Tip:
Highlight text to annotate it
X
Hello, I'm Norman Swan.
Welcome to this program -
Mulling It Over: Cannabis Intervention In Primary Health Care.
Cannabis is the least disapproved of, easiest to obtain
and most widely used illicit drug in Australia.
It used to, in the old days, be thought safe,
and probably is less toxic than, say, alcohol,
but is associated with psychosis, depression, anxiety,
respiratory and other disorders, including dependence.
This program is about equipping ourselves in rural clinical practice
to recognise cannabis-related problems and deal with them to minimise harm.
We'll examine the latest research and best practice.
We'll also look at cannabis use and interventions in Indigenous communities.
There are a number of useful resources available
on the Rural Health Education Foundation's website:
Before you go there, you've got to meet our panel.
Alan Clough is Associate Professor in the School of Public Health,
Tropical Medicine and Rehabilitation Science
and the School of Indigenous Australian Studies
at James Cook University in Queensland.
- Welcome, Alan. - Thanks, Norman.
Alan is principally recognised in Australia
for his significant contribution to research and practice
in the field of substance-use problems in Indigenous communities.
Professor Jan Copeland is director of the National Cannabis Prevention
and Information Centre.
- Welcome, Jan. - Evening, Norman.
Jan is a psychologist and has a PhD in Community Medicine and Public Health,
and has made major contributions to the field of cannabis research,
before taking on the directorship of the new centre.
Fares Samara is a general practitioner in Kempsey, in NSW,
and is a staff specialist in the Drug and Alcohol Service
in the North Coast Area Health Service in NSW.
- Welcome, Fares. - Hi, Norman.
Fares is a member of the Chapter of Addiction Medicine
and has been so for five years,
and has a special interest also in Indigenous alcohol and drug issues.
Last but not least, Tess Finch, manager of the Sutherland Cannabis Clinic,
in the South East Sydney Illawarra Area Health Service.
- Welcome, Tess. - Thank you, Norman.
Tess has a Diploma of Drug and Alcohol,
and has worked as a drug counsellor for six years.
So welcome to you all.
What we thought we'd do tonight is run case studies
and talk about the issues
as we go through what we think might be typical case studies.
If they're not meeting your needs and there are things you want to know
that we're not meeting in the case studies,
give us a call or fax us, and we'll address that.
If you give us a call, we'll bring you into the discussion
and you can join in with us.
So let's start with Ben.
Ben is a 20-year-old man, who,
in the course of a visit to his GP,
that's Fares, with a cough and a cold,
states that he's about to join
the Australian Defence Force,
and needs to take
a routine medical examination.
But he fesses up that he's scared
of the drug testing,
part of that job assessment, because
it might show positive for cannabis.
He says he only smokes cannabis
occasionally, once or twice a month.
The last time was about two weeks ago.
Your patient, Dr Samara.
Ben is obviously worried, with good reason,
because he might not get the job. It's his whole future.
He's smoking, once or twice a month, doesn't seem to be excessive.
Last time he smoked was two weeks ago.
So very likely, he will get a negative urine drug screen if we did one.
I would perform one for him.
To start with, probably I'll do it in a confidential way,
just between him and I.
But I will use this occasion to opportunistically have a talk to him
about cannabis and its effects and the possible problems it comes with.
Tess, a bit harmless, isn't it, a couple of times a month?
The issue is that Ben has started smoking a couple of times a month.
As Fares said, he does need some information on cannabis and the dangers.
He needs to monitor his use and to know how to monitor his use,
so that if it becomes problematic, he will recognise it.
NORMAN: What are the risks at that level of consumption?
The risks are that he might start to enjoy that feeling more
and associate with people who are smoking cannabis more regularly,
so it could increase his cannabis use. Also that he might..
NORMAN: He might start keeping bad company?
Yes.
He might also start to reach out for cannabis when he feels life is difficult
and use it instead of facing his problems.
His problem-solving skills will actually decrease.
Did we pluck this out of thin air, Jan, or is this a typical story?
No, Ben is a quintessential, typical Australian cannabis user.
I have a graphic that shows the findings
of the most recent National Household Survey.
We see that now, as the '60s and '70s
happy cannabis users are ageing,
the peak rates of overuse
are now 30 to 39.
NORMAN: Kids aren't taking it up?
No, and our next slide will show that the good-news story,
in terms of the very significant reductions in cannabis use
that we're seeing in 14- to 19-year-olds and the older age group up to 29.
So this is terrific.
However, we're seeing that those stuck in cannabis use
are showing more problems.
There's higher rates of daily use
and higher rates of people expressing difficulty in controlling their use.
It's a different pattern in Aboriginal communities?
It is. That shift in the age distribution hasn't really happened
in the remote Indigenous communities where I've done surveys.
Still get plenty of young users in the 16 to 19 years bracket
and in the 20 to 29.
- It hasn't declined? - It hasn't, really.
In fact, it's gone up, Jan?
Yes. We don't have great national data, but what we do have indicates
that while we've got a 13% reduction overall in the general community
since the mid- to late '90s,
we've got at least a 5% increase in Indigenous communities.
I know in the communities that Alan has been researching in,
extremely high rates of daily use amongst this younger age group,
which is concerning, given what we know about the risks.
And, Alan, the earlier you use, the worse the outcome?
That's right, yeah.
12, 13, 14 is what sometimes you see?
Yes, particularly in Indigenous communities,
less so in the general community.
We're learning more about brain development from epidemiological studies
that use before the age of 16 is the red flag for later problems
in terms of mental health and dependence.
And other uses.
The youngest age of first use I've seen in Indigenous communities is ten.
NORMAN: And you've seen even younger.
A couple of times, younger than that, in the town I live in.
NORMAN: So, why the change, Jan?
What's gone on in non-Indigenous communities?
Is it just not cool to smoke cannabis?
Well, that's what we think.
We've, just in the last five years,
had good public-health campaigns around cannabis.
We've had better and longer campaigns around tobacco.
We think that part of the smoking is uncool and dirty and messy message
is rubbing off to those users who were possibly never going to experience
significant problems with cannabis.
They were recreational and experimental users.
NORMAN: So they switched to other drugs, kids?
I think so, at least in rural areas.
It might be different in big cities.
We have a fair bit of people who use speed.
I've got more and more people presenting with amphetamine use,
and alcohol of course stays the same.
The problem in country areas is the mixing of these drugs.
NORMAN: What does the household survey show?
The household survey shows that alcohol and amphetamine use
has dropped overall.
But I'm sure in some rural communities where there's issues of availability...
So despite the moral panic about alcohol, it's dropped too?
A similar picture?
Yeah. And we're seeing the same thing
with males dropping off at a more rapid rate than females.
We're seeing a convergence in the rates of use,
particularly in those young age groups.
What we are seeing an increase in is ecstasy.
And you don't know why?
No, except it has a reputation of being a cleaner drug.
It's more a fun drug.
The reputation of cannabis is that it's a stupid drug, a *** drug,
it makes you tired and not with it.
Young people want to go out and dance and rage all night
and be able keep doing that, and they enjoy it more.
JAN: But coming down, they use cannabis for that.
Of course.
How does cannabis rate with other drugs, Tess?
Cannabis has been thought of as a soft drug,
but working in a cannabis clinic, where people are accessing treatment for it,
we find that people have a lot of problems from regular cannabis use.
75% of the people who attend at our clinic in particular use every day,
and it is impacting on most areas of their life -
their social functioning, their workplace,
their relationship in the family and financially.
So it's not the soft drug that it was once thought of.
Let's go back to Ben.
What are you actually going to recommend for him?
I'd recommend for him to give it up,
especially if he wants to join the Defence Force.
He just can't do it at all, even twice a month.
Other than that, just tell him to watch mixing it with alcohol, driving,
the legal implications of it.
Again, apart from these things, if he smokes twice a month
and he's not at the Defence Force
and he's careful not to be caught by the police,
I don't believe there is a direct health implication for him.
He would join the majority of smokers who smoke occasionally.
As you say, Alan, we're looking at a very different pattern of use
in Indigenous communities.
It's quite different.
We have high rates of very regular use there,
with up to 60% of the 13 to 36 years age group
in some communities I've done surveys using on at least a weekly basis.
Jan, what do we know are the predictors of cannabis use?
We've talked about the obvious ones of being a male in the 20 to 29 age group.
In terms of of occupational categories, we know that people in trades
who work outdoors are more likely to be cannabis users.
NORMAN: Really? - Yes.
More opportunity to use in less supervised
and perhaps fairly routine and mundane work for some people in trades.
The group that we're most concerned about, apart from Indigenous people,
is those with mental-health problems.
They have higher levels of cannabis and tobacco use.
Which way does it go?
Some research suggests that if you have depression and anxiety as a teenager,
that predicts drug use.
Then some people say the drug use causes mental-health problems.
I think some of it is an association.
We're not that clear about causality,
although now we have good longitudinal studies
that have followed people from birth.
Typically, they start using cannabis
before they start reporting significant mental-health problems.
NORMAN: Drug use may come first in some instances?
More typically.
Let's go to our next case study, Owen.
He's a 23-year-old Indigenous man
with a wife, two kids,
living in a remote community.
He's got a chance of getting a job
with a mining company
doing land rehabilitation.
When he's gone for a job,
he's tested positive several times
in a saliva test.
He really finds it a struggle
to give up, and give up smoking.
He and his family share a single room
in a crowded house.
Most of the people around him
smoke cannabis frequently.
He's finding it tough to give up,
but he's desperate for this job.
Is this a real story?
It's a real story, Norman.
It's got a positive outcome, though.
The guy got the job after awhile. He succeeded in the end.
Obviously a tolerant company, willing to give him a second go.
A very supportive company that were prepared to give him many chances
to pass the drug-testing regimes.
I interviewed this man back in 2001 when he was a cannabis user.
I believe he'd started using at about the age of 14.
He'd been abstinent, he told me, for about 12 months
prior to applying for the position, but living in such circumstances,
where he has little control over many aspects of his life,
he's probably suffering the peer pressure to join in with his family
and consume, perhaps on weekends,
then failing the test on Monday when he turns up for work.
A common story, from your point of view in a country town?
Very similar.
Aboriginal people have a higher rate of unemployment,
lower socio-economic conditions, crowded housing.
Very high rates of cannabis use, and in a binging fashion too.
It seems to have taken over from alcohol in previous generations.
A very early initiation into cannabis use
and very common, often in primary-school age.
But, yes, a similar situation we have.
It's quite common, really a problem, especially the early use
because we're worried about brain development, frontal-lobe development,
which doesn't mature until the 20s.
What help did this man get?
Got a lot of help from the mining company.
Also, he had the support of his family.
His own determination saw him through in the end.
Like most drug use - most people just give up?
He gave up. He wanted to change his lifestyle,
he saw the benefits of doing that.
Not only did the job get him the position and the money,
it got him alternative accommodation
so he could maintain that change in lifestyle.
Is that reflected across the board, Jan,
that most people who want to give up just do it?
Yes. That's the most common story of what we call self-managed change
in common with other drugs, particularly the illicits.
People give up when they have good enough reasons to give up.
They get married, they have the job they really want.
Particularly having a family is often a key turning point,
where people have enough reasons to make that change.
The costs are starting to outweigh the benefits.
Are there proven interventions to help people get off cannabis?
In terms of psycho-social interventions, yes.
Cognitive behaviour therapy has a very strong evidence base now.
Let's not just glance over that.
What is cognitive behavioural therapy focused on?
It's focused on helping people change the way they think about cannabis
and how they respond to those thoughts.
NORMAN: Give me an example.
I can't be creative unless I use cannabis.
I wouldn't be able to relax, to make music,
whatever they see as the positive expectancies about cannabis -
I can't relax in any other way.
It's helping people move beyond that catastrophising -
it would be the worst thing in the world if I had to stop.
I couldn't get through withdrawal. I'd have nothing to do.
Helping them address the way they're thinking about cannabis use.
Simple things. Well, I say simple. Of course they're not to the individual.
Identifying high-risk situations, helping them do behavioural things
like bury the ***.
Rearrange where they typically smoke cannabis.
NORMAN: Remove the cues and triggers.
Exactly. Keep away from cannabis-using friends.
It's very important to separate,
when you're working with people in treatment,
their behaviour from their personality.
If they've been using for a long time, they become entwined.
NORMAN: They become the drug? - Yes.
So to categorise cannabis use as a behaviour,
then look at the positive personality traits of the person
can be really helpful to them.
You won't find many psychotherapists in Aboriginal communities.
No. These kinds of services we've talked about there are scarce.
And if they are on the ground, they're possibly delivered by clinicians
who have other priorities in a busy rural or remote clinic.
It's likely that somebody like this is also heavily dependent on tobacco.
What's the story between tobacco and cannabis,
and does treating one help the other, Fares?
Most people mix the two drugs.
- The majority, is it 90%? - In Australia.
Smoke tobacco together with cannabis.
So when we want to treat the cannabis, we also have to treat the tobacco,
which makes it doubly difficult.
ALAN: That's true for Indigenous communities too.
We don't have good evidence about how best to treat that.
Nicotine-replacement therapy, for example,
at the same time seems to make sense, but we don't have evidence.
NORMAN: Eases the pathway.
Given that we're talking about culturally determined treatments, often,
with Indigenous communities,
does cognitive behavioural therapy work with Indigenous people?
We have no idea.
This is one of the areas
that have received absolutely no research attention.
I don't think there's any prima facie reason to suggest why not.
But we need to move it up a notch to include family
and community much more broadly than we usually would,
particularly to identify people that aren't using in the community,
that might be safe people for the individual
to move into that extended social network that might be safer for them.
I imagine Alan would have more insight.
I'm thinking of prevention strategies in remote communities I've worked in.
These are isolated places
with populations of perhaps 2,000 or 3,000 people maximum.
The kind of intervention strategies that are needed at the moment
with cannabis use endemic have to be population-based.
They've got to be provided at the community level,
ideally with some sort of collateral supply-control strategies
to break the circuit.
Then there might be possibilities for one-on-one treatment.
Are there different patterns of cannabis use around the country
in Aboriginal and Torres Strait Islander communities?
We don't have that systematic data.
The work I've done has been primarily concentrated in Eastern Arnhem Land,
in the Top End of the Northern Territory.
In those communities, I surveyed in detail 200 or 300 participants
in a number of communities.
Recently, I've toured through most communities
in Torres Strait and Cape York, interviewing some key people
and seeking their views about the issues relating to cannabis.
There are familiar echoes between the Cape York/Torres Strait information.
NORMAN: Such as?
The kinds of issues people talk about are frustration with the trafficking
and the huge financial impacts it makes in these communities,
the acute psychotic episodes that are clearly connected with cannabis misuse
and the heavy financial burdens.
I estimated in the Northern Territory, up to $1 out of every $6
in a community's bank account, if you like,
was being relocated into the cannabis trade,
quite apart from the more subtle mental-health effects.
You would see that a lot, Tess, even in a non-Aboriginal community.
Yes, we do see a lot of mental-health effects.
We actually collect data in the clinic,
and we find that people who come into the clinic
have a higher rate of symptoms of anxiety and depression
than has been previously diagnosed.
And that could be secondary to their cannabis use
or that could be an underlying mental illness that needs addressing.
What's your practice with people from Indigenous communities?
In the medical service where I work, in a large rural centre,
we've done things more on a cultural, community basis.
NORMAN: What Alan is talking about? - Similar.
We've done things with sports, for example.
We've taken groups of young men in their early 20s, about 20 of them,
and done weekly or second-weekly aerobics classes, swimming.
NORMAN: Community development? - Yeah. And art therapy.
We've taken families of cannabis users, and they've painted pictures.
NORMAN: Sounds nice, but does it actually work?
It's very difficult to evaluate these things.
We've got ongoing programs. We do what we can.
NORMAN: What about training Aboriginal health workers
in cognitive behavioural therapy?
That would be great.
There's been some work done in alcohol -
cognitive behavioural therapy for Aboriginal people.
It's been culturally modified for Aboriginal people
with a lot of pictorial methods and so on.
Strong Minds, Strong Spirit.
Whether things like that could be adapted for cannabis, I'm sure it can.
It's just, we need the effort and the resources.
ALAN: I agree with Fares.
We need those kinds of community- development activities at large.
The question of evaluating them though is enormously challenging.
They're very hard to control or direct
because community development always takes on a life of its own.
But I'm confident that those sorts of strategies,
in communities I've worked in, have an impact.
Whether you do individual counselling or you're talking about communities,
one of the prime objectives is to get people to engage in healthy activities
rather than the unhealthy activities they have been participating in.
For GPs watching, this is about engaging the team around you,
and the resource is whatever happens to be available in your area?
Yes, and whatever the person is interested in doing.
Working with individuals, they have different interests.
They will do best at being directed towards those interests.
Jan, the predictors here are about poverty and deprivation.
Yes. Absolutely. Social determinants are a major issue.
However, we're seeing in the Indigenous work that Alan has done
and also in the wider community,
that a predictor of managing to get control over cannabis use
is being involved in vocational activities -
employment, in particular.
FARES: Housing.
So the things that fix up the community, fix up the drug use.
Nick is a 17-year-old boy brought in
to see you, Fares, by his mother.
She tells you he stays up late,
often doesn't get to school, is moody,
anxious in the mornings.
When he does get to school,
he has arguments with his teacher.
His school performance is dropping off,
particularly in the last six months.
He's not eating much, and seems
to be acting quite strangely.
He doesn't talk much, keeps to himself.
What do you think?
It's a real worry. This boy, he's in that difficult age group.
The other difficulty is that his mother brought him in.
NORMAN: He doesn't want to be there. - No.
No. He's probably coerced. I could tell that from his body language.
The first thing I would do is ask the mother to leave the room
unless he insists on having her there.
But I think he was quite relieved when I asked her to leave the room,
and I had a chat to him just together.
First, I would need to gain his confidence and trust
that anything he would tell me would be confidential,
that I'm here to help him, not to judge him, not to...
NORMAN: Call the cops. - ..dob on him.
Yes. I'd assure him I'm not a policeman or a teacher or a parent,
I'm a doctor, and that it's all confidential,
and that if I broke confidentiality, I'd be breaking the law.
Having done that, hopefully he would open up.
A proportion of kids will take that on board and respond?
Definitely. Yes.
A 17-year-old, I'm sure that he would do it.
Legally, confidentiality is assured at that age, even from 14 up.
I'd have a good chat to him and see how his private life is going,
what his interests are, why is he having trouble at school
and his appetite, not sleeping, acting strangely.
I'll have to put it in his own language.
NORMAN: Give me an example of the script.
OK. I would say to him, how is it going at school?
Do you spend any time with your friends?
Do you have friends? Do you have a girlfriend?
NORMAN: What are you listening for?
I'm listening to what the teenager would say.
I'm hoping he would tell me... I suspect he's abusing a substance,
unless we're looking at a mental illness, such as schizophrenia,
which at that age...
He could still be just a normal teenager.
It sounds like it's getting worse.
I might not be able to do much the first time,
and I hope I can assess him again.
But it sounds like I could probably get some information off him.
If he did tell me that he's using cannabis...
Tell me how you broach that subject with a 17-year-old.
I'll say, do you spend a lot of time by yourself? What do you do on your own?
Do you watch TV a lot? Do you drink a lot of alcohol when you go out?
I start with alcohol because it's sort of more acceptable.
Then I ask about dope. I'll just call it dope. Do you smoke a lot?
Do you smoke cigarettes? Then go on to cannabis.
He would tell me. I'm sort of confident I would get it out of him, hopefully.
For the naive person who might not know what's going on here,
give us the technology of smoking dope.
What's the patois that one needs to have?
Ah. I'll ask him about bongs and cones.
That's most likely the way he would take it in.
Most people these days smoke those.
- In the old days... - It used to be the joint, in paper.
Now they smoke it in bongs, and that's proven to be more harmful.
It's a water pipe made up either of $300 worth of ceramic, a nice one,
or an empty plastic drink bottle. OJ, they call it.
NORMAN: And they put cones in that. What's a cone?
A cone is a brass, metal piece
that sits on top of the plastic tubing.
They stuff it usually with tobacco and cannabis,
they mull it - hence the name of our program -
and they stuff it in and they smoke it.
It's an individual amount of smoke,
and it's inhaled very deeply and it's very hot.
It goes straight into the lungs.
If he said, I smoke a bit, how would you assess how much?
To him, a bit might be quite a lot.
I'd say, how many times do you sit to smoke?
How many sessions a day do you have?
This boy, I'm guessing,
will probably have a few before school and a few after school.
He would have four, five sessions a day.
Then I would ask, how many cones per session do you have?
And he'd tell me, six, seven, eight cones.
We're looking at anything between 30 and 40 cones a day,
which is quite a lot of cannabis taken in.
He might not be able to tell me in this detail.
I'd ask him how much it costs him.
He'd be buying them in buddha sticks - a stick wrapped in aluminium foil.
That costs between $20 and $30, it depends where you are.
NORMAN: How many cones would you get out of a buddha stick?
Probably 10, 10 to 20.
Many kids smoke one or two sticks a day.
So they're spending a lot of money when you think about their income.
Do you ever ask where they get the money from?
I avoid that question. No, I don't ask them that.
I do worry about it but...
That's part of getting close to the risky side of the conversation.
You're focused on the drug use.
Yes. I want them to trust me, to tell me what I want to know to try to move on.
Most people who use drugs enjoy it. They quite like the drug, don't they?
Well, certainly, people aren't stupid.
They initially give as a reason that they want to enjoy themselves and relax
or just try it and have fun.
Typically, that reason is lost as people progress and develop dependence.
Soon they're smoking just to feel normal
because they're going through early stages of withdrawal
and are actually smoking for withdrawal relief.
NORMAN: Do you agree, Tess? - Yes.
Sometimes people who have moved to a dependence,
they know that they're feeling anxious, irritable.
They might be feeling in a very low mood when they don't have any cannabis.
Like Jan said, when they have cannabis, it relieves all those symptoms.
They just think they're doing it because they like it.
The problem with a regular smoker, if they smoke regularly enough
like this boy, if he kept doing it for a year or two,
all it takes is four or five hours since the last smoke
to start getting into withdrawals, maybe overnight.
They wake up in the morning already in withdrawal.
NORMAN: Give us the symptoms of withdrawal, Tess.
Symptoms include feeling irritable and anxious, having a low mood,
perhaps nausea.
Sleeplessness is a very common symptom.
Feeling quite restless.
Sometimes people might do a lot of sweating,
particularly when they're sleeping.
FARES: Aggression. - Depression, yeah.
NORMAN: These are questions you might ask
about how he's feeling in the morning.
Are there tools available to assess how dependent he might be?
Yes, we have on our website at ncpic.org.au
some assessment tools there,
including the severity-of-dependence scale,
which is a lovely, five-item, quick scale
which correlates well to a full DSM-IV diagnosis.
It focuses more on people's concerns about their cannabis use.
So it resonates well with the user, rather than being in technical language.
That's a very accessible instrument for people.
When I read out that that case study, a lot of people would have said,
this might be first-episode psychosis.
How would you go about assessing that?
It can be. And this is the concern - it can be aggravated by cannabis use.
It can also be just psychosis.
The symptoms don't seem to be yet severe enough to diagnose psychosis.
NORMAN: But he's at risk of it, isn't he, Tess?
Definitely.
He's at risk of it if there is a genetic predisposition
to some type of mental-health issue in the family history.
I thought it was clear, Jan, from epidemiology around the world,
that there is now an accepted causal relationship between cannabis use
and schizophrenia in the general population.
Where you've got high cannabis use, like Brixton in South London,
you've got high rates of schizophrenia.
Yes, although the Brixton situation is complicated by,
they have a high migration as well,
which is also a significant predictor of schizophrenia.
But I agree, the evidence is certainly shifting in that direction.
Recent meta-analysis has shown that even one episode of cannabis use
increases the risk at a population level of about 40%.
When we talk about people like this young man,
using at an early age and using heavily,
their rates of full-blown schizophrenia are at least double.
It's certainly a dose-dependent relationship.
In terms of psychosis, the likelihood is even higher
that they'll develop psychotic symptoms -
something like five times the rate with this sort of history.
You're talking about permanent brain changes in this age group?
That's certainly hypothesised.
There's been brain-imaging work that's come out fairly recently
which was with very high-level cannabis users over a long period of time.
It's now showing structural changes in the amygdala and hippocampus,
which are very concerning.
There's similar work being seen in animal models as well.
It's important, too, when you're talking about young people
who are diagnosed with a psychotic episode,
it's important to remember it does come out around that age of adolescence.
Those young adolescents who do have psychosis tend to use more and more.
They get trapped into cannabis use easily.
I think we need to be alert, too,
that once they've had that diagnosis, that experience,
that cannabis use very clearly exacerbates the symptoms
and makes the course much worse.
It must be bloody scary.
I've seen cases like this in notes in remote clinics
that have progressed to suicide attempts and completed suicides.
This guy's probably lucky he's gone to a clinician.
The withdrawal can make you quite aggro, can't it, Tess?
Yes. We often hear of clients who become very aggressive
when they're withdrawing from cannabis, and even inflict physical violence.
It can be a problem for families,
not only for partners but also for parents.
If the young person is living in the parents' home,
they can become violent, punch holes in walls, attack people.
What sort of questions would you ask young Nick
to see whether or not there might be delusional behaviour?
The usual questions of, has he heard any voices that weren't actually there?
Was he given any commands that were unusual that are new to him?
Did he see things that do not exist?
Does he have any thoughts of self-harm or harming others?
The usual questions of delusions - hallucinations, auditory and visual.
We've got a question from a general practitioner on the North Coast of NSW -
'Is there any relationship between smoking cannabis
and smoking wormwood cigarettes?'
Not that I'm aware of.
I've never even heard of wormwood cigarettes.
I guess the kind of people who smoke cannabis would try something else.
Like wormwood cigarettes.
FARES: They're not Indonesian? JAN: No, they're clove.
A question from a general practitioner in Queensland -
'Is there a link between infertility and cannabis use?'
There is some early evidence of that link.
It's been shown to affect testosterone levels and *** motility in males,
and also to affect the menstrual cycle in females.
Once they get past the infertility, in terms of reproduction more generally,
it does cross the placenta and it is excreted in breastmilk.
A general practitioner in South Australia asks,
'Is there a link between impotence and cannabis use,
and can that be used as a deterrent?'
Related to lowered levels of testosterone.
Even more simply, it's the anxiety and depression that a man would have.
If you're part of that ageing baby-boomer, cannabis user,
it might be the tobacco causing it.
With males, you can use gynecomastia.
Similar to alcohol has been shown with cannabis.
- No-one wants that either. NORMAN: Absolutely.
This comes from a general practitioner in country Victoria -
'What messages do you use for regular amphetamine users
who use cannabis to come down after a 12-hour bender?'
Mixing the two together is the worst thing they can do.
I was going to mention amphetamine
when we were talking about delusions and psychotic episodes.
That's probably more likely to happen if they mixed it.
Using cannabis to come down is definitely not the right thing.
Cannabis doesn't relax you, doesn't take away that anxiety
that the amphetamine would give you,
nor does it take away the depression you may feel when you come down.
It may make anxiety and paranoia even worse.
Tess, you've got this 17-year-old. Fares has referred him to you.
He's a heavy user. He doesn't really want to be there.
Fares has got him over the line, but he's really resentful.
How are you going to look after him?
I'm going to provide him with psychoeducation around cannabis,
but at his own pace.
I don't think you can rush youth
into things they don't want to be involved in.
My priority at the moment would be to keep communication lines open with him.
Even if I had to say, 'Look...'
I would acknowledge that he might not want to be there,
but we need to do this to keep your mum happy at the moment.
I would also, if the opportunity,
depending on the setting, presented itself,
try to engage his mother in some counselling separate to him.
Because at 17, the family will play a very big role
in directing that child back towards positive activities
and a strong family environment.
Teenagers are very influenced by their peers,
but the family influence will last longer and is stronger in the long run.
You'll do some family therapy?
No, I wouldn't. That's not my area.
If I thought it would help, I would refer them to family therapy.
But I would work behind the scenes with the mother, if I got the opportunity,
to try to help increase his self-esteem and his confidence.
But don't families need help?
If you only treat the kid and not the family...
Definitely. A session with the mother is wonderful.
I'd also refer her to a great organisation called Family Drug Support.
They've got a website, easy to find.
They support each other, give information,
do the things you were saying.
It's like anorexia or other drug use -
you've got to have a script to be able to deal with your teenage child,
and know how to behave and how not to behave.
Must be like walking on eggshells.
It can be really difficult for families.
The parents lose their self-esteem, they don't know what to do,
they're worried for the children.
It can spiral downwards quickly if the family aren't supported.
I was attending a drug conference a couple of weeks ago,
and there was evidence from the UK that if you don't treat the person at all
but treat the family, you can get excellent results.
In other words, forget about the person with the drug problem.
Just treat the family, and you start to help the drug problem.
That was part of an intervention we ran a few years ago
called the Adolescent Cannabis Check-Up,
where we first worked with the concerned other, typically the parent.
It's called unilateral family therapy - coaching people over the telephone
in how to approach the person with the cannabis problem.
It's very successful in helping engage them into treatment.
We have a resource on our website
called Talking With A Young Person About Cannabis,
which is freely available, which we used in our intervention.
We found that parents found it very helpful.
It's very clear if you have a couple -
one of them is trying to come off cannabis -
to explain to the other partner that these symptoms are going to happen,
to be prepared for them, to educate them about the symptoms
and to be patient and give them time.
I tell them, this is not John doing this, it's the drug coming out of John.
But sometimes the person living with the person has to accept
that they're not ready to come off, and you've got to get on with it,
which is what unilateral therapy does.
We also approach with young people more motivational...
As Tess was saying, we're not here to treat you or make you do anything,
we just want to talk with you about your cannabis use.
That approach helps engage young people.
Tell me what you say.
Things such as Tess said -
we know you're here to please your parent, and that's terrific.
That's a great first step.
Tell us about your experiences with cannabis.
What are the good things?
As we mentioned before, people typically have what seemed at the time
very good reasons for using cannabis.
Then we explore what might be less good things about cannabis.
They do come up with things,
particularly financial, with young people.
If they don't see the discrepancies in what they're raising,
we might say, you're not ready to think about change,
but how would you know when things weren't going well with for cannabis?
Then often they raise things they've already mentioned,
and highlighting discrepancies in those sorts of things
are a good technique with young people.
It works on the principle that every drug user, every dependent person,
has a part in their subconscious mind that doesn't want to use,
a part in their mind that they hate about the drug.
Our job is to stimulate that part
and bring out the negative aspects of their habit to them,
and let them verbalise it and say it.
Sometimes maybe write it down, bring it back next time,
in order to reinforce their willingness to change.
Otherwise people get defensive and defend their drug use -
no, it's not a problem.
It forces them into that kind of response.
If they're heavily dependent, you've got to talk them through that.
They might be scared it's like ***
and they'll have to detox in a major way.
Yes, it's always good to talk to them and explain to them
the cycle of cannabis use, cannabis dependence, cannabis withdrawal,
Help them be aware of what feelings are associated with that.
Ask, do they identify with any of those feelings
or any of that information to try to continue to engage them.
Let's go to our next case study, Gail.
She's 45 years old,
a single mum, two teenage kids.
She lives in a rural, coastal town,
in fact, your town, Fares.
She's been smoking cigarettes and
cannabis regularly for about 20 years.
She's got a productive cough
and recurrent respiratory infections.
She comes to you saying she's
having trouble holding it all together.
She feels demotivated,
she doesn't like going to the shops,
doing what she used to.
She just feels a bit worthless.
She's depressed, and at times she's probably anxious,
which is the flipside of the coin.
She's going through mood disturbances, most likely related to the cannabis.
Either caused by the cannabis or aggravated by it over 20 years.
So this is classic dual-diagnosis territory?
Yes, and it's a classic case - single mother, difficult circumstances.
NORMAN: What are you going to do for Gail?
She will need treatment.
Like we said earlier, I will explain to her first about information.
It wouldn't be as difficult as the guy before.
NORMAN: She's ready for help? - She's further on the cycle of change.
She's motivated to change.
We will talk to her about withdrawal symptoms,
and help her through the withdrawal period,
which can last up to three to six weeks.
People say that when you talk about comorbidity, the dual-diagnosis story,
that if you've got depression, you won't get people off drugs
until you treat the depression, and the other way round.
In other words, you've got to treat the mental illness.
The question I have for you, Jan and Tess, is,
is cognitive behavioural therapy enough to lift the lid,
that you're going to treat both at the same time,
or is there a case for a short-duration antidepressant?
Is there any evidence for that, Jan?
Cognitive behaviour therapy started with mental health.
It started as a treatment for depression.
A skilled clinician should be able to apply CBT to both conditions.
NORMAN: Does it work through the fog of cannabis if she's a heavy user?
If she's intoxicated at the time, that is certainly a problem.
It's much easier if people come to treatment
not heavily intoxicated, anyway.
But if that's not working in the first instance,
then someone like Fares might be the next port of call.
Even if she wasn't intoxicated, even if she'd stopped,
she will be so anxious and depressed, she will not be sleeping,
she will be irritable,
that she will find it difficult to engage in cognitive behavioural therapy.
She won't be able to keep the appointment,
let alone concentrate and do the homework and exercises.
This is where I believe some pharmacotherapy
as well as psychotherapy might help.
Randomised trials have been disappointing.
That's right, so far.
But we've done some work on anti-anxiety medication
that I've been prescribing for seven years.
It's also used in South Australia.
Short-term, mild treatment for anxiety,
sometimes coupled with antidepressive behaviour would be good.
Here, I want to mention that
the only accepted treatment for anxiety is benzodiazepines.
I would like to discourage my colleagues in prescribing benzodiazepines
for someone who's trying to stop...
NORMAN: You create a new set of issues? - Yes.
We're finishing up some clinical guidelines around cannabis,
and we do mention, after much debate and angst,
that's the line of last resort.
You mentioned pericyazine and other antidepressants.
We know they're used quite a lot off-label for cannabis withdrawal
and reduction of craving.
I've found that, anecdotally, very useful.
People have less symptoms of anxiety, they can sleep better,
they can engage better.
NORMAN: Do you have trouble getting them off antipsychotics?
Very easy. It's only a small dose.
We use a quarter of the dose that's used for psychotic...
Which is one of the ones the randomised trial showed nothing?
No, pericyazine has not been subject to a trial.
We've done a reverse study, and we're hoping that...
What's the outcome for someone like Gail if she is motivated?
I think it's very good.
If we can manage to encourage her through whatever means,
whether it's through medication or counselling, to cease cannabis use,
it could be a very short turnaround
until the time she's so pleased that she's stopped using.
NORMAN: And she's ready for other therapy.
Yeah, and her life has changed dramatically.
She's somebody you could have a mental-health plan for?
Definitely.
This is one where a GP can access help from a psychologist,
who will be spending 12 times an hour and a half with her throughout the year.
A GP could never do that, nor has the skill to do that.
Not too many around in Aboriginal communities.
We've interviewed women like Gail.
It's very unlikely she'd come to clinical attention
unless she went to the clinic for another reason.
But you can be sure they're out in those remote places.
Yet again, the resources to help people like that
with culturally appropriate CBT in Aboriginal, Indigenous
and Torres Strait Islander communities is important.
We're talking about two teenage kids. Nobody's talking about men.
I was going to raise that.
NORMAN: Are they at risk? - Absolutely.
We don't have good studies, unfortunately,
on intergenerational issues with cannabis use,
but we know that's what we're seeing.
There's families that have been using cannabis for two and three generations.
As the evidence is building about the harms related to cannabis use,
particularly in this kind of pattern,
it may well be that for the first time it's being recognised as a problem
attributable to some of the families' difficulties.
We've got a question from a psychologist in New South Wales -
'Is there evidence to support the proposition
that long-term cannabis use results in memory loss?'
Yes, certainly memory and learning are one aspect.
NORMAN: Is that an intoxication phenomenon
or long-term phenomenon when you come off?
What we see is, those memory problems improve with long-term abstinence.
It's a positive message that does improve over time when people stop.
I was distracted when you were talking about the teenagers -
what would be the recommendations to deal with these teenage children?
First, the positive role model of their mother stopping cannabis use
and having better information to share with them
and for it to become a family discussion around cannabis -
I thought it was fine when I was a teenager, but this is where it led me.
Do you often see kids with parents in this situation?
Sometimes we see kids with parents.
I agree with Jan.
The most important thing is that the mother turns her life around
and becomes a positive role model for those children.
What we've already spoken about around adolescence applies.
If they start to engage in smoking cannabis,
she'll need to apply the same strategies
and pull them back towards positive, healthy activities.
What I don't understand yet is, what is the treatment goal?
Are we aiming for controlled use? Are we aiming for abstinence?
What's the story?
It depends on the person, on the stage of addiction they're in.
We don't tell them which one they should do.
We try to reduce the harm.
Initially, we try to control the use, but we hope to set a goal.
NORMAN: It's not a path of great success, controlled use.
I agree. It's often more difficult to reduce than to stop altogether,
go through the withdrawal, then stay off it.
However, trying to direct a client into a goal
that isn't their goal isn't a path for success either.
Sometimes it's better to let the client say,
my goal is to reduce, and then review it as you go along
if you can have more sessions with that client.
They often swing towards abstinence.
What's the evidence on goal setting, Jan?
No evidence, unfortunately.
We're at such an early stage with cannabis.
That's why it's so great that we've got a cannabis centre
that we can start looking at some of these issues.
Generally, I think Tessa's right,
that the advice should be cutting down with an aim to quitting
should be short-term.
They should have a goal of two to three weeks as a quick date
to be cutting down towards.
That's the recommendation for those who ultimately want to quit.
Often I find that it's more difficult for them to try to keep cutting down
and keep having this mental...
You wouldn't do it with tobacco. They're addicted to tobacco as well.
They'll want to go back to tobacco.
It's impossible with tobacco. You can't.
NORMAN: Abstinence is the aim with tobacco.
I think It needs to be the aim with cannabis too.
Sometimes people have such a strong relationship with cannabis
that they really fear the thought of never using it again.
They really struggle with abstinence for that reason.
But as treatment progresses and they start to reduce,
their thoughts around that can change.
We did follow-up studies after three years
in some Eastern Arnhem Land communities.
In the meantime, there had been targeted community-development activities,
youth-development activities
and also stringent supply-control strategies implemented.
The results were that there were still plenty of willing cannabis users
in the population, but what had changed was their access to cannabis
and the frequency with which they used it.
A lot of those core social problems and community problems
and some of the acute psychotic episodes also dropped back in the follow-up.
- But it was still around? - Still around. Plenty of willing users.
Hard to control. Tell us a little bit about NCPIC.
It's an innovative response of the Government's to community concern
about cannabis use.
It's a consortium of key mental-health,
drug and alcohol research and clinicians, criminal justice.
So bringing a whole new perspective to the issue of cannabis.
We have three main aims.
One is to provide evidence-based information,
because that's one issue we identified -
people don't necessarily have good-quality information about cannabis.
We have a lot of resources downloadable on our website.
We also aim to train the workforce.
We provide free training nationally.
On our website you'll see the types of training -
from community awareness about what are the harms associated with cannabis
through how to deliver up to six sessions of cognitive behaviour therapy.
We're also developing new interventions.
As a result of that, we now have free interventions available via the post.
If you're a rural GP, you can't provide CBT,
your client can access free interventions via the mail.
We also are about to launch an intervention on our website
and also through our free national helpline: 1 800 30 40 50
People can call just to ask questions about cannabis,
or, now, how to access interventions.
Cannabis clinics - you work in New South Wales. Are they in any other state?
No, they're only in New South Wales.
They're an initiative of the New South Wales Department of Health.
They were set up because there was a large number of cannabis users
who weren't accessing treatment at the established drug-and-alcohol services.
It was felt that if separate clinics were set up
and marketed to that population, that would increase the access,
and that's exactly what's happened.
Around 50% of people who attend New South Wales cannabis clinics
haven't had any treatment prior.
They're referring themselves, or GPs can refer them?
Yes. Any health professional can refer them,
as long as the person gives consent. They're free.
NORMAN: You give them evidence-based therapy?
Yes, we do, for around six sessions,
but very flexible, depending on the needs of the person.
NORMAN: What sort of results are you getting?
At Sutherland, we have around 50% to 53% success rate,
that is, people who have met
their treatment goal when they finish.
NORMAN: How many centres are there?
There's five centres
across New South Wales,
with another one about to open.
Centres on the North Coast,
in the Central-West
and on the Central Coast
have satellite centres at a lot of community health centres.
If anyone would like to see exactly where those clinics are,
they could access that information
through the Sutherland Cannabis Clinic website, which you can google.
NORMAN: And we'll have it on the Rural Health Education Foundation website.
Fascinating, this discussion. Thank you all very much.
What are your take-home messages for those watching, Tess?
I think that the take-home message
is that parents play an important role with young people, as we talked about.
That's something that hasn't been talked about a lot,
so I'd like people to remember that.
Also, that there are clinics out there for people to access
and GPs to phone if they want information.
At least in New South Wales. Maybe in other States in years to come. Fares?
My message to my colleagues, the GPs,
is that knowing that most people go first to the GP for any problem,
is that first of all, they need to ask the question.
Assess the drug and alcohol history of the patient,
especially these people we were talking about.
Familiarise themselves with the withdrawal symptoms
because they're very important, and with the treatment of withdrawal symptoms.
Avoid ***, or benzodiazepines, as I mentioned earlier,
and know how to refer - to NCPIC or to the cannabis clinics
or to psychologists through the mental-health plan.
NORMAN: Jan?
I wanted to reinforce, to keep cannabis top of mind if you're a GP
or a primary-health care practitioner, to ask the question
and to know that resources are available through NCPIC free nationally
and also through our 1 800 30 40 50 number,
where you can have referral to all kinds of interventions
and any question about cannabis will be answered.
NORMAN: Alan?
Unfortunately, it appears, from our consultations and research,
that cannabis has become endemic in many remote and Indigenous communities.
There's clearly a lack of services in particular for individuals,
but most urgent is the need for multiple-component,
community-based intervention strategies
that can build community capacity to raise awareness
and to try to support families and other groups.
Because things that cure communities will help the drug problem.
Thank you all very much.
I hope you've enjoyed tonight's program on cannabis in primary health care.
If you're interested in obtaining more information about the issues raised,
there are a number of resources available
on the Rural Health Education Foundation website:
And there will be links to the websites we've discussed tonight.
Don't forget to complete and send in your evaluation forms,
and please register for CPD points by completing the attendance sheet.
I'm Norman Swan. Bye for now.
Captions by Captioning & Subtitling International
Funded by the Australian Government Department of Families, Housing,
Community Services and Indigenous Affairs�