Dr. Jack Krasuski: Dear colleague, welcome. It’s Dr. Jack. This morning I’m here with Dr. Ximena Sanchez-Samper. Ximena, thank you so much for joining us once again for another conference.

Dr. Ximena Sanchez-Samper: Thank you very much for inviting me.

Dr. Jack Krasuski: Well, you know, we’re talking a day after the presentations that you had. Again, very wonderful, and the thing that I so much appreciated about your talks is they’re very grounded in the current research. You always share this practical, actionable advice that you give us. We’re clinicians. We’re sitting across the desk from a patient. We have to make decision. We have to know what to say, what to ask, what to prescribe, whether it’s a medication or psychotherapy, or whatever it is, so I really appreciate your very actionable, down-in-the-trenches advice. Just for a few minutes, maybe you can give us some of those actionable, practical highlights from your talks.

Dr. Ximena Sanchez-Samper: Absolutely. Again, thank you for inviting me. I think probably some of the main take-home messages are that adolescents and young adulthood is a critical time in brain development and that what adolescents and young adults or what youth are exposed to during those very crucial years can have an impact on their adulthood. Adolescence and young adulthood is a perfect time to learn a language, to become proficient in a sport, to play an instrument, because our brains are in that stage of neuroplasticity and act like sponges. The flip side of that story is that your brain age of onset of exposure to drugs and alcohol will have a profound mark on them as well. It’s not the same to delay, delay, delay your exposure to drugs and alcohol into your late 20s, maybe 30s if you want to try being Zen, but starting to use or experiment with substances at a young age can certainly predict later problematic use. That, for me, is one of the main take home messages. It’s that onset matters.

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Dr. Jack Krasuski: When we have a teenager spending a substantial part of his day high, intoxicated, that’s bad enough because you can’t really process things in the normal way when you’re intoxicated sometimes for the majority of the day every day with a lot of teens we see. But it goes beyond that, you’re saying that it actually impacts brain development. That changes that person forever. That’s scary.

Heavy Youth Cannabis Use and Psychosis

Dr. Ximena Sanchez-Samper: Between the ages roughly of 12 to 25, it is when the majority of our brain development, academic development happens as well. One of the other things that we know about heavy cannabis use is that there is a relationship between heavy cannabis use and psychosis and it’s very different to have your first psychotic break towards your late 20s than to have your first psychotic break when you’re still in your teenage years and you haven’t been able to secure and put in your back pocket a lot of that intellectual growth that you will need for subsequent years.

I think probably the other, this sort of piggybacks on another one of the take home messages, which is certainly that we have a responsibility as psychiatrists, as pediatricians, as parents, as teachers, to educate youth about the risks and harms of cannabis and other drugs, but certainly cannabis or marijuana is one of those where there is a lot of misinformation and minimization about the consequences of marijuana. Marijuana in this day and age, as you may have learned from the lecture, is not the same marijuana that was around back in the 1960s and 1970s. The THC content and potency of marijuana in this day and age, on a good day, is around 17%, if not higher with some of those oil concentrates or even edibles.

Recreational Cannabis a Mixed Message to Youth

One of the things that we know from an epidemiolologic standpoint is that when consequences are minimized, use goes up. The more youth believes erroneously that the edibles or that smoking marijuana is harmless, the more they will use. In a country now a days where the majority of states are placing on their ballots important thing such as decriminalization, legalization of marijuana for recreational use, or medical use of marijuana, I worry that these are giving that mixed message to youth that marijuana is not harmful and in many ways we’re placing policy before good medical practice.

Dr. Jack Krasuski: Yes. Yes.

Dr. Ximena Sanchez-Samper: And giving the wrong messages.

Dr. Jack Krasuski: Yes. I do worry too because the marijuana industry is now an industry. I guess it always was, but now it’s official. There is venture capital funds for investing and marijuana farms and advertising and building brands. I think it’s one of those situations where yes, marijuana being illegal and leading to a long prison sentence is even for just people with enough for personal use, the pendulum was too much one way.

Dr. Ximena Sanchez-Samper: Agreed.

Anticipating Higher Rates of Schizophrenia

Dr. Jack Krasuski: It just ruined too many lives that way through the criminal justice system. I think the pendulum could certainly swing too far where, again, it’s all positive. When you say mixed messages, I don’t even think they’ll be mixed. It’ll be all like, it’s all great, because they’ll be advertising on the internet and then magazines, all positive. I do think, you know, I just anticipate there will be higher rates of schizophrenia or maybe schizoaffective disorder developing here and maybe we’ll need to suffer through again a lot of lives ruined in that way until we find some rational middle ground.

Dr. Ximena Sanchez-Samper: I agree and that’s why there has to be full clarity on the definition of decriminalization and what that means and the pros and the benefits from that.

Dr. Jack Krasuski: Right.

Dr. Ximena Sanchez-Samper: Versus legalization of marijuana for recreational use and/or for medical use and more importantly, the laws and rules around that about how much is allotted or allowed for both medical use or recreational use and what exactly it is that we’re talking about.

Dr. Jack Krasuski: Like another point you made about the harm was it’s actually been found to be associated with lowering or you can say anticipated lowering of IQ by like eight points, and that huge. That’s like half a standard deviation.

Dr. Ximena Sanchez-Samper: Correct.

Dr. Jack Krasuski: So I think, maybe for some teens if the psychosis risk doesn’t kind of do it for them, then telling them you’re just not going to be nearly as smart as you would have otherwise been, maybe that’s a message, which is a completely true and backed up by data, maybe that would hold some people from maybe abusing more than they would. I do think there are countervailing messages about these cautions. There’s one more thing that really made me feel very uneasy. What you were presenting is that the people who, especially the edibles, they package them up to be like candy. You have edible gummies and candy bars, and these things are so powerful. As you were pointing out, if you eat one candy bar, that’s between maybe 6 to 20 times what a normal dose for intoxication would be. Whether you’re an adult, a teenager, a child, you might, unbeknownst to you, eat way too much and even if you were eating it because you know you want the marijuana high, you might be completely unaware about the dose.

Dr. Ximena Sanchez-Samper: Correct.

Dr. Jack Krasuski: In a way overdose yourself, going into some florid psychotic episode of intoxication and that scares me. It made me think, and this is one thing I’d like to share with the audience, I think if we have any patient, an adult or teen, who has their own children and obviously in our screening we ask them if they use any drugs, of abuse, do you smoke marijuana or edible marijuana, whatever it is, vaping marijuana, cannabis I should say, THC, and if they have children, just say, you have to be very, very cautious. This stuff looks like candy. How are you securing that? How are you securing that? This stuff is made to look green and orange and blue and colorful. It looks like candy. It is candy. It’s just candy with a bunch of high doses of 50 to 100 mg of THC in there.

Dr. Ximena Sanchez-Samper: Correct.

Dr. Jack Krasuski: In something that looks like one serving. That’s crazy. It’s scary too.

Dr. Ximena Sanchez-Samper: I agree with you, and the study that you were referring to is the Dunedin study from New Zealand.

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Dr. Jack Krasuski: With the IQ you’re saying.

Dr. Ximena Sanchez-Samper: With the IQ, with the IQ drops. Certainly, that study was done in a time in which the THC content of marijuana was much lower than the marijuana that we’re seeing now. The marijuana back in the 1960s, 1970s, maybe close to the 1980s, it was a 1:1 ratio between THC and CBD, which is a cannabidiol. The THC is psychogenic, neurotoxic, and the CBD is a neuroprotective antipsychotic, so when you had a 1:1 ratio, things were evening themselves out, but now as the ratio of THC has gone up, the CBD ratio has stayed flat and stayed the same. I think that’s why we’re seeing the decline in IQ and the greater disposition for psychosis. It also talked about some of the genetic predispositions that can lead to somebody developing a psychosis under the influence of marijuana versus not. Certainly, with regards to the edibles and the marketing, or the deceitful marketing to youth.

Dr. Jack Krasuski: It’s deceitful, I like that. That’s very true. It is deceitful. They pretend they’re like brand names. You had – what is it?

Dr. Ximena Sanchez-Samper: The Pot Tarts.

Dr. Jack Krasuski: Pot Tarts. Yes.

Dr. Ximena Sanchez-Samper: Or the Keef Kat.

Dr. Jack Krasuski: Right, right, right, and they look like the real thing.

Dr. Ximena Sanchez-Samper: They look like the real thing. As a said in the presentation, the last time that you shared a chocolate bar with 12 of your friends was when?

Dr. Jack Krasuski: That would be the edible dose, but of course, who’s going to eat that? It’s crazy.

Dr. Ximena Sanchez-Samper: Also, the amount of time that it takes for your body to digest an edible and feel its effects also takes a lot longer. When you’re inhaling a substance it’s going to reach your brain much faster than when you take it orally, so what happens with a lot of youth is they start to each that chocolate bar or that brownie.

Dr. Jack Krasuski: No. I don’t feel anything.

Dr. Ximena Sanchez-Samper: I’m not feeling anything. I’m not feeling anything. I’m not feeling anything. They keep eating until when it finally hits and that’s why the psychosis or the psychotic episode is so severe.

Dr. Jack Krasuski: It sounds to me that in our role as clinicians that one of the things that we really need to really anticipate devoting more time to is the psychoeducation. It’s really, we may be the only person giving that countervailing message. Hold on a second. There’s more to this than all the happy talk that you’re hearing. What else would you recommend that we could practically do as clinicians to help steer, even primary prevention, keeping people from even going down that path?

Dr. Ximena Sanchez-Samper: First and foremost, I would feel very proud if people kept copies of our presentations on their desktops or their slides somewhere, the hands outs. That’s how I typically lay out my presentations in a way that I hope is very practical and psychoeducational. It so good when these go back home and they’re sitting in from of patients. They can say, look, I went to this interesting conference and they spoke to me about a screening tool known as The Craft. It’s only six questions. Let me ask them to you to see what you think. They can pull that out and do it. Or they can say, when a teen is sort of challenging them and minimizing the consequences of marijuana and saying things that a lot of teens say, such as it’s safe, it’s never killed anyone, it can be used as medicine, it’s natural, that they can pull out the slides and say, well, actually, let me show you some of the data on how not everybody’s doing it, contrary to what you’re saying, what happens to your brain because I have found certainly in my practice that when I relate to my patients, again especially when I’m working with adolescence and young adults, like we’re equals, our connection, our rapport becomes much stronger.

Dr. Jack Krasuski: You don’t want to talk down to them.

Dr. Ximena Sanchez-Samper: Absolutely.

Dr. Jack Krasuski: Or patronize them. Yea. They’re very sensitive. They will feel that.

Dr. Ximena Sanchez-Samper: Yes, yes.

Dr. Jack Krasuski: Even subtle patronization.

Dr. Ximena Sanchez-Samper: Correct, correct. Certainly, the majority of them are intrigued and like learning about the brain and what happens. I find that as a motivational tool, educating them on what really goes on behind the scenes, and that their choices can and do matter, it is very helpful.

Dr. Jack Krasuski: I like what you said, that they’re actually hungry to learn like, how does this affect me and my brain?

Dr. Ximena Sanchez-Samper: Correct.

Dr. Jack Krasuski: Yea. That’s wonderful. I think it certainly provides that opening. I think as a clinician myself, I’d almost feel like, I know I have to talk to this teen about the horrors of marijuana but I know they’re not going to pay any attention. I’m like dreading it before I even open my mouth because I have set my own expectations in a negative way. Oh, you’re saying like, hey, let’s learn. Let me share with you.

Dr. Ximena Sanchez-Samper: Correct.

Dr. Jack Krasuski: Here’s some stuff you can look up yourself. Don’t just take my word for it. A very positive approach. Look at this. There are some really bad things here, but it’s fascinating and I really want you to learn more about this.

Dr. Ximena Sanchez-Samper: Correct. Because if you get into that good/bad, yes/no polarizing conversation with them, then it is like you’re playing tug of war with them. The more you pull in one direction saying this is bad for you, because they’re hearing that from their parents, but the more you pull one direction, the more likely they are going to need to pull in the other.

Dr. Jack Krasuski: Of course.

Dr. Ximena Sanchez-Samper: Then you end up alienating instead of bridging that gap. Maybe another sort of piece of advice or food for thought for your listeners is if you’re able to, or if you’re not trained already in motivational enhancement therapy or motivational interviewing, by all means there are various courses that are presented around the country. Learning how to use those skills to elicit change talk in teens is extremely powerful. I have found that learning about MI has been something extremely helpful.

Dr. Jack Krasuski: Wonderful. Thank you. I agree with you. Dr. Sanchez-Samper, thank you so much. Thank you again for being part of this. I so much appreciate it.

Dr. Ximena Sanchez-Samper: Always a pleasure. Thank you for having me.

Dr. Jack Krasuski: Okay.

Dr. Ximena Sanchez-Samper: Thank you.

Dr. Jack Krasuski: Goodbye audience.