have Dr. Tony George, professor.  We will take questions, all the questions at the end. So next, we'll go right into Dr. Tony George's presentation, professor at University of Toronto.  Okay, well, good afternoon, everyone, and it's a pleasure to be here. And I just wanted to thank Dana once again because she came to me about six months ago  with this idea and she told me about it, and the only things I could think were, yes, ma'am, and you had me at hello.  So thank you, Dana, for moving this forward and organizing this. All right, so let's see. Okay, so I'm going to talk to you a little bit about cannabis as it relates to people  with schizophrenia, and, you know, I spent the first many years of my career trying to understand tobacco and schizophrenia, and so cannabis seemed like the next big challenge  in that population, and I come at it in the context of Canada, which like California and many U.S. states has legalized, but it's the entire nation of 40 million people in  Canada that now sit under one framework, and what I want to talk to you about first is how this has impacted on people with mental illness, and second, talk to you about I think  what could be considered an innovative evidence-based neuroscience-informed treatment for comorbidity of cannabis addiction in people with schizophrenia.  So just some acknowledgments, funding, I'm co-principal editor of a journal in the field of psychiatry called Neuropsychopharmacology, and particularly want to thank the support  of the NIH for the work that I'm going to show you, NIDA, and so the first study is an epidemiologic study called the International Cannabis Policy Study, and it is a survey  of health and economic outcomes pre- and post-legalization of recreational cannabis use, which happened in October 2018.  So we've now crossed five years, and we've been trying to figure out what have been the policy and economic and health and mental health impacts of Canadian cannabis legalization,  so a colleague of mine at the University of Waterloo in Ontario, Dr. Dave Hammond, has a grant that has been renewed for another five years, that we're collecting data since  for cannabis legalization in Canada in 27, 2018, and every year since then, we do this big survey, and about 45,000 Canadians longitudinal survey, and what I'm going to show you is  the data very quickly from, it asks the question, what happens to cannabis use and even daily cannabis use in people with defined mental illness?  Now, one of the limitations is, of course, this is all based on self-report, okay, and  the outcomes are, you know, all self-report, including diagnosis, so there's the big limitation  out front, but this team, led by my graduate student, Miriam Sorku, they're, I guess, on the left-hand side, and supported by Ziva Cooper at UCLA, and Wayne Hall at David Castle  in Australia, and Andrea Weinberger at Yeshiva in New York, has found that amongst, in the  first two years of this study, the only group that changed, significantly changed, its daily cannabis use were people with schizophrenia or psychosis, so that's at least, you know,  it's almost a six-fold increase, the odds ratio there is close to six. No other mental illness group, including people with substance use disorders, alcohol use  disorder, bipolar disorder, unipolar mood disorders like depression, PTSD, had a significant change, it was only this group, so take-home messages, you know, since we started doing  this in Canada, possibly the most vulnerable group of people with mental illness has borne a disproportionate impact, they may be only one or two percent of the population, but  they are, as many of you know who are clinicians, a big part of, you know, the burden of services  that, service delivery that we do, so not a good thing, if true, but we're continuing to collect data on this, and so it just sort of, you know, highlights to me why we need  to have important treatment approaches to doing this, and we don't have any effective behavioral or even pharmacologic treatments, and there may be many reasons why, there's  a tough nut to crack, but, you know, one thing that we've been doing in Toronto, and I just  came from the ACMP conference in South Florida, and we presented a symposium on using non-invasive  brain stimulation to treat addiction, and so RTMS is sort of the, probably the most well-known of these, is using magnetic fields to stimulate the brain, and it's been shown  to be effective in Parkinson's disease, it's approved for treating depression, it's even approved for smoking cessation, or cleared for smoking cessation by the FDA, as it says  there about a little over two years ago now, and so we apply these magnetic fields to the brain with the hope that we can, you know, address some of the underlying pathophysiology  that explains not only the schizophrenia and the cannabis addiction, but the comorbidity of the two, and we know that about 30 to 40% of people with schizophrenia have cannabis  use disorder, as opposed to less than 3% of the U.S. population, so this is an important issue to deal with, and so this just shows you we've targeted the prefrontal cortex,  or the frontal lobes, this is my former PhD student, Carolina Kozak, who led this study, which happened between 2018 and 2021, it was supposed to be finished in two years, and  it took four, because something called the pandemic came along, and the idea here is if we can stimulate the deficient area in schizophrenia, that is the prefrontal cortex,  the hypoactivity associated with that, which leads to positive and negative symptoms of the disorder, we can address the fact that the prefrontal cortex regulates the subcortical  areas that are probably directly dysfunctional, and cause these patients to be so addiction vulnerable. So that was our basic premise, very simple. Stimulate the frontal lobes, enhance the brakes,  turn down the dysregulated effective reward centers.  So with that, we did this study, we call it the CAN Stimulate Study, the Cannabis Schizophrenia Treatment with Intensive Magnetic Stimulation.  Not one of my better acronyms, but there it is. We had a great team, almost an all-star team in Toronto and a few collaborators elsewhere to help us do this.  It was funded by and supported by NIDA. They've been very supportive about this. And basically what we did is we used standard brain stimulation for 28 days, 20 sessions,  Monday to Friday, 30-minute sessions. I won't get into all the treatment details, but we randomized people to either get active stimulation or sham stimulation.  Sham stimulation meant they had a coil, you can see there, and it buzzed, just like the real coil when we gave active, but it was inactive, buzzing coils  that didn't deliver a magnetic field. So the patients couldn't discriminate it, the active from the sham, which was really great because this is a truly randomized,  double-blind study in that respect. So it's got a lot of internal validity in that way. And let's see if I can make this go forward here.  Okay, so, oh, you know what, that's the consort drive. You can't even see that.  We did this by the book. This is Caroline and Darby, who led the study. Caroline is a PhD student, and Darby was a master's student now. But anyway, we screened 100 people,  and we got 24 people into the study, and along the way, six dropped out even before we fully randomized them. So we only had 19 people, 10 in the sham group  and nine in the active group, and I'm sorry you can't see that so well. Some of the formatting got lost. This is just basically a description of the study. These were mostly men.  They were about, age-wise, they're about 30 to 35 years old.  High school-level education, average intelligence, mostly taking second-generation antipsychotics,  otherwise clinically stable, and let's see here, using about a gram a day on average. So they were cannabis use disorder, mild, or usually moderate, sometimes severe,  and otherwise a fairly refractory sample of people who, if they hadn't tried to quit in treatment, which is, it's rare to get these people treatment,  honestly, even in a big place like CAMH, they were very resistant. So these are hard-to-treat kind of people that clinicians in our schizophrenia program  or in the community referred to us. And so these are the results, effectively. So this is the first bit of good news. When we studied these people,  we wanted to make sure they stayed in the trial, and the retention rates were spectacular. In fact, in the four weeks of treatment, 100% of the people who started the study  in the active group with RTMS finished the study, and 85% or 80% in the sham group, the control group, finished the study. And there's one good explanation for that.  We paid the research participants progressive amounts of money every time they showed up for a session. So there was a good incentive, but the really good thing about that  is they almost got all of the treatment. So that's why we think that this is, you know, for real. This wasn't an effect of some random effect, and it's a small sample.  I can tell you, it doesn't sound impressive, 20 people with schizophrenia in a trial like this. That was a lot of work. And first of all, big dropouts historically,  but just simply giving them the incentive to show up for the treatment made such a difference. And even like my schizophrenia colleagues were like, wow, we've never seen this,  and that's the power of incentives, and we know all about that in addictions. Okay, so here's the top line results. This is the change in cannabis use  in the active versus sham groups, nine and 10 respectively in those groups. And if you look on the left-hand side, you see what happens to cannabis use.  And what we saw was a 60% reduction in cannabis use, self-report, compared to the sham group, only about a 5% reduction. So not quite significant statistically,  but the effect size of .72 was in the medium to large range. So that's really good news. And even when we looked at urine toxicology,  it's not as pretty, but you see a nice separation. We're using a rapid point of care test to do this. So not as pretty, but it's also a small sample,  and this was published last year in the journal Schizophrenia. And then just to go on beyond that, this is what happened to cannabis craving. So again, not pretty,  but what you see there in the open circles there is a pretty steady 50 to 60% reduction in cannabis craving over time, and really what turns out to be no significant  or no appreciable change in the sham group. So positive effects on consumption, craving,  and the other thing was we looked at concurrent tobacco use. And what's really interesting in our previous studies, not with brain stimulation,  we showed that people with schizophrenia who quit cannabis actually have an increase in tobacco use. So what we did here is a lot of these people  didn't quit cannabis use, but they reduced significantly. And what we showed, a nice validation of our initial findings, is that in those who reduced in the active group,  there was an increase, sorry, in the sham group, there was an increase in tobacco use, but that increase was completely suppressed by active magnetic stimulation.  So kind of interesting, again, a small sample, but it says something about the interrelationships between changing cannabis use and tobacco use  and how we might potentially treat that. And we've, in previous studies, shown that RTMS is effective in reducing tobacco craving in these people. So this is my left brain summary.  Stimulating the frontal lobes leads to a decrease in cannabis use in craving. Actually, I didn't show you this, but in positive symptoms of schizophrenia,  so delusions, hallucinations, and thought disorder. It increases some aspects of cognition, like sustained attention, and it decreases tobacco use.  So, and it's extremely well-tolerated and safe. So I've already told you this, you know, legalization has brought some potentially negative things,  like an increase in daily cannabis use selectively among people with schizophrenia, but possibly we may have a evidence-based treatment that may be utilized to treat these people.  So with that, let me stop and hand it over to Howard. Thank you.  Thanks so much, Tony. And thanks, everyone, for being here. It wouldn't be an appropriate addiction conference in California without talking about cannabis.  So really appreciate this opportunity. So just curious, show of hands, how many people in the room live in a state that has legalized cannabis, or country? OK, wow.  Well, this is not going to be that new to a lot of you then. Curious, since legalization, have you seen changes in terms of how many people show up  for treatment, what it's like to treat them? Just curious, a couple of people, if you want to call out any changes you've observed since legalization.  What was that? No difference. No difference. People think it's fine because it's legal. People think it's fine because it's legal, so it de-stigmatizes it.  Probation thinks it's fine. Probation thinks it's fine because it's legal. So suddenly, that kind of stick that would often push people into treatment is no longer there.  Kids are using more. Also, the kind of issues people are coming in with when they have cannabis use issues, are you seeing a change in that?  More mania in the ED, particularly amongst young people. Yes. So a lot of what we heard when legalization happened was that the public health implications weren't  going to be that bad. But we certainly have seen some implications of that. So I'm going to delve a little bit into what that looks like. So just again, to repeat on disclosures,  I personally have no disclosures to share. Our research is supported by the California Department of Cannabis Control, and it uses a lot of public data  from the California Department of Health Care Services. But the opinions here are not theirs. They are ours at UCLA. So our objectives here are going to be  to describe statewide, regional, and county trends in cannabis use disorder among the Medicaid population here in California specifically since adult use legalization in 2016.  Part of the reason Medicaid is particularly important to look at is because Medicaid covers is the number one payer of substance use disorder treatment in the United States.  So it's a very good proxy in terms of looking at a health care system. Second, we're going to look at trends in specialty admissions for cannabis use disorder.  And then also take a look at how treatment has changed in terms of retention and treatment outcomes before and after legalization.  And I also want to acknowledge my colleagues at UCLA, Dhruv Khurana, Brittany Bass, and Darren Urata, who helped out with a lot of this work.  So for background, we're going to answer two big questions here in this talk this afternoon. First, one thing we know is from research done in Canada  and also various states across the US that adult use legalization, or AUL, is associated with decreases in cannabis's price,  increases in use, and increases in the rates of frequent use, and more consumption of high-potency cannabis concentrates, all of which can lead  to increased prevalence of cannabis use disorder. But what we don't know is, what about at the local level? One thing that's important to keep in mind  is a lot of cannabis-related policy, particularly when it comes to treatment, when it comes to public health interventions, occurs not at the state level, which is always  what we look at, but it occurs at the local level. It's up to counties. It's up to cities. And just curious, Jeremy, you can't answer. Anyone know how many counties California has?  29? Close, 58. Double it. How many cities? This is a good one.  300? OK, here's 350, 400. 4,000. 5,000, that's too high. 538. So needless to say, there's a lot of variation in California. And California is a very big state.  But I'm sure in your states as well, there's probably a lot of variation by county and city. So what we're hoping is that with our work  here talking about differences at the regional and local levels, it can show why it's important to look at these things beyond the state-level data, which  is what the population surveys, like the National Survey on Drug Use and Health, gives us. Our second question focuses on treatment. What does legalization do to treatment?  We know from studies that have looked at SUD treatment systems using data through 2017 that legalization is associated with less treatment utilization,  largely because people are not being compelled in the same way. But it's not really associated with any changes in outcomes. And by outcomes, we measure this in two ways  when we're looking at big administrative data sets. One is retention, which we think of as 90 days as generally what's recommended by NIDA, and also treatment completion.  But the question about this is this is data from up to 2017. As you may have observed and may know, and especially if you have looked at billboards around  here since being in California, cannabis has become a lot more potent and has a lot of different forms. So these studies that look at data from 2017,  what about all of the evolutions that we've seen in terms of the things that people are consuming and how they're consuming them in the past six years?  Has this impacted the course of treatment along the way? As for our methods, so this is where the Department of Health Care Services data comes in that we use for this.  So what we did was we calculated the prevalence of cannabis use disorder using Medicaid claims. And this is for approximately 10.8 million Californians  each month from 2016 through 2020. 2016, you'd think, well, why didn't you look at it earlier? The answer is that because of changes in the ICD codes,  it's very difficult to look kind of pre-2015 to post-2015, unfortunately. So we had to look kind of post-legalization in terms of those trends.  In terms of calculating what is the rate, what is the prevalence among the Medicaid population, we use a rolling average because we know that a cannabis use disorder isn't  something like a cold. You don't have it for a week, and then it goes away. So how do we estimate this? Well, what we did was we did a three-month rolling average  for each municipality. And the reason we did this is we know that, on average, a US adult sees a medical provider once every three months, and CUDs last a long time.  So chances are, if you have a CUD, you will have had it for three months at the point your physician identifies it or it shows up in codes.  And then we calculated the monthly prevalence statewide by region and with our 58 counties. We did not get to our 538 cities. Someone else can do that, or I can do it  if they give me a lot more money. As for our second question, we looked at CUD admissions and the share of admissions. So not just looking at our cannabis admissions  going up or down, but is it going up or down relative to overall admissions for addiction treatment in Medicaid for individuals age 18 plus?  And this, we do have the data pre-legalization. From 2010 to 2020, this is about 1.4 million admissions in the publicly funded system for Medicaid beneficiaries.  We considered a CUD admission if marijuana or hashish was indicated as the primary substance. And in addition to admissions, we looked at retention, 90 days, and discharge status.  The way this database works, it has about 10 or 12 different discharge statuses. And there are four of them that say treatment was completed  or we had satisfactory progress in treatment. So that is how we defined a successful discharge. So here we take a look. And again, this is starting in 2016.  And I apologize that the numbers on the bottom there, you can't see the months fully. But we see the Medicaid claims population with the CUD diagnosis going up.  And the error bars are very small because we have a very large sample. But it is a significant increase over time. But then what's interesting is that's statewide.  Here we look at it breaking down the state by urban counties, suburban counties, and rural counties. And it was a lot of fun organizing all 58 counties  into one of these three categories, I assure you. But what you'll notice, and it's a little difficult to see, but so the rural counties, the red, highest.  Because the red counties, the rural counties, for those of you who are not from California, we have the area known as the Golden Triangle up in Northern California focused  around Humboldt, which is an area where there has historically been a lot of cannabis growth and illicit cannabis markets. So the rates have always been high.  So if you look at it, on the one hand, it's high. It didn't really change that much. And that's where a lot of the rural counties are. Then you look at the gray.  That's the suburban counties. The one that's actually moving is the green line. So you'll notice it's the urban counties. And particularly, the urban counties,  if you know your California geography, a lot of them are in the southern part of the state. And that gets borne out here if we  look at these 58 counties borne out by the five regions. And these are the regions as defined by the California Department of Agriculture. So again, the orange line on top,  certainly the highest prevalence. But it's not really going up. It's actually going down in these northern counties where cannabis growing has always been fairly prevalent.  Then you see the other regions, the blue, the gray, and the red. It's kind of flat. But the green line, if you look at it, it's a little up and down.  And it gets garbled with the gray line. But it goes from about 8.0 in 2016 to about 11 to 12.0 in 2020. So while we see overall statewide there's an increase,  four out of five regions in the state, it's actually kind of flatter going down. And where we're seeing it increase is just in the southern counties,  particularly where we are right now. So just to show here's a color-coded map. And this is looking at all 58 counties. The darker the color, the higher the prevalence. You can see.  So here's 2016, 2017, 2018, and 2019. So what you see is there's that very dark green in the upper left that kind of gets a little lighter over time.  And you'll notice that there is some very light green in those big southern counties that starts to get progressively darker over time, indicating more prevalence in these counties.  And just to underscore how much it is the big southern counties that are driving this change, here are the counties that have had yearly increases  in Medicaid prevalence year over year 2016 to 2019. We have San Bernardino, which is the fifth most populous county in the state. Orange County, the third most populous.  Riverside, the fourth most populous. And San Diego, here we are, the second most populous county in the state. So it really is these southern states where we see this.  So we'll talk about those implications in a second. Moving on to the results on the treatment side of things. Here are cannabis admissions over time from 2010 to 2020.  Look, it's going down following legalization. So you can say, well, it's been decreasing since legalization.  But I'm not even a quantitative researcher. I'm a qualitative guy. And one thing I can tell you is it was going down even before that, if you look to the left side of the picture.  So it's not really that legalization made a giant difference, as much as we see a continuation of trends of decreasing admissions over time.  Question comes up of, well, we see these decreases. Is this because overall SUD treatment is decreasing? And the answer is no. So this chart, rather than the raw numbers,  is showing out of all SUD admissions, how many are for cannabis? And we see cannabis's share is decreasing over time. So cannabis accounts for 20% in early 2010, down to about 10%,  half of that in 2020. So again, to the point about less people entering treatment, less people being compelled into treatment, we see that.  Also, something of interest, someone mentioned youth before. A lot of concern is around youth and the consequences of use, if you break down where is there a big change in terms of who's going into treatment, the blue line is 12 to 25-year-olds. The orange line, I think that's orange, is adults.  So what you see is where it's really, really dropping is among the youth. And this is problematic because of the fact that we know that youth are particularly susceptible to this.  We're seeing a lot of the negative consequences for youth as well. Also, it's interesting, though, because if you look at the data on use, at least in California,  use among youth hasn't actually changed that much since legalization. It's the squares like us, the 26-year-olds and more, who actually care if it's legal or not,  and it makes a difference. So it's actually use has gone up among adults, but treatment utilization has gone down among youth.  Then if you look at cannabis's share of admission, so again, this is as a percentage, again, we see the percentage of youth admissions going down over time,  kind of continuing a preexisting trend. Here we take a look at retention in terms of the outcomes of treatment. So the green line is retention for cannabis, and just  to get a sense of the context, the blue line is retention statistics for all other substances. And the pattern is pretty similar. Both kind of look like a three-year-old trying  to draw a straight line, kind of gradually going down a little bumpy. Then if we look at successful discharge, very similar thing in terms of the trend,  no statistically significant differences. So what are the limitations and conclusions? So a few limitations to know. One is that CUD prevalence trends may be issues not  about actual prevalence of cannabis use, but rather is it being identified by a treatment system? So if my county shows cannabis use decreasing, could it just be that the doctors  in my county aren't doing a good job identifying it and coding it when it comes up? However, given the fact that we see differences in admissions  and the trends in prevalence, we don't think that's the case. Because in most cases, when it's documented, we would expect someone to get some kind of service.  So what are the conclusions? So first of all, Medicaid claims data indicates significant statewide increases in cannabis use disorder.  But a closer look indicates that it's mainly driven by the populous Southern California counties, particularly those outside of LA. So what this means is that we need to do research  to figure this out. Why is this happening? Why are there increases in some counties? And we should also figure out what policies can we make to increase cannabis prevention,  early intervention and treatment. And then also in counties where there are decreases, what is it that they're doing right?  Or is it a matter of policy or something that they're doing? It's interesting when I shared this data with an audience of treatment providers from across California,  someone from Northern California raised their hand. And they said, the reason you're not seeing an increase in cannabis use disorder is  because everyone is using fentanyl in my county. So that was very sobering in terms of thinking of that as a quote-unquote success. But still research needs  to identify what's working well in the prevention field. And there's a group, Lynn Silver and her group at the Public Health Institute in Northern California.  Remember how I mentioned 538 cities? She actually, she and her group have gone through all 538 cities and all 58 counties codes to look at if you have a dispense,  like actually saying how do they regulate dispensaries? What rules do they have about advertising? So a lot of our next step is going to be to take that data  on what every municipality is doing and line it up to this to see if it makes a difference. Other conclusions. Admissions have been decreasing in California since legalization.  This is continuing a trend that was going on previously. And California's adult use legalization does not appear to have significantly shifted long-term transit admissions,  retention, or discharge. Also, I'm going to add something just because Dana had mentioned differences by race ethnicity. We have an article currently under review.  And what it's showing is that admissions are actually decreasing for whites, but not for non-Hispanic blacks and Hispanics. So there are many potential reasons for that.  One is we have data that shows that when people from those populations use cannabis, they're at greater risk for developing a disorder. That's one working hypothesis.  But these are things we're going to be unpacking in the future as well. And here are my references if you'd like to read up. And please feel free to email if you have any questions.  Thank you.  Hi, everybody. I'm going to just talk very, very briefly about some of the findings, and I thought the presentations were phenomenal, so thank you very much, and thank you, Dana,  for putting together this symposia. I'm just going to just make a couple of comments, and then we can open up for some questions. In terms of Dana's presentation, I think the  question that I have, and maybe other people have as well, is, okay, what does this mean for us in terms of treatment? And I think that, you know, clearly when you start getting  co-use, it seems that you have a more persistent, severe use pattern, and perhaps also substance  use disorder. Although Dana's presentation talked about cannabis use and tobacco use, you would assume that a good percentage of these individuals actually meet criteria for  cannabis use disorder and tobacco use disorder, but that was one question that I had, and I think that, you know, one of the questions that comes up is that there, you know, Meg  Haney has done research at Columbia in the laboratory, finding that people who were co-using  tobacco and marijuana were at greater risk of relapse in the laboratory model, but there's also data in treatment settings which have also shown that those who smoke tobacco as  well as cannabis are more dependent on the cannabis, they have more psychological problems, and of poor cessation outcomes, sort of similar to what Dana's research suggests in terms  of perhaps psychiatric comorbidity. You know, one of the questions I had as she was speaking is that, you know, what are the items of the scale that she was using and how relevant  it is for clinicians in terms of actually, are these individuals with a psychiatric diagnosis?  I mean, one thing we know, which is interesting, is there's an epidemiologist, Adi Talati, again at Columbia, who followed cohorts of people with tobacco use disorder, and what  he found is perhaps no surprise, that the current individuals have much higher rates of psychiatric comorbidity than people from the 40s and 50s when drug use, or in this  case tobacco use, was normative. As something becomes less normative, you tend to see more  psychopathology, and so I think that the fact that there was this co-use was not unexpected and was sort of consistent with that it may be more difficult for these individuals to  quit and more likely to have psychiatric comorbidity. I also think that, you know, one of the questions  is what are the treatment options, and of course the first thing that comes to mind is varenicline. I was talking to Kevin Gray, who's in the audience, about, you know, does  varenicline not only work for tobacco, but does it also maybe work for marijuana, and that's something that would be interesting to look at, and I think Kevin may have data  looking at that question, but it really begs the question that we really need comprehensive treatment, that if you have somebody coming in with psychopathology and cannabis use and  tobacco use, you're probably going to have to have multimodal treatment for these individuals, including both pharmacotherapy and various psychotherapies. Tony's talk really got my  attention as well, as someone who's very interested in dual diagnosis. You know, it's sort of  sobering to see that you're seeing more and more daily use, particularly in patients with schizophrenia or psychosis, and that if you have daily use, the chances of developing  a substance use disorder, in this case cannabis, is much more likely than the National Survey on Drug Use and Health has shown that, and that's the case here. I was very interested  in the TMS study component. It's such a hard thing to do, is getting individuals, particularly  people with schizophrenia, to come in every day for a period of weeks. The fact that you were able to accomplish that is remarkable. You know, people would poo-poo a study with  20 individuals in it, maybe, or 19, and I wish the study was larger because it seemed like there were a lot of trends and possibilities of an effect, and you can imagine, maybe with  a sensitivity analysis with 40 or 60 patients, you'd have a significant finding, but I think  it definitely is amazing pilot data to perhaps go ahead and do a larger trial. It seems like you might have to do almost a multi-site to be able to do this kind of work, and then  the question, of course, comes who's going to fund it and will NIDA fund it, which is a big hope. The other thing I will say is because I've been in this field for 30 years,  you know, there are effective treatments for individuals with schizophrenia and substance use disorders. There's a big literature with Bob Drake, who's done a lot of work, Bellock,  Kim Muser, and the problem is, is that their studies involve using comprehensive interventions, pharmacotherapy, very intensive treatments, and when you do all of that, no surprise,  treatment works. The problem is, is that the uptake of these interventions are very poor in most mental health clinics, so we have evidence-based treatment that does work. Now,  it would be great if TMS works as well, but we already have established treatments. They're just not applied, and part of the problem is evidence-based treatments are just not  generally applied in the treatment community because of resources, so while I'm delighted to hear about TMS, you know, the question I have is how well will the uptake be in the  community, and how can we get a treatment, and combining it with CM, which seems to be the way to go, that's a big question that came up as I listened to this. And finally,  with Howard Padua's talk, again, very, very interesting, because, you know, it's sort  of a little counterintuitive, you know, cannabis use disorder is going up, but therefore treatment  admissions are going down, but as somebody mentioned in the audience, and I think is true, is that as, you know, people, as marijuana use becomes normative, it becomes less of  a thing to go into treatment, and almost it's like, it's chastised if you consider going into treatment, you know, like, why would you consider treatment for marijuana? It's  a medication that's available for different medical conditions, at least, not FDA approved, but certainly out there, and you also have a situation where, you know, you talk to your  peers and say, if you're going in for treatment for marijuana, they'd almost probably laugh at you at this point. We do a lot of marijuana research at Columbia, and we put out ads,  and what happens when, we get a lot of business, but what the participants say to us when they come in is, I can't believe there's finally a treatment for marijuana, like, I didn't  think there was treatment, like, I thought you're just supposed to get better without treatment or you don't need treatment. So I think that's some of the factor of why we're  seeing a decrease. The other issue is somebody else mentioned in the audience about legalization,  that with the legalization of it, a lot of individuals, particularly adolescents, which is where they saw the decline, adolescents are often mandated into treatment, they're  not going willingly, so if suddenly that is removed, you're going to see less treatment emissions perhaps because of that, and there's a paper that just got published recently using  the NISDA data, which also showed the same thing by Menace and colleagues, M-E-N-N-I-S, and in that study, they're finding the same thing, which goes along with Howard's data,  but another study actually showed when it's legal, legal referrals into treatment, there's  not much of a difference, and particularly it's going up in ethnic minorities, in African-American  and Hispanic populations, so their rates are going up, particularly when the carceral system is involved, and that was one of my questions about maybe Howard can answer about  the communities, the southern communities, is it getting recognized more because of certain  biases of clinicians and that in a wealthier or a northern county, I don't know California well enough, but I'm thinking Sedona, I'm thinking, you know, where the wine country  is or whatever, you know, is there more likely to not be recognized by their physicians as having a cannabis use disorder, and that is there an inherent bias in our medical system  where certain populations are more likely to be recognized for it. Anyway, so those are my comments, and I'll open up for, I don't know if anyone wants to respond to what I've  just said, maybe in the panel, before we take some questions.  So I guess we have a few minutes for questions, so maybe if people want to come up to the mic. Yeah, and Howard, do you want to comment on my comment first before people come up to  the mic? Sure, so I think it's a really interesting question when it comes to case identification,  because you can look at this issue from two sides. On one side, you can say there's stigma, and there's certainly rape bias and things of that sort that make it more likely that  if you have a client from a certain racial or ethnic group, you're more likely to pathologize an issue and refer them to treatment. On the other hand, you can say, well, that person  is actually getting help, whereas the other patient who is not being recognized is not getting help. So I think that's part of it. The other thing to keep in mind is while I  believe the black African American population in Southern California is much more than in  other parts of the state, the Hispanic population is really throughout, particularly in those very northern counties that have always had a lot of very high levels of cannabis. So  I think the simple answer is it's complicated, but I think it also, the other area where I think there's an interesting signal is the fact that among, and as I mentioned, among  those who use cannabis, it seems that black and Hispanic populations are more likely to run into problems, more likely to develop disorders. And I think this also speaks to  part of the broader logic of legalization, which at least here in California was sold as a way to correct the social injustices of the drug war, which is wonderful. But a  lot of the way that was done was by saying, we're going to put all of these cannabis shops  in black and brown communities, and then are we shocked when we see cannabis use increasing  in the black and brown communities? So it's interesting that it was supposed to be a remedial  social justice progress thing to help them benefit from it economically. But as a result, it's also increased some of the problems in these various same communities that was based  on the public health assumption that cannabis is harmless. Selling it as just economic opportunity,  not a potential public health problem. And that's something where I think as a field, we need to do a lot in terms of communicating to the public and policy makers that pot is  not indeed harmless, but to not look like Nancy Reagan willy-nillies while we do it. So that's the trick. Thank you. Did you want to say it? We'll go to the first question.  Thank you so much. Anna Skandos from New York. We speak a lot about incentives, right? And the power of incentives. So I'm wondering, maybe you could speak from the perspective  of California. What is the incentive for...  People don't go into treatment. It doesn't cost money, right? So it looks good on paper. Here's all this treatment, and yet we're still saving money.  So I'm just wondering if you have any thoughts about that. Well, it's complicated. Again, I think that the question of incentives,  it's interesting, because you have some communities that have been very, very reluctant to encourage the industry. You have a lot of cities that have absolute bans.  You cannot sell it except medically. Then you have other places that have invested in it as an opportunity to advance social economic goals.  So I think a lot of it comes down to the constituents. And I think that the people who are concerned about cannabis as a public health constituency in California  are very vocal, but very small, and really dwarfed by the industry. The concern about big cannabis becoming like big tobacco is very real.  And I think because of that, the political benefits, or the politics of it, are shaped in a way that policymakers think of this as a matter  of economic opportunity without it being a real health cost. And also, policymakers, and this is not unjustified, when they think of the health costs of substance use,  they think fentanyl. They think methamphetamine. They think homelessness. They don't think the teenager with hyperamnesis. So I think that the incentives, it  comes down like with everything in our society. It's about voters putting in smart policymakers and bringing things to people's attention. Oh, boy. OK. Thank you.  And just to add to that, in Canada, we've had very similar things. We had gone into it with the hope that we would take a public health model. But unfortunately, the commercial side  has really come in. And the promise of taking some of those tax revenues and reinvesting that into creating treatment has not happened.  And so it's one of those, if you don't build it, they won't come. And I think that's what, in many ways, has happened. We don't have opportunities, so people don't seek treatment.  So we'll go over to this side. Hi. My name is Willow Neimark, and I work at Hazelden in Oregon. And my impression, anyway, is that cannabis  has been even more available in Oregon than California. And there's really evident biases in the community of cannabis is always good, never bad.  And I think that also extends to the payers for treatment, such that in a residential setting, insurance companies don't want to pay for it if it's only cannabis, even if they've  had really significant consequences of their use. So I don't know if that extends to the Medicaid payer system also. And maybe there have been a shift in the way they view cannabis.  Well, I think that potentially. I think also, though, the fact that the cannabis is very different, that we still think of the cannabis  from the 70s or the stuff that I never saw in my dorm in the 90s that was 2% to 3% versus the stuff that's now 30%. So I think the public still thinks of it  as this fun cheech-a-chom thing instead of the heavy drug that it really is nowadays. Do you have to stop? Yeah.  So I am very sorry, but in the interest of time, we probably, I think, you know, this was such a thought-provoking discussion. And we thought we had lots of symposias on cannabis  in the past. I think there is clearly a lot more we need to learn and discuss. But we have the next symposia. So I was going to. Is it right here? It's right here.  So I was going to request people who have questions, the panelists are available, please continue your discussion outside. And I'm going to thank you.  Thank you for such a wonderful presentation.
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