What do we know about adolescent cannabis use? Prevalence, harms and interventions webinar

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What do we know about adolescent cannabis use? Prevalence, harms and interventions webinar

 

 

Oh good evening, everyone and welcome to the positive choices webinar series: my name is marina ball and I’m going to be facilitating this session today. Before I continue, I would like to acknowledge the traditional owners of Australia and recognized a continuing connection to land, water and culture. I am currently on the land of the dark and young people and pay my respects to the elders past present and emerging.

I further acknowledge the traditional owners of the country on which you are based and pay my respects to the elders past present and future. I would also like to acknowledge the Aboriginal and Torres Strait Islander people joining us for the webinar. Today we have two speakers with us today who are going to be talking about adolescent cannabis, use its prevalence, harms and intervention. Our first speaker is Tom Freeman, who is an associate professor at the University of thought in the UK and is the director of Addiction and Mental Health Group over there. Our second speaker is Jack Wilson.

He is a PhD candidate at the Matilda Center for research. In substance, use and mental health at the University of Sydney before we begin the presentation, I will give you a brief housekeeping and also give you an introduction of positive choices. So, currently you are on listen-only mode, which means that we cannot see you or be, and we cannot hear you. However, we will have a question-and-answer session towards the end of the webinar. So if you do have any question on questions, please add it to the Q & A panel in your screen.

This webinar is being recorded and we will be making it available on the positive choices portal if you’re not familiar with positive choices. Let me give you a brief introduction. Positive choices was developed by the researchers at the Matilda Center and national drug and Research Institute at Curtin University. It was developed in consultation with teachers, parents and students and is funded by the Department of Health. It provides a central access point with accurate, up-to-date drug and alcohol information, as well as educational resources.

We have a number of learning resources, fact: sheets, videos and games to engage young people. We also provide classroom based drug prevention programs that are proven to reduce drug-related harm. I will now hand over to our speaker, Jack, who will talk to you about cannabis use over to you jack. Thank you, sweetie, okay, all right, okay, so thank you for listening everyone, and before we begin our meeting, I would like to acknowledge the traditional owners of Australia and recognize their continuing connection to the land, water and culture I’m currently on the land of the gadigal people Of the eora nation and pay my respect to their elders, past present and emerging, I further acknowledge the traditional owners of the country on which you are all and pay respect to their elders, past present and emerging all right, so just to provide a brief outline to

What we’ll be talking about today? I will firstly talk about the characteristics and trends of adolescent cannabis use as well as speak about the the effects that 19 may have on adolescent cannabis use Tom will talk about cannabinoids, cannabis, potency and different cannabis products and I’ll be talking about the endocannabinoid system as Well, as why adolescents are a particularly vulnerable, a particularly high risk of cannabis related harms. I’Ll then finish off by talking about the evidence, around prevention and treatment, and Tom will finish off by talking about harm reduction strategies. I think it’s also important to note here that there is a lot of content that we’ll be getting through today, and because of that, we might not be able to go into detail that some of you might want us to go into.

And, and so if there is anything that you would like us to go into further detail in the future, we’re happy to do one of these talks again, I’m sure Tom will be happy to also be involved all right. So bit of background cannabis is the most prevalent illicit drug worldwide, with approximately one hundred and eighty eight million cannabis users in the past year. Now 2.1 million of those are Australian aged over the 14 years of age and which makes them about ten point. Four percent of that population, 17 percent of twelve to seventeen year olds report ever using cannabis and five percent report using it weekly. The average age of first juice is just over 18 years of age and although reasons for cannabis use are very complex, the most common silent reason is curiosity as well as influences from friends and family. So I will be talking about two different datasets when talking about adolescent cannabis use prevalence, and that is the a ihw dataset which is a household survey.

Data set of 24,000 straily ins, a portion of which are young people and, in addition to that, I’ll also bring up the Guerin and Y data set, which is a secondary school data set of 20,000 secondary school students. So, as you can see, there’s a slight contrast in in how these datasets report trends over time. The household survey data shows a slight decline from 2004 to 2006. Well, there are a piece of e, a slight increase according to secondary school data in our use from 15 % to 17 % from 2011 to 2017. But the household survey data does report that there are minor increases in weekly use, so those that are using appear to be using more really and just to put it in international perspective. There is a reported slight increase within the US and European datasets, and I think it’s also important to know that, although within Australia there seems to be a slight increase or a slight decrease, this is really nothing compared to the more dramatic declines in alcohol and adalah And tobacco use among adolescents, so what we were thinking?

Why is that? Why isn’t cannabis really showing that same trend and one of the reasons may be changing perceptions around cannabis? Use I mean legal cannabis policies are becoming more common. We I’m sure we all know about this. In Australia there are legal medicinal cannabis products and therapy excludes administration, and there is also a surge towards trialing policies for recreational use. Now the household dataset does report that among young people there is an increased support for legalizing cannabis, as well as fewer young people, supporting penalties for illicit cannabis use, as well as more young people approving regular adult cannabis use.

Despite this among young people, cannabis is still most commonly nominated as the drug associated with drug problems, so rates of cannabis use may be changing in the face of changing perceptions, but I mean over 19 may have a more dramatic impact on a lesson cannabis use and We know that the Australian Bureau of Statistics has reported a pretty dramatic increase in nervousness and restlessness compared to before both restrictions and these people and sorry like alcohol. These people may be using cannabis to cope with some of those symptoms, and these people may be at the greatest risk of developing cannabis use disorder. Now I think it’s important to highlight the effects of over 90 non cannabis use may depend on availability, with restrictions, limiting human movement and the movement of products.

This has a pretty severe impact on the drug market, but it has been argued that cannabis use cannabis is less affected compared to other drugs because of its locally manufactured compared to other drugs such as heroin or cocaine, that are that are typically sourced from other countries. So what does the initial data say on how covert 19 may have impacted on adolescent canvas use? Well, we can see that there has been slight increase in use in the Netherlands but a decrease in the UK. A special report of the global drug survey came out and they reported a 40 % increase in cannabis use compared to before coated 19, which fiction’s in Australia has the second highest proportion of that increase use compared to any other country and most of the most common Reasons for this increase appear to have that appear to be that people have more time to use a drug or boredom.

Now. There is also concern over how young people use cannabis, typically through joints and bones, which puts them at a greater risk of infection, and they are all young people also more likely to engage in risky, behaviors and less likely to adhere to social distancing rules. It’S also important to acknowledge that the transition to homeschooling it may reduce the the information and prevention programs that are typically offered to to students. So that’s definitely something to be concerned about as well. So now that I’ve talked about cannabis, prevalence and trends over time and how over 19 may have impacted on these Tom will now discuss different cannabis products and including THC content and CBD as well thanks jack so run into Tom Freeman from the University of Bath. In the UK – and it’s really a pleasure to be able to speak with you today so when we think about cannabis, it’s often considered as a single drug, but actually can’t the cannabis plant produces many different cannabinoids and he’s going to have contrasting pharmacological effects.

I have important consequences for the consumer, so the most studied cannabinoids are THC and CBD, and you can see based on the effects that they have. They can have quite contrasting events, so THC is intoxicating, it couldn’t get people high and it can be a rewarding experience for some people, but particularly at high doses. Thc can increase anxiety and transient psychotic like symptoms. We know that one of the most reliable effects of THC is to impair cognition and also THC is addictive both in in humans and non-human animals, and we know that THC has these effects partially because of its impact on the endocannabinoid system and dogs going to talk About a bit more about this later, but you can see on the right here. This shows some of the regions in the brain where we have a high density of cannabinoid receptors. So areas like hip campus, which is very much involved in memory.

The prefrontal cortex is very much involved in planning and decision-making inhibitory control and the basolateral amygdala just below the hippocampus is. This is a reward and emotion related region. So when we think about the effects of THC, the endocannabinoid system matches on to its subjective and cognitive effects and our CBD is very interesting because it’s not an intoxicating cannabinoids. So when people use CBD they don’t tend to have any notable effects. But what it has been shown to do is particularly among clinical samples to have some potential benefits, for example in reducing anxiety and reducing psychotic like symptoms. There have been two clinical trials showing that CBD could be an effective treatment for the psychosis. Cbd also shows pro cognitive effects, particularly in people who have low cognition to start with, so it can improve memory and CBD may have potential as an anti addictive drug. So, overall, THC and CBD have very contrasting effects and a balance between these in cannabis could have important consequences, those who consumed it and when we think about different cannabis products. It’S really important to think about how they’re produced in the plant, and so the cannabis plant produces at least 144 different cannabinoids.

I’M only going to talk about THC and CBD today, because is the most widely studied and typically the most abundant in the plant. But all of the cannabinoids are produced in these glandular trichomes that you can see here, and these glandular trichomes play a protective role to the plant, and so there are two things they do and primarily one is to protect the plant against UV lights, which could be Harmful and a bomb and another is that they contain sticky secretions. So if an insect was crawling on the plant and the sticky secretions could trap them and kill the insect. So you find these glandular trichomes and hence the cannabinoids in the most important part of the cannabis plant, which is the flowering tops of the female plants. And you can see this on the image on the right there. You see a very high density of these try these try cones and that’s where the cannabinoids are produced and if we think about these trichomes – and this can lead us to understand why different cannabis products are made and why they might have different health effects.

Another thing about THC and CBD is it their production is genetically determined and there are three main different types of plants. So if you were to sample a cannabis plant from the population, it would typically fall into one of these three categories. So, on the horizontal axis, you can see the THC content and on me sorry on the vertical axis you can see the THC content and on the horizontal axis you can see the CBD content. Most cannabis plants produced for recreational use are THC dominant, and this means that they just produce high levels of THC. You won’t see much if any CBD in these plants, it makes sense of people who are growing cannabis juices because it can be more profitable because THC reduces intoxication. You can make more profits of THD dominant plant.

You do get mixed, THC, CBD strains and, as you can see here, this is shown in the middle. You see a moderate amount of THC and CBD for these, and there is some interest in this in both recreational and medicinal markets and it’s less common in THC dominant and finally, you have the CBD, dominant plants, these mainly produce CBD and just a very small amount Of THC and what these plants are used to produce are the CBD products that you might see on the high street Inaba I’ll talk about these a bit more in detail. But if you saw a CBD oil product, it would have very low levels of THC and these products that producing CBD, dominant cannabis plants. Of course, you do see variation between THC and CBD in terms of their ratio and different cannabis products when we think about thermal cannabis. Typically, this just contains THC, but there are very different types of herbal cannabis.

So, if left in its natural environment, cannabis is fertilized, so the female plants are fertilized by the males and as a result they produce seeds. You can see this on the left and the seed production reduces energy from the plant produced THC. So you might see a low level of THC around 6 % for a seated herbal cannabis, but what growers discovered was if you separated two female plants from the male’s they wouldn’t become fertilized and as a result, more of that energy would be used to produce THC And there are other methods, such as growing indoor and to increase UV light, wheezing hydroponic, growing methods. With with these kinds of methods, you can get around 15 % THC or increasing up to 20 to 30 percent THC limit and, as you can see, with some of these products, often called sensor media go hydro on the bottom right you can see.

This is a product called white widow named after its appearance, and you can see if you look closely they’re actually and the trichomes are visible to the naked eye. So you can see how much THC is is located on this cannabis product, which is very different from the seed of all kind of this on the left. Now cannabis resin is a different kind of product and there are different ways of making this, but one is by using a screening method and what you can do. It’S a very simple procedure. Growers have that hurdle cannabis product and they rub it over this screen, and the aim here is to detach the trichomes it’s a very crude method, but what it does is it detaches these program, heads from the cell and they fall through the screen.

It’s then produce loose substance called Keith, which is essentially the trichomes, and this is sometimes sold on recreational markets, but it’s not so common more commonly. What it’s done is that this substance isn’t pressed into resin or hashish, and so you can see here an example of resin or hashish. This often contains THC and sometimes CBD, when it’s particularly when it’s produced using mixed strains and see the THC concentrations can be quite high with cannabis resin when compared to verbal cannabis, and then a more recent development has been. The term concentrates and the first of these to really take taker impact, was butane, hash oil. So this uses somewhat similar principles to kind of is resin, but but a bit more advanced.

So so producers take their herb or kind of its material and they put it into a glass tube and then by using butane, they pass butane free, this glass tube and the butane dissolves, the cannabinoids from the trichomes passes through and then collects in a tray. This can then be heated for a process called purging, and this produces a concentrated product so to shatter named after it’s brittle appearance with around 80 % THC, and then this can get up to around 90 depending on the extraction process, and the reason that these methods Are more efficient than the saving method is actually extracts the contents of the trichomes cell? So with the cannabis resin it was just the cell heads being detached and so that’s less efficient. But the concentrates extract directly from the cell and when we think about concentrates such as butane, hash oil. There were several concerns here.

Firstly, butane is a very flammable substance and typically this is produced in unregulated and unsafe environments. So there have been several cases where buildings have exploded and there have been fatalities because concentrated production has gone wrong, which is quite a concern for the for the health of the producers. And another concern is that when you purge the solution, you actually left with residue solvents and so the product that people inhale is not safe according to medicinal standards. So there is a risk with these products that you’re inhaling I’m dangerous levels of the butane solvent and, of course, there are other concerns about the potency of the product that we’ll get into later. I should add that people have moved to more safe methods of extractions. Such as co2, but one of the risks, particularly in illicit environments, is that a method like this is very easy to do, as you can see with the rudimentary equipment, and so it’s particularly in illegal environments, when this kind of production method could could be taken forward And potentially go wrong and then edibles. This is another new development and it’s particularly its exploded in the legal cannabis markets in the u.s

So edibles are very, very popular in the legal cannabis markets, less so in legal cannabis market, but are starting to take effect and one of the concerning things about edible products. Isn’T they take a common, a common snack which might be attractive to children? So when I was the child, pop-tarts was a very unhealthy snack that I would never have a breakfast because it really is just sugar. In fact, you shouldn’t eat this. I was told as a child, but what they’ve done is attractive to children, they’ve taken and pop-tarts and they’re changing to pop-tarts, which look very very similar, but they contained 35 milligrams of THC.

It’s not surprising. These are attractive to the youth, and one of the major risks of these other products is accidental overdose. If we look in Colorado, which was an early state to legalize cannabis, what we can see is that 50 % of all admissions to pediatric hospitals for cannabis would use edible products, bearing in mind that these represented around 20 % of all of all sales. It’s really disproportionately high and so as a real risk of edible products that you might have accidental ingestion by children, adolescents and even pets. Now I’ll talk today isn’t focused on medicinal cannabis products, but it’s important to illustrate that they do exist and people may have access to them. So dronabinol is widely. Is the nausea and vomiting due to chemotherapy and it can come in capsules such as it’s a 5 milligram, THC, capsule and then sativex is a plant extract of THC and CBD used for spasticity and multiple sclerosis?

Epidural X was recently approved for the treatment of childhood. Severe forms of epilepsy – and this is just a CBD product, so looking at these first free products, you can see that there’s variation in some products being just THC, i’m dronabinol, others being just CBD, dialects and Sativex is a combination so similar to the recreational market. The medicinal products vary in their imbalance of THC in CBD, and also there’s better akan or other medicinal cannabis products which, as you can remember from my previous slide, this medicinal cannabis resembles Street cannabis. It looks just like sense, media, and in fact it is differences – is a better account of all other medicinal cannabis.

Products are produced to GMP, so they have standards of quality and the concentrations of THC and CBD will be more close to what they advertise that essentially it is the same product, and so this point of medicinal cannabis product is very difficult to distinguish from recreational cannabis. Once it’s taken out of it, it’s a prescription pot. I’Ve been researching, THC and CBD for over 10 years, and in that time I could never have imagined how how widely available CBD products would be. It’s really it’s quite astounding how many CBD products are available now and one of the products which is quite new is cannabis lights, which again just looks like a recreational cannabis product. This actually is a CBD dominant strain, and so it contains very low levels of THC. So in some countries cannabis light can be sold legally as a CBD product and other countries have no tolerance of any THC content. But again this is very to distinguish from other medicinal or recreational cannabis products. Cbd oil is very, very widely available around the world and it can be used potentially for health benefits.

Although the claims around these are not supported by scientific evidence and as this is progressed, we’ve seen a vast array of products, for example CBD hummus. If you want it to consume the CBD as part of your your lunch, you could, and even CBD dog treats, so so really there’s no limit to how how many products CVD can be found in these days, and there are some concerns particular when people are using These for their suppose, at health benefits with these Norma dissing or CV products are daily doses that people consume are around 25 milligrams and it is a low dose of CBD. By contrast to clinical trials that have found medicinal benefits of CBD is typically test. 200 to 1500 milligrams, the CBD.

So if somebody decided to use the CBD oil because they thought it might reduce their anxiety – and this was based on some research – I’d read it’s very, very unlikely that they would reach a dose CBD. All is liked are very limited. Phonological activity due to this low dose and so essentially going to be an expensive per 0, but in terms of the risks, because these products are extracted from the cannabis plant, CBD dominant strains still produce some THC, and so there is a risk of THC content leading To a positive urine screen, if you had a workplace or school based drug testing service, you might you might come as a positive test result having not even believe that you’re taking cannabis, you still have been exposed to THC, and particularly people used a lot of these Products, it is possible to reach intoxicating doses of THC, so you could easily in just 2 to 5 milligrams of THC. If you use many of these products – and this could have many health risks of Jack we’ll cover later.

Finally, some it can have no receptor, agonists or spice. These are very different to all of the other products I’ve discussed because they don’t contain plant-based, cannabinoids, THC or CBD. So what synthetic cannabinoid receptor agonist drugs are is a combination of synthetic drugs added to in a plant material, so there’s no kind of this plant here, it’s just plant material that has no activity mixed with chemicals. These are typically imported from China and they are sprayed onto the plant material and mixed in a crude way similar to the butane hash or which is done in a crude environment. This is often done with cement mixers, so people would mix the plant material with the product. This is an imperfect process very different to protect to production of a medicinal drug. So what happens is that you get variable drug concentrations and it might be that somebody consumes a small bit of spice and they find that there’s no effects, and so they think that it’s not very strong and then they can conceive a higher dose and they’ve actually Picked up a hotspot – and this is where there’s a high concentration of the drug and then this might be enough to make movi dose.

So it’s a very variable drug product, but in terms of the concentration of drugs within the product, but also the different combinations of chemicals and within and across different batches and from a pharmacological perspective. These are full receptors, receptor, agonist, cb1, receptors and so THC is a partial agonist, and this means it has weaker activity. As a result, these synthetic cannabinoid receptor agonist and have much more severe adverse effects such as seizure and death, and these are very, very risky and should be avoided at all costs and when we think about generally kind of aspersions he has been increasing in recent decades. Looking at the different products, it’s a high potency sense, Amelia or hydro cannabis at Dominic, Dominic, sand market in Australia, the UK, US and Europe and, of course, as we know, with alcohol consumption, if people have a spirit, they may consume less when compared to a beverage Of a lower concentration of alcohol, so people do potentially adapt their behavior when there was when they have the kind of this product with different THC.

So, for example, people might add less cannabis to their joints to add more THC or they might inhale less deeply. But we found from ecological studies is that this adaptation is only partial, so it would do somewhat adapt to changes in THC, but not effectively. So as THC increases in the product there’s a higher dose of THC delivered, potentially resulting in greater harms. This is a combination of previous studies published since 1972 2017, what’s called a meta-analysis of previous studies which investigated THC in herbal cannabis and as you can see on the vertical axis, you can see THC concentrations on the horizontal axis. You can see yeah. So overall, there’s been quite a clear increase in THC concentrations rising over time from 1970. In particularly in recent years, you can see very very significant changes in THC, so within herbal cannabis, the annual increase was one point three percent over a year and four Hacha resin. It was point five, eight percent, so kind of aspersion see has been increasing in recent years, both in herb or cannabis and in cannabis.

Resin. Okay, so now speak about adolescent arms, an endocannabinoid system. So, as Thomas mentioned, Kano’s potency is increasing quite dramatically and our lessons may be especially susceptible to the harms associated. Now I’m sure we all know that adolescence is marked by a period of dramatic cognitive development where they, where, during this time, they often seek reward in the face of uncertainty or potential negative outcomes, and a great example of this is early cannabis use now and therefore, Might not be surprising that adolescents demonstrate so Ellison’s that use cannabis at an early age demonstrate poorer inhibition and attention, as well as requiring additional neural responses to do as well as non-users. Overall, this suggests that sensation, seeking and and deficits in inhibition and attention may serve as risk factors for early age. Cannabis use. The cognitive deficits may not just be a risk factor, but they also may be a consequence of early cannabis use now, and this may be due to the impact that early age cannabis has on the endocannabinoid system. Now the effects of cannabis occur primarily through the endocannabinoid system, which is a biological system important in human development.

It’s made up of neurotransmitters called endocannabinoids as well as neural receptors and plays a critical role in that early development. It’s responsible for jet there. It can assist in the generation of neurons, particularly during cognitive development, and it’s also responsible for a wide range of functions, including memory and, and you can see in the figure there that the endocannabinoid system occupies a wide spatial range of our neural system. So during the important time of neuro mature raishin, the endocannabinoid system plays a very important role and hence it may be more vulnerable to disturbances from exogenous cannabinoids such as THC, which could have a Supra physiological effect on our cannabinoids and account knowledge. Receptors. Almost like an overload, therefore, altering normal brain functioning and possibly leading to an increased risk in mental health outcomes and cognitive impairments. Now, after evaluating the evidence around the effects of our lesson cannabis use, we can see that the greatest argument is for an increased risk of psychotic symptoms, followed by anxiety and in some cases, depression.

There is also some longitudinal evidence to suggest a link between early age, cannabis, use and possible neurological decline, particularly in IQ and episodic memory. Now I think the greatest message to get from this slide is that impossible II. Most of the talk is that these effects – sorry these, that early cannabis users are at the greatest risk when they use cannabis at an earlier age, more frequently and at a greater quantity. Unfortunately, little evidence has looked at how potency impacts on this association. So much of the evidence looking at the impact of cannabis potency on health outcomes is in adults. If we look inside the lab, we can see that study show a dose-dependent relationship between THC consumption and harms such as cognitive impairment, anxiety and psychotic like symptoms. If we look at observational studies, we can see that these effects persist beyond acute intoxication with where those using more potent cannabis products are more likely to have cannabis, use, disorder, psychotic conditions and depression and anxiety.

One particular study shows that compared to those using low potency, cannabis, use of high potency cannabis poses are four times greater risk of cannabis, use problems and a two times greater risk of anxiety disorders. So it’s important to look at the limitations of this research, so we can conserve ich an consider future research now, although studies looking at the health effects in adults are very helpful in drawing conclusion from the impact of cannabis, use, it’s very difficult to general. As these findings to adolescents, so future research must employee measures of cannabis potency when looking at adolescent cannabis use – and they can do this by including verbal descriptions in the questions.

So, for instance, when asking young people about what type of cannabis they use, maybe ask them about. You know what color was didn’t have seeds, some of those things that Tom suggested earlier. It also may be really helpful to include those pictorial aids, so pictures of the different types of cannabis, and in doing this we can guarantee a more accurate assessment of cannabis time. So considering that young, considering that people usually use cannabis at that sort of in that adolescent period, school is a great setting for delivering prevention programs. So a few systematic reviews have identified what works best in prevention, programs, prevention in terms of reduce sort of delaying the onset of cannabis use. Now we can see that interactive programs are superior to lecture style, so making sure that the participants are interactively engaged within the program.

It’s also important to adopt a social influencer approach, so not just not just giving information about cannabis use and the harms, but also helping young people develop skills to resist substance use. The instructor has also been found to be a pretty strong predictor of prevention program, efficacy. So teachers and clinicians must be provided with with the necessary information in delivering these programs. It’S also important to acknowledge the role of parental relationships and incorporating this into these programs. We know that parental style and family structures can have a pretty strong association with the initiation of cannabis, use and age which, at the age at which people use cannabis and the frequency in which they use. So another type of intervention is called prevention and it was developed by researchers at the University of Montreal.

Now Provencher is a personality target intervention for those that are at a greater use of a greater risk of using cannabis, and it identifies those personality Pro profiles for those that might be a greater risk and focuses on motivational factors for risky behavior. You know, while also providing coping skills now Provencher typically delivers four workshops where they focus on four different types of risk: personality profiles and those are anxiety, sensitivity, hopelessness, impulsivity and sensation. Seeking now, prevention has shown to reduce the odds of consumption 21 24 months following intervention compared to those that were at a higher risk that did not use the program.

I do not receive the program so, despite higher levels of problematic cannabis use. Very few people who use cannabis, seek assistance from a health professional and, as young people develop problematic cannabis patterns. Psychosocial treatment should always be the primary treatment option, so systematic reviews again have shown that optimal programs incorporate a combination of cognitive, behavioral therapy, motivational enhancement therapy and contingency management, approaches and they’re, also a mix of digital and clinical delivery. So emphasizing that digital delivery again, they have also been shown to be optimal when they have more than four sessions and delivered for over a month. Now, unfortunately, all those psychosocial treatments have been shown to lead to reductions in cannabis use at post treatment.

There is little evidence to suggest that these reductions persist long term now. Overall, there are a few limitations to consider when looking at prevention and treatment programs. So few programs have cannabis specific sessions and this is pretty concerning because there are risk factors in harms that are unique to cannabis, so there needs to be an increase in cannabis. Specific sessions also there’s a little discussion about different cannabis products or THC content, and this is quite concerning, because we’ve just heard about how THC is associated with those harms. Also, few studies have assessed the efficacy of treatment in adolescents, often looking at adults. So considering that the aim of these interventions is to facilitate the avoidance of cannabis related harm, Tom will now discuss some strategies to aim to minimize that harm thanks jack, so as as Jack Illustrated there.

If a young person is using cannabis, treatment really is the best option. Ideally, the best thing to do would be to stop using canvas altogether, but the long-term effects of treatment are mixed. For some people, it’s not effective. Some people are unable to quit completely and, for some people quitting isn’t actually their desired goal. They might prefer to use cannabis, and with this in mind, harm reduction guidelines can be very helpful because we know that the risks of cannabis can be very modifiable, depending on the way in which cannabis is used and so kind of Canada’s lower risk. Cannabis use guidelines have really been instrumental in this process before this there were never any evidence-based guidelines widely available to people who use cannabis. So these are ten recommendations based on a systematic, systematic review of the evidence and to anyone who is in contact with people who use cannabis and might be interested in reducing their harm.

I’D recommend this resource, so the first recommendation is important. The best way to reduce the rest, the risks of harm, is by completely abstaining. So if people can completely abstain, that’s the best thing to do if you can encourage that, but those who do choose to use a really important thing to do is to delay taking up cannabis until later in life. So if you avoid that adolescent period, you can potentially avoid the effects of THC on your neuro developmental processes is going to be met, much less risky if you use it in adulthood. Another key recommendation is identifying and choosing the lower risk cannabis products and those specifically are cannabis. Products with low THC or low THC to CBD ratios another point as illustrate as earlier.

Don’t use synthetic cannabinoids. These are far more risky and should be avoided at all costs. Now, when cannabis is used, it’s often burnt so smoking cannabis does carry significant risks and if you can find a safe way of using that doesn’t involve burning. This is preferable. Also, there are harmful smoking practices, for example, combining cannabis with tobacco. This can increase your risks of cannabis dependency and it can expose you to tobacco and potentially create an addiction to tobacco. In addition to cannabis, another important recommendation is to limit and reduce how often you use cannabis. This is possibly the most important one, because if we look at the adverse effects of cannabis, one of the most reliable predictors is frequency of use. If you’re a daily cannabis user. Your risk of psychosis is considerably higher than if you somebody uses occasionally and the same for cannabis, use, disorders and cognitive impairment.

So if you do use frequently reducing the amount, the number of days you use is very important as dragon I discussed cannabis can have cognitive imperative EPS, and so it’s really important that people don’t use and drive or to operate machinery, and this can be a risk In terms of accidents, how the relationship between cannabis and mental health is complex and we don’t have time to go into the full details here, but if you do have mental health problems or you have a family history of these, you should avoid cannabis and also, if You’re pregnant you should avoid cannabis, because THC can cross the placenta and these risks can have additive and potentially synergistic effects, so it’s best to to take all of them. If you avoid combining this with these risks, that can further reduce the harms that you experience. So, overall, these these evidence-based guidelines are very helpful and they are really good starting place for reducing the harms of cannabis. However, they do have some limitations at present, for example, they don’t have any recommendations based on the quantity of use. You can see the two recommendations that are related to your specific products and type of use.

They just speak about the type of products you use and how often you use them, but they don’t say how much you should use and how we could avoid harm that way, and this contrasts with with alcohol, where we have very good harm reduction guidelines for alcohol Around the world and if we think about alcohol guidelines, they’re very much based around concept of quantity of use, so, for example, in Australia, we have a concept of a standard drink and this can be used to for any different type of drink, whether it’s beer, wine Or spirits, based on our recommendations for healthy adults, you should drink no more than 10 standard drinks a week. This way you can cut your lifetime risk of harm. So by having this quantitative recommendation, this is a very effective way of reducing risks compared to having no quantitative information at all oppan cannabis. We don’t have that yet, but, as I showed you, there are different kind of its products.

They all contain THC. So the concept of the standard THC unit may be something that people could use to monitor their consumption and reduce, though risks so, for example, with less than the THC unit of five milligrams of THC, which is a low dose that can produce intoxicating effects, but not Adverse effects in my users, this could be a concept of use of people, could could use in terms of monitoring consumption on a weekly or monthly basis. I hope the concept of the standard SI unit is moving forwards in terms of NIDA the National Institute on Drug Abuse, and so it may be that in the future there are similar health based guidelines to those we have on alcohol. For example, you should consume no more than 10 THD units per week, and in order to make these recommendations we would need to have stronger evidence in order to guys guide consumers in this way, they’re thinking about to adolescents.

This could be a really good, concrete way to give recommendations about how much more vulnerable they are, because people like Jack and myself often provide the message of saying adolescents are more vulnerable, but by having quantitative recommendations, we can really say how much more vulnerable they are, And by doing this we can really hopefully encourage them to delay their use and by illustrating the increased harms based on quantity when using adolescents. Okay, so John’s gonna wrap up now, oh btw Jack. So I would usually take this time to wrap up and summarize what we’ve gone through tonight, but I’m aware that we don’t have much time left and for more questions.

I’ll just prove the summary, but I’m not sure Smyly. Perhaps you have these slides online. So people look through yes Jack. Thank you so much Jack and Tom Tom that was so informative, so much information in each slide that you talked about. Yes, the slides and the recorded webinar will be made available on the positive choices website. So we have some time left for questions so without any delay I’ll get to the questions. So the first question is: is there any long term impact of cannabis use on the neuromuscular system, yeah Tom? Perhaps this might be something they are you aware of anything?

I’M not aware of any long term impact, no, No okay! So that’s okay, and this second question is for Tom. You mentioned that 2014 studies found people who use cannabis partially adapted their smoking behavior when smoking stronger products, and also that in recent years for potency and types of products increased, is there any recent research on whether people adapt their behavior with these new products? Is an interesting question, so these studies were conducted in the UK. One one was by migrate and one was by a group in the Netherlands, quite similar studies, and so so for our study. We found that people as TBC increased their. I did less cannabis to their joints and the Dutch study found primarily the titration is based on less inhalation, and these were based on as THC increased.

They inhaled less cannabis, and these were based on typical herbal products. There was a very recent study published just last week that looked at concentrate used as well as herbal cannabis use, and there was some evidence of titration and people asked to consume higher or lower concentration products within those categories. So a particularly potent concentrates versus a less potent concentrate and the same for the herbal product. There was some evidence of titration, but what it did show is that those who consume the concentrates, the most potent product had higher THC in their blood. So it is a case whereby, typically as THC rises, you do get more THC, not completely it’s not it’s, not a one-to-one relationship, but generally, as THC increases. You get more THC in your blood interesting. Thank you Tom. The next question is among all Italians who use cannabis.

What proportion will become long-term users? Is it that the younger they start the higher? They are at risk of dependency? Absolutely so that’s one of the most robust fine in terms of risk of dependency, so people there are varying estimates of the risk of dependency and people who use often people would say it’s around one. In ten more recently, estimates have been around 30 % of people who use cannabis have a kind of misuse disorder. If you use an adolescent’s that increases to 50 % or higher so the young, you start the greater your risk of developing and kind of assistance or they’re characterized by assistant use, despite adverse consequences. I’Ll just extend on what Tom also said that one in 10 has always been sort of something that’s been communicated around the literature and yeah. Definitely there’s some.

Some newest studies, including one by my supervisor, Christina Morrell, has found that the the risk is actually much higher than one in ten okay. The next question is about your thoughts on how we can encourage young people who use cannabis to seek help. Are they not seeking help? Are they not seeking help because they don’t identify the cannabis use as problematic yeah? I mean, I think it’s. I think it’s sort of a bit of both. I think it’s sort of it’s both that they that they’re not often where they should be and as well as people, you know, sometimes don’t associate their cannabis use as problematic. A lot of people say you know it’s a plant, it’s not harmful, and I mean, although that’s sort of that’s something that really needs to be educated to users.

So it really drills the importance of information to young people, especially yeah, especially letting them know what what we know so they can be equipped with making the right choices and also preparing programs and treatment of as well. So I think, there’s a lot of a lot of onus on researchers, particularly this next question would be to Tom’s it on the harm reduction and guidelines you shared one of the guideline was to avoid smoking burnt cannabis. The question is, what does the current evidence say? Are safer ways of using okay so going back to the first recommendation, the safest methods of cannabis use is not to use any at all. Obviously, it’s important to note that if you do use combusting cannabis is dangerous when compared to either an inhaled method of, for example, a vaporize method or an edible method. And I should note that there have been risks, particularly in the u.s

 

Around vaping related injuries, and these were from particular cartridges that were made with THC concentrate. So there are some vaping related methods which are dangerous, but these are very limited and if you vape a normal kind of its products such as circle cannabis, this is much safer than combusting. So, essentially, you should be either vaping or using edible products, but you should avoid cartridges which are made with THC rather than a cannabis product itself. I hope that answers the question. It I’m afraid it’s not a particularly easy one to answer, and I should also add that donees recommendations were made before the problems came came out with these vaping related injuries. So it’s quite a nuanced message with the vaping, but overall vaping is safer than combustion.

I think it is important to answer this next question, so how do you help students and young people understand the difference between medicinal and recreational cannabis, yeah, a very important question. I think it’s important to identify why what types of medicinal cannabis being provided and why and the evidence around that and that’s difficult to communicate to to school students. But we’ve got to find out a way of being able to synthesize that and make it user friendly. So to speak, and and also just to sort of drill down there, as Tom said, the the it’s best to not use cannabis at a young age and to avoid those those harms. So yet I understand that it is very difficult to sort of divide between that medicinal and recreational cannabis use and and communicate that to young people. Tom, do you have anything to add you know just to add to that. I would recommend anyone who’s, considering this issue to speak to a healthcare professional one.

One good way to distinguish would be that if your physician recommends that you should use a medicinal cannabis products and they’ve assessed your symptoms and they believe that this an effective, safe treatment, then you could consider that as an option. There are many cases where people might think they’re using cannabis in a medicinal way. Actually they could be somewhat self-medicating and there’s a real risk here, both in terms of the product they’re using and the reasons they’re using it. So medicines are typically provided in a very controlled environment, using specific dosing regulations, and so it’s there’s a lot of overlap, but people think they using kind of its medicinal e, but actually they’re.

Not so also the evidence for medicinal cannabis there’s some evidence, but it is only for a few conditions. Is there really strong evidence so important to have that in mind best to speak to a health care professional? If you don’t, we have a few more questions. Just wondering if you guys can stay a few extra minutes some of these questions, yeah, okay. So the next question is: is there information on whether and how much polysubstance use, including cannabis, as opposed to cannabis, use alone or as the primary drug of concern, might be a driver into treatment? Well, sir, so you good, you go tom, very good Rick. I was just going to discuss the high prevalence of tobacco use amongst those using cannabis and especially when tobacco use in joints and so yeah. That’s something to consider, but in terms of treatment – and I don’t know, do you want to extend on that Tom? Can I just check that I understood the question: was this about whether police prosecution is a particular route into treatment? Could you repeat the question, sir? Is poly substance use as opposed to cannabis use alone or as the primary drug of concern or driver into treatment?

So yeah, based on the data cannabis, is a primary drug, is the majority of of cases but poly substance use is common and it’s often difficult to tease apart. The role of other drugs such as tobacco is often overlooked, and other drugs, such as alcohol, but generally cannabis as a primary drug, does account for a significant proportion of treatment admissions. I think it definitely varies on a case-by-case basis, so each person has their own set of problems and it’s something. When you look at treatment figures, you can often forget that each person has their own story and their own unique circumstances and just add that Charis uses quite frequently used by those with opioid dependence as well yeah. There is very little evidence to sort of look into the impact that cannabis use may have on those with, and so there are a lot of other substances conditions where cannabis may be the secondary drug use as well. So the next question is how how can you explain to a young person who uses cannabis to reduce the anxiety on a daily basis that it actually increases the anxiety yeah?

This is a tricky, a tricky thing to do in a motivational interviewing session. You might be exploring some of their potential positives as well as some the negatives of the drug, and you might see that there’s ambiguity whereby people do see some positives and they keep on using it perhaps through these anxiety. But it might be that in the long term they’re finding that as sleep is becoming disrupted, they are becoming more chronically anxious. I mean this is more of a negative effects, but of course we don’t know that for all people, cannabis increases anxiety for some people. It might have beneficial effects, and so this would be another situation where, on a case-by-case basis, it wouldn’t be that kind of it increases anxiety for everyone.

Okay, I’ll ask you two more questions, so the next question is: are there female and male differences in risk of harms from THC yeah sex differences is really interesting. Area of research and the findings have been mixed, but typically, what people see is that females do tend to be more sensitive to the effects of THC. Also, there’s some evidence that females respond more in terms of pain relief, so there may be some differences, perhaps related to the endocannabinoid system that make females more sensitive. Also, in terms of dependency, females are less likely to come forward to treatment, but they’re also less likely to try cannabis amongst those who do try. Females can have a poorer trajectory in terms of dependency and the last question I’d like to put forward is: would you agree that $ 1.00 in cannabis use is a major risk factor to poly substance use disorder in the future, so I can eat?

Can you say that again it’s ready, would you agree that adolescent cannabis use is a major risk factor to all the substance use in the future? Yes, I mean well, yes, a higher proportion of those that use more harmful substances, often use cannabis prior to that substance. But the reason for this is unclear, and this is typically communicated via the Gateway theory or a slippery slope argument. It can all be pretty cringe because this relationship is quite complex and but yeah. It’s definitely something to look out for that. Once someone uses cannabis, they are, they may be more likely to use other substances, and but whether this is due to the the sort of whether this is due to a lot of background factors or the pharmacology of cannabis and other systems that are whereby, if those Drugs are consumed.

That’s another whole argument soon, um Tom, do you have anything else? To add to that? No, I think that’s great okay, okay. I think I will in the question and answer section now. If you have any further questions, please do send us an email at info at positive choices: dot. Okay, oh and my apologies to those whose questions we couldn’t address here due to the lack of time. But if you do want your questions answered there, we are happy for you to email us and I would like to thank you again, Tom and Jack, for all your presentation and for making time for us and for the positive choices, audience and yeah for your informatics Session. Thank you so much. Thank you. Thank you. Thank you.