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High-Potency Cannabis Tied to Impaired Brain Development, Psychosis, Cannabis-Use Disorder
It’s becoming clear that (CUD).
That was the message delivered by Yasmin Hurd, PhD, director of the Addiction Institute at Mount Sinai in New York, during a press briefing at the American Psychiatric Association (APA) 2024 annual meeting.
“We’re actually in historic times in that we now have highly concentrated, highly potent cannabis products that are administered in various routes,” Dr. Hurd told reporters.
Tetrahydrocannabinol (THC) concentrations in cannabis products have increased over the years, from around 2%-4% to 15%-24% now, Dr. Hurd noted.
Dr. Hurd and colleagues wrote in a commentary on the developmental trajectory of CUD published simultaneously in the American Journal of Psychiatry.
Dramatic Increase in Teen Cannabis Use
A recent study from Oregon Health & Science University showed that adolescent cannabis abuse in the United States has increased dramatically, by about 245%, since 2000.
“Drug abuse is often driven by what is in front of you,” Nora Volkow, MD, director of the National Institute on Drug Abuse, noted in an interview.
“Right now, cannabis is widely available. So, guess what? Cannabis becomes the drug that people take. Nicotine is much harder to get. It is regulated to a much greater extent than cannabis, so fewer teenagers are consuming nicotine than are consuming cannabis,” Dr. Volkow said.
Cannabis exposure during neurodevelopment has the potential to alter the endocannabinoid system, which in turn, can affect the development of neural pathways that mediate reward; emotional regulation; and multiple cognitive domains including executive functioning and decision-making, learning, abstraction, and attention — all processes central to substance use disorder and other psychiatric disorders, Dr. Hurd said at the briefing.
Dr. Volkow said that cannabis use in adolescence and young adulthood is “very concerning because that’s also the age of risk for psychosis, particularly schizophrenia, with one study showing that use of cannabis in high doses can trigger psychotic episodes, particularly among young males.”
Dr. Hurd noted that not all young people who use cannabis develop CUD, “but a significant number do,” and large-scale studies have consistently reported two main factors associated with CUD risk.
The first is age, both for the onset and frequency of use at younger age. Those who start using cannabis before age 16 years are at the highest risk for CUD. The risk for CUD also increases significantly among youth who use cannabis at least weekly, with the highest prevalence among youth who use cannabis daily. One large study linked increased frequency of use with up to a 17-fold increased risk for CUD.
The second factor consistently associated with the risk for CUD is biologic sex, with CUD rates typically higher in male individuals.
Treatment Challenges
For young people who develop CUD, access to and uptake of treatment can be challenging.
“Given that the increased potency of cannabis and cannabinoid products is expected to increase CUD risk, it is disturbing that less than 10% of youth who meet the criteria for a substance use disorder, including CUD, receive treatment,” Dr. Hurd and colleagues point out in their commentary.
Another challenge is that treatment strategies for CUD are currently limited and consist mainly of motivational enhancement and cognitive-behavioral therapies.
“Clearly new treatment strategies are needed to address the mounting challenge of CUD risk in teens and young adults,” Dr. Hurd and colleagues wrote.
Summing up, Dr. Hurd told reporters, “We now know that most psychiatric disorders have a developmental origin, and the adolescent time period is a critical window for cannabis use disorder risk.”
Yet, on a positive note, the “plasticity of the developing brain that makes it vulnerable to cannabis use disorder and psychiatric comorbidities also provides an opportunity for prevention and early intervention to change that trajectory,” Dr. Hurd said.
The changing legal landscape of cannabis — the US Drug Enforcement Agency is moving forward with plans to move marijuana from a Schedule I to a Schedule III controlled substance under the Controlled Substance Act — makes addressing these risks all the timelier.
“As states vie to leverage tax dollars from the growing cannabis industry, a significant portion of such funds must be used for early intervention/prevention strategies to reduce the impact of cannabis on the developing brain,” Dr. Hurd and colleagues wrote.
This research was supported in part by the National Institute on Drug Abuse and the National Institutes of Health. Dr. Hurd and Dr. Volkow have no relevant disclosures.
A version of this article appeared on Medscape.com.
It’s becoming clear that (CUD).
That was the message delivered by Yasmin Hurd, PhD, director of the Addiction Institute at Mount Sinai in New York, during a press briefing at the American Psychiatric Association (APA) 2024 annual meeting.
“We’re actually in historic times in that we now have highly concentrated, highly potent cannabis products that are administered in various routes,” Dr. Hurd told reporters.
Tetrahydrocannabinol (THC) concentrations in cannabis products have increased over the years, from around 2%-4% to 15%-24% now, Dr. Hurd noted.
Dr. Hurd and colleagues wrote in a commentary on the developmental trajectory of CUD published simultaneously in the American Journal of Psychiatry.
Dramatic Increase in Teen Cannabis Use
A recent study from Oregon Health & Science University showed that adolescent cannabis abuse in the United States has increased dramatically, by about 245%, since 2000.
“Drug abuse is often driven by what is in front of you,” Nora Volkow, MD, director of the National Institute on Drug Abuse, noted in an interview.
“Right now, cannabis is widely available. So, guess what? Cannabis becomes the drug that people take. Nicotine is much harder to get. It is regulated to a much greater extent than cannabis, so fewer teenagers are consuming nicotine than are consuming cannabis,” Dr. Volkow said.
Cannabis exposure during neurodevelopment has the potential to alter the endocannabinoid system, which in turn, can affect the development of neural pathways that mediate reward; emotional regulation; and multiple cognitive domains including executive functioning and decision-making, learning, abstraction, and attention — all processes central to substance use disorder and other psychiatric disorders, Dr. Hurd said at the briefing.
Dr. Volkow said that cannabis use in adolescence and young adulthood is “very concerning because that’s also the age of risk for psychosis, particularly schizophrenia, with one study showing that use of cannabis in high doses can trigger psychotic episodes, particularly among young males.”
Dr. Hurd noted that not all young people who use cannabis develop CUD, “but a significant number do,” and large-scale studies have consistently reported two main factors associated with CUD risk.
The first is age, both for the onset and frequency of use at younger age. Those who start using cannabis before age 16 years are at the highest risk for CUD. The risk for CUD also increases significantly among youth who use cannabis at least weekly, with the highest prevalence among youth who use cannabis daily. One large study linked increased frequency of use with up to a 17-fold increased risk for CUD.
The second factor consistently associated with the risk for CUD is biologic sex, with CUD rates typically higher in male individuals.
Treatment Challenges
For young people who develop CUD, access to and uptake of treatment can be challenging.
“Given that the increased potency of cannabis and cannabinoid products is expected to increase CUD risk, it is disturbing that less than 10% of youth who meet the criteria for a substance use disorder, including CUD, receive treatment,” Dr. Hurd and colleagues point out in their commentary.
Another challenge is that treatment strategies for CUD are currently limited and consist mainly of motivational enhancement and cognitive-behavioral therapies.
“Clearly new treatment strategies are needed to address the mounting challenge of CUD risk in teens and young adults,” Dr. Hurd and colleagues wrote.
Summing up, Dr. Hurd told reporters, “We now know that most psychiatric disorders have a developmental origin, and the adolescent time period is a critical window for cannabis use disorder risk.”
Yet, on a positive note, the “plasticity of the developing brain that makes it vulnerable to cannabis use disorder and psychiatric comorbidities also provides an opportunity for prevention and early intervention to change that trajectory,” Dr. Hurd said.
The changing legal landscape of cannabis — the US Drug Enforcement Agency is moving forward with plans to move marijuana from a Schedule I to a Schedule III controlled substance under the Controlled Substance Act — makes addressing these risks all the timelier.
“As states vie to leverage tax dollars from the growing cannabis industry, a significant portion of such funds must be used for early intervention/prevention strategies to reduce the impact of cannabis on the developing brain,” Dr. Hurd and colleagues wrote.
This research was supported in part by the National Institute on Drug Abuse and the National Institutes of Health. Dr. Hurd and Dr. Volkow have no relevant disclosures.
A version of this article appeared on Medscape.com.
It’s becoming clear that (CUD).
That was the message delivered by Yasmin Hurd, PhD, director of the Addiction Institute at Mount Sinai in New York, during a press briefing at the American Psychiatric Association (APA) 2024 annual meeting.
“We’re actually in historic times in that we now have highly concentrated, highly potent cannabis products that are administered in various routes,” Dr. Hurd told reporters.
Tetrahydrocannabinol (THC) concentrations in cannabis products have increased over the years, from around 2%-4% to 15%-24% now, Dr. Hurd noted.
Dr. Hurd and colleagues wrote in a commentary on the developmental trajectory of CUD published simultaneously in the American Journal of Psychiatry.
Dramatic Increase in Teen Cannabis Use
A recent study from Oregon Health & Science University showed that adolescent cannabis abuse in the United States has increased dramatically, by about 245%, since 2000.
“Drug abuse is often driven by what is in front of you,” Nora Volkow, MD, director of the National Institute on Drug Abuse, noted in an interview.
“Right now, cannabis is widely available. So, guess what? Cannabis becomes the drug that people take. Nicotine is much harder to get. It is regulated to a much greater extent than cannabis, so fewer teenagers are consuming nicotine than are consuming cannabis,” Dr. Volkow said.
Cannabis exposure during neurodevelopment has the potential to alter the endocannabinoid system, which in turn, can affect the development of neural pathways that mediate reward; emotional regulation; and multiple cognitive domains including executive functioning and decision-making, learning, abstraction, and attention — all processes central to substance use disorder and other psychiatric disorders, Dr. Hurd said at the briefing.
Dr. Volkow said that cannabis use in adolescence and young adulthood is “very concerning because that’s also the age of risk for psychosis, particularly schizophrenia, with one study showing that use of cannabis in high doses can trigger psychotic episodes, particularly among young males.”
Dr. Hurd noted that not all young people who use cannabis develop CUD, “but a significant number do,” and large-scale studies have consistently reported two main factors associated with CUD risk.
The first is age, both for the onset and frequency of use at younger age. Those who start using cannabis before age 16 years are at the highest risk for CUD. The risk for CUD also increases significantly among youth who use cannabis at least weekly, with the highest prevalence among youth who use cannabis daily. One large study linked increased frequency of use with up to a 17-fold increased risk for CUD.
The second factor consistently associated with the risk for CUD is biologic sex, with CUD rates typically higher in male individuals.
Treatment Challenges
For young people who develop CUD, access to and uptake of treatment can be challenging.
“Given that the increased potency of cannabis and cannabinoid products is expected to increase CUD risk, it is disturbing that less than 10% of youth who meet the criteria for a substance use disorder, including CUD, receive treatment,” Dr. Hurd and colleagues point out in their commentary.
Another challenge is that treatment strategies for CUD are currently limited and consist mainly of motivational enhancement and cognitive-behavioral therapies.
“Clearly new treatment strategies are needed to address the mounting challenge of CUD risk in teens and young adults,” Dr. Hurd and colleagues wrote.
Summing up, Dr. Hurd told reporters, “We now know that most psychiatric disorders have a developmental origin, and the adolescent time period is a critical window for cannabis use disorder risk.”
Yet, on a positive note, the “plasticity of the developing brain that makes it vulnerable to cannabis use disorder and psychiatric comorbidities also provides an opportunity for prevention and early intervention to change that trajectory,” Dr. Hurd said.
The changing legal landscape of cannabis — the US Drug Enforcement Agency is moving forward with plans to move marijuana from a Schedule I to a Schedule III controlled substance under the Controlled Substance Act — makes addressing these risks all the timelier.
“As states vie to leverage tax dollars from the growing cannabis industry, a significant portion of such funds must be used for early intervention/prevention strategies to reduce the impact of cannabis on the developing brain,” Dr. Hurd and colleagues wrote.
This research was supported in part by the National Institute on Drug Abuse and the National Institutes of Health. Dr. Hurd and Dr. Volkow have no relevant disclosures.
A version of this article appeared on Medscape.com.
FROM APA 2024
Top Predictors of Substance Initiation in Youth Flagged
, new research suggests.
Aside from sociodemographic parameters, risk factors for substance use initiation include prenatal exposure to substances, peer use of alcohol and nicotine, and problematic school behavior, among other things, the study showed.
The results show certain modifiable risk factors may play a role in preventing youth from starting to use substances, said study author ReJoyce Green, PhD, research assistant professor, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston.
“If we’re designing, say, a prevention program or an early intervention program, these are things that could make a difference, so let’s make sure we’re bringing them into the conversation.”
The findings were presented at the annual meeting of the American Psychiatric Association American Psychiatric Association (APA) and published online in The American Journal of Psychiatry.
Critical Risk Factors
Use of alcohol, tobacco, and cannabis often begins during adolescence. One recent survey showed that 23% of 13-year-olds reported using alcohol, 17% reported vaping nicotine, and 8% reported vaping cannabis. Other research links younger age at substance use initiation to a more rapid transition to substance use disorders and higher rates of psychiatric disorders.
Previous studies examining predictors of substance use initiation in the Adolescent Brain Cognitive Development (ABCD) Study dataset focused primarily on self-reported measures, but the current study also looked at models that include hormones and neurocognitive factors as well as neuroimaging.
This study included 6829, 9- and 10-year-olds from the ABCD Study who had never tried substances and were followed for 3 years.
A sophisticated statistical approach was used to examine 420 variables as predictors of substance use initiation. Initiation was defined as trying any nonprescribed substance by age 12 years. “That’s including a single sip of alcohol or puff of a cigarette,” said Dr. Green.
In addition to alcohol, nicotine, and cannabis, researchers looked at initiation of synthetic cannabinoids, cocaine, methamphetamine, and ketamine, among other substances.
Self-reported measures included demographic characteristics, self and peer involvement with substance use, parenting behaviors, mental and physical health, and culture and environmental factors.
The analytical approach used machine-learning algorithms to compare the ability of domains to identify the most critical risk factors. Magnitudes of coefficients were used to assess variable importance, with positive coefficients indicating greater likelihood of substance initiation and negative coefficients indicating lower likelihood of initiation.
By age 12 years, 14.4% of the children studied reported substance initiation. Alcohol was the substance most commonly initiated (365 individuals), followed by nicotine (94 individuals) and cannabis (40 individuals), with few or no children initiating other substances.
Both those who did and did not initiate substances were similarly aged, and most participants identified as White and non-Hispanic. But the substance-use group had a lower percentage of girls and higher percentage of White participants compared with the no-substance-use group.
The model with only self-reported data had similar accuracy in predicting substance use initiation (area under the curve [AUC], 0.67) as models that added resource-intensive measures such as neurocognitive tests and hormones (AUC, 0.67) and neuroimaging (AUC, 0.66).
Religious Predictors
The strongest predictors of substance use initiation were related to religion: Youths whose parents reported a religious preference for Mormonism were less likely to initiate substance use (coefficient, -0.87), whereas youths whose parents reported a religious preference for Judaism were more likely to initiate substance use (coefficient, 0.32).
The third top predictor was race: Black youths were less likely to initiate substance use (coefficient, -0.32). This was followed by youths whose parents reported a religious preference for Islam who were also less likely to initiate substance use (coefficient, -0.25).
The research examined over 15 different religious categories, “so we really tried to be expansive,” noted Dr. Green.
It’s unclear why some religions appeared to have a protective impact when it comes to substance use initiation whereas others have the opposite effect. Future research could perhaps identify which components of religiosity affect substance use initiation. If so, these aspects could be developed and incorporated into prevention and intervention programs, said Dr. Green.
Next on the list of most important predictors was being a part of a household with an income of $12,000-$15,999; these youths were less likely to initiate substance use (coefficient, 0.22).
Within the culture and environment domain, a history of detention or suspension was a top predictor of substance use initiation (coefficient, 0.20). Prenatal exposure to substance use was also a robust predictor in the physical health category (coefficient, 0.15).
Other predictors included: parents with less than a high school degree or GED (coefficient, -0.14), substance use availability (coefficient, 0.12), and age at baseline (coefficient, 0.12).
The study also showed that better cognitive functioning in selected domains (eg, cognitive control, attention, and language ability) is associated with a greater likelihood of substance use initiation.
Shaping Future Prevention
Applying these findings in clinical settings could help tailor prevention and early intervention efforts, said the authors. It might be prudent to allocate resources to collecting data related to self-, peer-, and familial-related factors, “which were more informative in predicting substance use initiation during late childhood and early adolescence in the present study,” they wrote.
Researchers will continue to track these children through to a 10-year follow-up, said Dr. Green. “I’m really curious to see if the factors we found when they were 12 and 13, such as those related to peers and family, still hold when they’re ages 17 and 18, because there’s going to be a huge amount of brain development that’s happening throughout this phase.”
The group that initiated substance use and the group that didn’t initiate substance use were not totally balanced, and sample sizes for some religious categories were small. Another study limitation was that the analytic approach didn’t account for multilevel data within the context of site and families.
Commenting on the findings, Kathleen Brady, MD, PhD, distinguished university professor and director, South Carolina Clinical and Translational Research Institute, Medical University of South Carolina, said that the study is “critical and complex.” This, she said, is especially true as cannabis has become more accessible and potent, and as the federal government reportedly considers reclassifying it from a Schedule I drug (which includes highly dangerous, addictive substances with no medical use) to a Schedule III drug (which can be prescribed as a medication).
“The part that is the most frightening to me is the long-lasting effects that can happen when young people start using high-potency marijuana at an early age,” said Dr. Brady. “So, any information that we can give to parents, to teachers, to the public, and to doctors is important.”
She’s looking forward to getting more “incredibly important” information on substance use initiation as the study progresses and the teens get older.
The study received support from the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse.
A version of this article appeared on Medscape.com.
, new research suggests.
Aside from sociodemographic parameters, risk factors for substance use initiation include prenatal exposure to substances, peer use of alcohol and nicotine, and problematic school behavior, among other things, the study showed.
The results show certain modifiable risk factors may play a role in preventing youth from starting to use substances, said study author ReJoyce Green, PhD, research assistant professor, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston.
“If we’re designing, say, a prevention program or an early intervention program, these are things that could make a difference, so let’s make sure we’re bringing them into the conversation.”
The findings were presented at the annual meeting of the American Psychiatric Association American Psychiatric Association (APA) and published online in The American Journal of Psychiatry.
Critical Risk Factors
Use of alcohol, tobacco, and cannabis often begins during adolescence. One recent survey showed that 23% of 13-year-olds reported using alcohol, 17% reported vaping nicotine, and 8% reported vaping cannabis. Other research links younger age at substance use initiation to a more rapid transition to substance use disorders and higher rates of psychiatric disorders.
Previous studies examining predictors of substance use initiation in the Adolescent Brain Cognitive Development (ABCD) Study dataset focused primarily on self-reported measures, but the current study also looked at models that include hormones and neurocognitive factors as well as neuroimaging.
This study included 6829, 9- and 10-year-olds from the ABCD Study who had never tried substances and were followed for 3 years.
A sophisticated statistical approach was used to examine 420 variables as predictors of substance use initiation. Initiation was defined as trying any nonprescribed substance by age 12 years. “That’s including a single sip of alcohol or puff of a cigarette,” said Dr. Green.
In addition to alcohol, nicotine, and cannabis, researchers looked at initiation of synthetic cannabinoids, cocaine, methamphetamine, and ketamine, among other substances.
Self-reported measures included demographic characteristics, self and peer involvement with substance use, parenting behaviors, mental and physical health, and culture and environmental factors.
The analytical approach used machine-learning algorithms to compare the ability of domains to identify the most critical risk factors. Magnitudes of coefficients were used to assess variable importance, with positive coefficients indicating greater likelihood of substance initiation and negative coefficients indicating lower likelihood of initiation.
By age 12 years, 14.4% of the children studied reported substance initiation. Alcohol was the substance most commonly initiated (365 individuals), followed by nicotine (94 individuals) and cannabis (40 individuals), with few or no children initiating other substances.
Both those who did and did not initiate substances were similarly aged, and most participants identified as White and non-Hispanic. But the substance-use group had a lower percentage of girls and higher percentage of White participants compared with the no-substance-use group.
The model with only self-reported data had similar accuracy in predicting substance use initiation (area under the curve [AUC], 0.67) as models that added resource-intensive measures such as neurocognitive tests and hormones (AUC, 0.67) and neuroimaging (AUC, 0.66).
Religious Predictors
The strongest predictors of substance use initiation were related to religion: Youths whose parents reported a religious preference for Mormonism were less likely to initiate substance use (coefficient, -0.87), whereas youths whose parents reported a religious preference for Judaism were more likely to initiate substance use (coefficient, 0.32).
The third top predictor was race: Black youths were less likely to initiate substance use (coefficient, -0.32). This was followed by youths whose parents reported a religious preference for Islam who were also less likely to initiate substance use (coefficient, -0.25).
The research examined over 15 different religious categories, “so we really tried to be expansive,” noted Dr. Green.
It’s unclear why some religions appeared to have a protective impact when it comes to substance use initiation whereas others have the opposite effect. Future research could perhaps identify which components of religiosity affect substance use initiation. If so, these aspects could be developed and incorporated into prevention and intervention programs, said Dr. Green.
Next on the list of most important predictors was being a part of a household with an income of $12,000-$15,999; these youths were less likely to initiate substance use (coefficient, 0.22).
Within the culture and environment domain, a history of detention or suspension was a top predictor of substance use initiation (coefficient, 0.20). Prenatal exposure to substance use was also a robust predictor in the physical health category (coefficient, 0.15).
Other predictors included: parents with less than a high school degree or GED (coefficient, -0.14), substance use availability (coefficient, 0.12), and age at baseline (coefficient, 0.12).
The study also showed that better cognitive functioning in selected domains (eg, cognitive control, attention, and language ability) is associated with a greater likelihood of substance use initiation.
Shaping Future Prevention
Applying these findings in clinical settings could help tailor prevention and early intervention efforts, said the authors. It might be prudent to allocate resources to collecting data related to self-, peer-, and familial-related factors, “which were more informative in predicting substance use initiation during late childhood and early adolescence in the present study,” they wrote.
Researchers will continue to track these children through to a 10-year follow-up, said Dr. Green. “I’m really curious to see if the factors we found when they were 12 and 13, such as those related to peers and family, still hold when they’re ages 17 and 18, because there’s going to be a huge amount of brain development that’s happening throughout this phase.”
The group that initiated substance use and the group that didn’t initiate substance use were not totally balanced, and sample sizes for some religious categories were small. Another study limitation was that the analytic approach didn’t account for multilevel data within the context of site and families.
Commenting on the findings, Kathleen Brady, MD, PhD, distinguished university professor and director, South Carolina Clinical and Translational Research Institute, Medical University of South Carolina, said that the study is “critical and complex.” This, she said, is especially true as cannabis has become more accessible and potent, and as the federal government reportedly considers reclassifying it from a Schedule I drug (which includes highly dangerous, addictive substances with no medical use) to a Schedule III drug (which can be prescribed as a medication).
“The part that is the most frightening to me is the long-lasting effects that can happen when young people start using high-potency marijuana at an early age,” said Dr. Brady. “So, any information that we can give to parents, to teachers, to the public, and to doctors is important.”
She’s looking forward to getting more “incredibly important” information on substance use initiation as the study progresses and the teens get older.
The study received support from the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse.
A version of this article appeared on Medscape.com.
, new research suggests.
Aside from sociodemographic parameters, risk factors for substance use initiation include prenatal exposure to substances, peer use of alcohol and nicotine, and problematic school behavior, among other things, the study showed.
The results show certain modifiable risk factors may play a role in preventing youth from starting to use substances, said study author ReJoyce Green, PhD, research assistant professor, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston.
“If we’re designing, say, a prevention program or an early intervention program, these are things that could make a difference, so let’s make sure we’re bringing them into the conversation.”
The findings were presented at the annual meeting of the American Psychiatric Association American Psychiatric Association (APA) and published online in The American Journal of Psychiatry.
Critical Risk Factors
Use of alcohol, tobacco, and cannabis often begins during adolescence. One recent survey showed that 23% of 13-year-olds reported using alcohol, 17% reported vaping nicotine, and 8% reported vaping cannabis. Other research links younger age at substance use initiation to a more rapid transition to substance use disorders and higher rates of psychiatric disorders.
Previous studies examining predictors of substance use initiation in the Adolescent Brain Cognitive Development (ABCD) Study dataset focused primarily on self-reported measures, but the current study also looked at models that include hormones and neurocognitive factors as well as neuroimaging.
This study included 6829, 9- and 10-year-olds from the ABCD Study who had never tried substances and were followed for 3 years.
A sophisticated statistical approach was used to examine 420 variables as predictors of substance use initiation. Initiation was defined as trying any nonprescribed substance by age 12 years. “That’s including a single sip of alcohol or puff of a cigarette,” said Dr. Green.
In addition to alcohol, nicotine, and cannabis, researchers looked at initiation of synthetic cannabinoids, cocaine, methamphetamine, and ketamine, among other substances.
Self-reported measures included demographic characteristics, self and peer involvement with substance use, parenting behaviors, mental and physical health, and culture and environmental factors.
The analytical approach used machine-learning algorithms to compare the ability of domains to identify the most critical risk factors. Magnitudes of coefficients were used to assess variable importance, with positive coefficients indicating greater likelihood of substance initiation and negative coefficients indicating lower likelihood of initiation.
By age 12 years, 14.4% of the children studied reported substance initiation. Alcohol was the substance most commonly initiated (365 individuals), followed by nicotine (94 individuals) and cannabis (40 individuals), with few or no children initiating other substances.
Both those who did and did not initiate substances were similarly aged, and most participants identified as White and non-Hispanic. But the substance-use group had a lower percentage of girls and higher percentage of White participants compared with the no-substance-use group.
The model with only self-reported data had similar accuracy in predicting substance use initiation (area under the curve [AUC], 0.67) as models that added resource-intensive measures such as neurocognitive tests and hormones (AUC, 0.67) and neuroimaging (AUC, 0.66).
Religious Predictors
The strongest predictors of substance use initiation were related to religion: Youths whose parents reported a religious preference for Mormonism were less likely to initiate substance use (coefficient, -0.87), whereas youths whose parents reported a religious preference for Judaism were more likely to initiate substance use (coefficient, 0.32).
The third top predictor was race: Black youths were less likely to initiate substance use (coefficient, -0.32). This was followed by youths whose parents reported a religious preference for Islam who were also less likely to initiate substance use (coefficient, -0.25).
The research examined over 15 different religious categories, “so we really tried to be expansive,” noted Dr. Green.
It’s unclear why some religions appeared to have a protective impact when it comes to substance use initiation whereas others have the opposite effect. Future research could perhaps identify which components of religiosity affect substance use initiation. If so, these aspects could be developed and incorporated into prevention and intervention programs, said Dr. Green.
Next on the list of most important predictors was being a part of a household with an income of $12,000-$15,999; these youths were less likely to initiate substance use (coefficient, 0.22).
Within the culture and environment domain, a history of detention or suspension was a top predictor of substance use initiation (coefficient, 0.20). Prenatal exposure to substance use was also a robust predictor in the physical health category (coefficient, 0.15).
Other predictors included: parents with less than a high school degree or GED (coefficient, -0.14), substance use availability (coefficient, 0.12), and age at baseline (coefficient, 0.12).
The study also showed that better cognitive functioning in selected domains (eg, cognitive control, attention, and language ability) is associated with a greater likelihood of substance use initiation.
Shaping Future Prevention
Applying these findings in clinical settings could help tailor prevention and early intervention efforts, said the authors. It might be prudent to allocate resources to collecting data related to self-, peer-, and familial-related factors, “which were more informative in predicting substance use initiation during late childhood and early adolescence in the present study,” they wrote.
Researchers will continue to track these children through to a 10-year follow-up, said Dr. Green. “I’m really curious to see if the factors we found when they were 12 and 13, such as those related to peers and family, still hold when they’re ages 17 and 18, because there’s going to be a huge amount of brain development that’s happening throughout this phase.”
The group that initiated substance use and the group that didn’t initiate substance use were not totally balanced, and sample sizes for some religious categories were small. Another study limitation was that the analytic approach didn’t account for multilevel data within the context of site and families.
Commenting on the findings, Kathleen Brady, MD, PhD, distinguished university professor and director, South Carolina Clinical and Translational Research Institute, Medical University of South Carolina, said that the study is “critical and complex.” This, she said, is especially true as cannabis has become more accessible and potent, and as the federal government reportedly considers reclassifying it from a Schedule I drug (which includes highly dangerous, addictive substances with no medical use) to a Schedule III drug (which can be prescribed as a medication).
“The part that is the most frightening to me is the long-lasting effects that can happen when young people start using high-potency marijuana at an early age,” said Dr. Brady. “So, any information that we can give to parents, to teachers, to the public, and to doctors is important.”
She’s looking forward to getting more “incredibly important” information on substance use initiation as the study progresses and the teens get older.
The study received support from the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse.
A version of this article appeared on Medscape.com.
FROM APA 2024
The DEA Plans to Reschedule Marijuana: What Happens Next?
The US Drug Enforcement Agency (DEA) is moving forward with plans to move marijuana from a Schedule I to a Schedule III controlled substance under the Controlled Substance Act (CSA), the US Department of Justice officials announced this week.
First reported by the Associated Press and since confirmed by this news organization through a US Department of Justice spokesperson, the news made international headlines. Despite the media splash, the final rule is still months away.
How did we get here? What happens next? What impact might rescheduling have on clinicians, patients, researchers, and the medical cannabis industry?
Why Reschedule? Why Now?
The DEA’s decision is based on a 2023 determination from the US Food and Drug Administration (FDA) that marijuana has a legitimate medical use and should be moved to Schedule III.
This class includes ketamine, acetaminophen with codeine, and buprenorphine.
Even though the manufacturing, distribution, sale, and use of marijuana has long violated federal law, 38 states and Washington, DC, have legalized medical cannabis, and 24 states and DC have legalized its recreational use.
Congress has allowed states leeway for the distribution and use of medical marijuana, and current and previous presidential administrations have chosen not to aggressively pursue prosecution of state-allowed marijuana use, the Congressional Research Service (CRS) reports.
Pressure to address the conflict between federal and state laws and an increasing interest in drug development of cannabis and cannabis-derived products probably contributed to the DEA’s decision, said Stephen Strakowski, MD, professor, and vice chair of psychiatry at Indiana University in Indianapolis, and professor and associate vice president at University of Texas in Austin.
“The trend toward legalization is everywhere and even though nationally the feds in this instance are lagging the states, the pressure to legalize has been intense for 50 years and it’s not surprising that the DEA is finally following that lead,” Dr. Strakowski told this news organization.
How Does Rescheduling Work? What’s the Timeline?
The DEA will submit a formal rule proposing that marijuana be moved from Schedule I to Schedule III to the White House Office of Management and Budget. The timing of the submission is unclear.
Once the proposed rule is posted to the Federal Register, there will be a public comment period, which usually lasts 30-60 days.
“This will likely generate a lot of public comment,” Robert Mikos, JD, LaRoche Family Chair in Law at Vanderbilt University Law School in Nashville, Tennessee, told this news organization. “Then the agency has to go back and wade through those comments and decide if they want to proceed with the rule as proposed or modify it.”
A final rule will probably be posted before the end of the current presidential term in January, Mr. Mikos said. While a lawsuit blocking its implementation is possible, there is a “low chance that a court would block this,” he added.
How Will Rescheduling Affect Medical Marijuana?
For medical marijuana, changing the drug to a Schedule III means that it can legally be prescribed but only in states that have legalized medical cannabis, Mr. Mikos said.
“If you’re a patient in a state with a medical marijuana law and your physician gives you a prescription for medical marijuana and you possess it, you will no longer be guilty of a federal crime,” he said.
Rescheduling could also benefit patients who receive care through the Veterans Administration (VA), Mr. Mikos said. For several years, the VA has had a policy that blocked clinicians from prescribing medical marijuana because as a Schedule I drug, it was determined to have no accepted medical use.
“It’s possible the VA may drop that policy once the drug gets rescheduled. If you’re in a medical marijuana state, if you’re a VA patient, and you don’t want to spend the extra money to go outside that system, this will have meaningful impact on their lives,” Mr. Mikos said.
But what about patients living in states that have not legalized medical cannabis?
“You still wouldn’t be committing a federal crime, but you could be violating state law,” Mr. Mikos said. “That’s a much more salient consideration because if you look at who goes after individuals who possess small amounts of drugs, the state handles 99% of those cases.”
The manufacture, distribution, and possession of recreational marijuana would remain illegal under federal law.
What Does It Mean for Medical Marijuana Dispensaries?
Though rescheduling makes it legal for clinicians to prescribe medical marijuana and for patients to use it, the actual sale of the drug will remain illegal under federal law because rescheduling only changes prescribing under the CSA, Mr. Mikos said.
“If you’re a dispensary and you sell it, even if it’s to somebody who’s got a prescription, you’re still probably violating the Food, Drug and Cosmetics Act. Rescheduling doesn’t change that,” he said.
“Even assuming the DEA follows through with this and it doesn’t come undone at some future date, the industry is still going struggle to comply with the Controlled Substances Act post rescheduling because that statute is going to continue to impose a number of regulations on the industry,” Mr. Mikos added.
However, rescheduling would change the tax status of the estimated 12,000-15,000 state-licensed cannabis dispensaries in the United States, allowing access to certain tax deductions that are unavailable to sales involving Schedule I controlled substances, James Daily, JD, MS, with Center for Empirical Research in the Law at Washington University School of Law in St. Louis, told this news organization.
“Many cannabis businesses do in fact pay federal taxes, but the inability to take any federal tax credits or deductions means that their effective tax rate is much higher than it would otherwise be,” Mr. Daily said.
Although new federal tax deductions would likely available to cannabis businesses if marijuana were rescheduled to Schedule III, “their business would still be in violation of federal law,” he said.
“This creates a further tension between state and federal law, which could be resolved by further legalization or it could be resolved by extending the prohibition on tax deductions to include cannabis and not just Schedule I and II drugs,” he added.
Will Rescheduling Make It Easier to Conduct Cannabis-Related Research?
Research on medical cannabis has been stymied by FDA and DEA regulations regarding the study of Schedule I controlled substances. Although rescheduling could lift that barrier, other challenges would remain.
“Schedule III drugs can be more easily researched, but it’s unclear if, for example, a clinical trial could lawfully obtain the cannabis from a dispensary or if they would still have to go through the one legal federal supplier of cannabis,” Daily said.
The FDA reports having received more than 800 investigational new drug applications for and pre-investigational new drug applications related to cannabis and cannabis-derived products since the 1970s, the agency reports. To date, the FDA has not approved any marketing drug applications for cannabis for the treatment of any disease or condition.
In January 2023, the agency published updated guidelines for researchers and sponsors interested in developing drugs containing cannabis or cannabis-derived compounds.
It’s unclear whether those guidelines would be updated if the rescheduling moves forward.
Does Rescheduling Marijuana Pose Any Risk?
In its report to the DEA that marijuana be rescheduled, the FDA was careful to note that the agency’s recommendation is “not meant to imply that safety and effectiveness have been established for marijuana that would support FDA approval of a marijuana drug product for a particular indication.”
That’s a notation that clinicians and patients should take to heart, Dr. Strakowski said.
“It’s important to remind people that Schedule III drugs, by definition, have addiction and other side effect risks,” he said. “The celebrity marketing that sits behind a lot of this is incompletely informed. It’s portrayed as fun and harmless in almost every movie and conversation you see, and we know that’s not true.”
Previous studies have linked cannabis to increased risk for mania, anxiety disorders, and schizophrenia.
“It is increasingly clear that marijuana use is linked to poor outcomes in people who struggle with mental illness,” Dr. Strakowski said. “We have no evidence that it can help you but there is evidence that it can harm you.”
Dr. Strakowski likens cannabis use to alcohol, which is a known depressant that is associated with worse outcomes in people with mental illness.
“I think with cannabis, we don’t know enough about it yet, but we do know that it does have some anxiety risks,” he said. “The risks in people with mental illness are simply different than in people who don’t have mental illness.”
Dr. Strakowski, Mr. Mikos, and Mr. Daily report no relevant disclosures.
A version of this article appeared on Medscape.com.
The US Drug Enforcement Agency (DEA) is moving forward with plans to move marijuana from a Schedule I to a Schedule III controlled substance under the Controlled Substance Act (CSA), the US Department of Justice officials announced this week.
First reported by the Associated Press and since confirmed by this news organization through a US Department of Justice spokesperson, the news made international headlines. Despite the media splash, the final rule is still months away.
How did we get here? What happens next? What impact might rescheduling have on clinicians, patients, researchers, and the medical cannabis industry?
Why Reschedule? Why Now?
The DEA’s decision is based on a 2023 determination from the US Food and Drug Administration (FDA) that marijuana has a legitimate medical use and should be moved to Schedule III.
This class includes ketamine, acetaminophen with codeine, and buprenorphine.
Even though the manufacturing, distribution, sale, and use of marijuana has long violated federal law, 38 states and Washington, DC, have legalized medical cannabis, and 24 states and DC have legalized its recreational use.
Congress has allowed states leeway for the distribution and use of medical marijuana, and current and previous presidential administrations have chosen not to aggressively pursue prosecution of state-allowed marijuana use, the Congressional Research Service (CRS) reports.
Pressure to address the conflict between federal and state laws and an increasing interest in drug development of cannabis and cannabis-derived products probably contributed to the DEA’s decision, said Stephen Strakowski, MD, professor, and vice chair of psychiatry at Indiana University in Indianapolis, and professor and associate vice president at University of Texas in Austin.
“The trend toward legalization is everywhere and even though nationally the feds in this instance are lagging the states, the pressure to legalize has been intense for 50 years and it’s not surprising that the DEA is finally following that lead,” Dr. Strakowski told this news organization.
How Does Rescheduling Work? What’s the Timeline?
The DEA will submit a formal rule proposing that marijuana be moved from Schedule I to Schedule III to the White House Office of Management and Budget. The timing of the submission is unclear.
Once the proposed rule is posted to the Federal Register, there will be a public comment period, which usually lasts 30-60 days.
“This will likely generate a lot of public comment,” Robert Mikos, JD, LaRoche Family Chair in Law at Vanderbilt University Law School in Nashville, Tennessee, told this news organization. “Then the agency has to go back and wade through those comments and decide if they want to proceed with the rule as proposed or modify it.”
A final rule will probably be posted before the end of the current presidential term in January, Mr. Mikos said. While a lawsuit blocking its implementation is possible, there is a “low chance that a court would block this,” he added.
How Will Rescheduling Affect Medical Marijuana?
For medical marijuana, changing the drug to a Schedule III means that it can legally be prescribed but only in states that have legalized medical cannabis, Mr. Mikos said.
“If you’re a patient in a state with a medical marijuana law and your physician gives you a prescription for medical marijuana and you possess it, you will no longer be guilty of a federal crime,” he said.
Rescheduling could also benefit patients who receive care through the Veterans Administration (VA), Mr. Mikos said. For several years, the VA has had a policy that blocked clinicians from prescribing medical marijuana because as a Schedule I drug, it was determined to have no accepted medical use.
“It’s possible the VA may drop that policy once the drug gets rescheduled. If you’re in a medical marijuana state, if you’re a VA patient, and you don’t want to spend the extra money to go outside that system, this will have meaningful impact on their lives,” Mr. Mikos said.
But what about patients living in states that have not legalized medical cannabis?
“You still wouldn’t be committing a federal crime, but you could be violating state law,” Mr. Mikos said. “That’s a much more salient consideration because if you look at who goes after individuals who possess small amounts of drugs, the state handles 99% of those cases.”
The manufacture, distribution, and possession of recreational marijuana would remain illegal under federal law.
What Does It Mean for Medical Marijuana Dispensaries?
Though rescheduling makes it legal for clinicians to prescribe medical marijuana and for patients to use it, the actual sale of the drug will remain illegal under federal law because rescheduling only changes prescribing under the CSA, Mr. Mikos said.
“If you’re a dispensary and you sell it, even if it’s to somebody who’s got a prescription, you’re still probably violating the Food, Drug and Cosmetics Act. Rescheduling doesn’t change that,” he said.
“Even assuming the DEA follows through with this and it doesn’t come undone at some future date, the industry is still going struggle to comply with the Controlled Substances Act post rescheduling because that statute is going to continue to impose a number of regulations on the industry,” Mr. Mikos added.
However, rescheduling would change the tax status of the estimated 12,000-15,000 state-licensed cannabis dispensaries in the United States, allowing access to certain tax deductions that are unavailable to sales involving Schedule I controlled substances, James Daily, JD, MS, with Center for Empirical Research in the Law at Washington University School of Law in St. Louis, told this news organization.
“Many cannabis businesses do in fact pay federal taxes, but the inability to take any federal tax credits or deductions means that their effective tax rate is much higher than it would otherwise be,” Mr. Daily said.
Although new federal tax deductions would likely available to cannabis businesses if marijuana were rescheduled to Schedule III, “their business would still be in violation of federal law,” he said.
“This creates a further tension between state and federal law, which could be resolved by further legalization or it could be resolved by extending the prohibition on tax deductions to include cannabis and not just Schedule I and II drugs,” he added.
Will Rescheduling Make It Easier to Conduct Cannabis-Related Research?
Research on medical cannabis has been stymied by FDA and DEA regulations regarding the study of Schedule I controlled substances. Although rescheduling could lift that barrier, other challenges would remain.
“Schedule III drugs can be more easily researched, but it’s unclear if, for example, a clinical trial could lawfully obtain the cannabis from a dispensary or if they would still have to go through the one legal federal supplier of cannabis,” Daily said.
The FDA reports having received more than 800 investigational new drug applications for and pre-investigational new drug applications related to cannabis and cannabis-derived products since the 1970s, the agency reports. To date, the FDA has not approved any marketing drug applications for cannabis for the treatment of any disease or condition.
In January 2023, the agency published updated guidelines for researchers and sponsors interested in developing drugs containing cannabis or cannabis-derived compounds.
It’s unclear whether those guidelines would be updated if the rescheduling moves forward.
Does Rescheduling Marijuana Pose Any Risk?
In its report to the DEA that marijuana be rescheduled, the FDA was careful to note that the agency’s recommendation is “not meant to imply that safety and effectiveness have been established for marijuana that would support FDA approval of a marijuana drug product for a particular indication.”
That’s a notation that clinicians and patients should take to heart, Dr. Strakowski said.
“It’s important to remind people that Schedule III drugs, by definition, have addiction and other side effect risks,” he said. “The celebrity marketing that sits behind a lot of this is incompletely informed. It’s portrayed as fun and harmless in almost every movie and conversation you see, and we know that’s not true.”
Previous studies have linked cannabis to increased risk for mania, anxiety disorders, and schizophrenia.
“It is increasingly clear that marijuana use is linked to poor outcomes in people who struggle with mental illness,” Dr. Strakowski said. “We have no evidence that it can help you but there is evidence that it can harm you.”
Dr. Strakowski likens cannabis use to alcohol, which is a known depressant that is associated with worse outcomes in people with mental illness.
“I think with cannabis, we don’t know enough about it yet, but we do know that it does have some anxiety risks,” he said. “The risks in people with mental illness are simply different than in people who don’t have mental illness.”
Dr. Strakowski, Mr. Mikos, and Mr. Daily report no relevant disclosures.
A version of this article appeared on Medscape.com.
The US Drug Enforcement Agency (DEA) is moving forward with plans to move marijuana from a Schedule I to a Schedule III controlled substance under the Controlled Substance Act (CSA), the US Department of Justice officials announced this week.
First reported by the Associated Press and since confirmed by this news organization through a US Department of Justice spokesperson, the news made international headlines. Despite the media splash, the final rule is still months away.
How did we get here? What happens next? What impact might rescheduling have on clinicians, patients, researchers, and the medical cannabis industry?
Why Reschedule? Why Now?
The DEA’s decision is based on a 2023 determination from the US Food and Drug Administration (FDA) that marijuana has a legitimate medical use and should be moved to Schedule III.
This class includes ketamine, acetaminophen with codeine, and buprenorphine.
Even though the manufacturing, distribution, sale, and use of marijuana has long violated federal law, 38 states and Washington, DC, have legalized medical cannabis, and 24 states and DC have legalized its recreational use.
Congress has allowed states leeway for the distribution and use of medical marijuana, and current and previous presidential administrations have chosen not to aggressively pursue prosecution of state-allowed marijuana use, the Congressional Research Service (CRS) reports.
Pressure to address the conflict between federal and state laws and an increasing interest in drug development of cannabis and cannabis-derived products probably contributed to the DEA’s decision, said Stephen Strakowski, MD, professor, and vice chair of psychiatry at Indiana University in Indianapolis, and professor and associate vice president at University of Texas in Austin.
“The trend toward legalization is everywhere and even though nationally the feds in this instance are lagging the states, the pressure to legalize has been intense for 50 years and it’s not surprising that the DEA is finally following that lead,” Dr. Strakowski told this news organization.
How Does Rescheduling Work? What’s the Timeline?
The DEA will submit a formal rule proposing that marijuana be moved from Schedule I to Schedule III to the White House Office of Management and Budget. The timing of the submission is unclear.
Once the proposed rule is posted to the Federal Register, there will be a public comment period, which usually lasts 30-60 days.
“This will likely generate a lot of public comment,” Robert Mikos, JD, LaRoche Family Chair in Law at Vanderbilt University Law School in Nashville, Tennessee, told this news organization. “Then the agency has to go back and wade through those comments and decide if they want to proceed with the rule as proposed or modify it.”
A final rule will probably be posted before the end of the current presidential term in January, Mr. Mikos said. While a lawsuit blocking its implementation is possible, there is a “low chance that a court would block this,” he added.
How Will Rescheduling Affect Medical Marijuana?
For medical marijuana, changing the drug to a Schedule III means that it can legally be prescribed but only in states that have legalized medical cannabis, Mr. Mikos said.
“If you’re a patient in a state with a medical marijuana law and your physician gives you a prescription for medical marijuana and you possess it, you will no longer be guilty of a federal crime,” he said.
Rescheduling could also benefit patients who receive care through the Veterans Administration (VA), Mr. Mikos said. For several years, the VA has had a policy that blocked clinicians from prescribing medical marijuana because as a Schedule I drug, it was determined to have no accepted medical use.
“It’s possible the VA may drop that policy once the drug gets rescheduled. If you’re in a medical marijuana state, if you’re a VA patient, and you don’t want to spend the extra money to go outside that system, this will have meaningful impact on their lives,” Mr. Mikos said.
But what about patients living in states that have not legalized medical cannabis?
“You still wouldn’t be committing a federal crime, but you could be violating state law,” Mr. Mikos said. “That’s a much more salient consideration because if you look at who goes after individuals who possess small amounts of drugs, the state handles 99% of those cases.”
The manufacture, distribution, and possession of recreational marijuana would remain illegal under federal law.
What Does It Mean for Medical Marijuana Dispensaries?
Though rescheduling makes it legal for clinicians to prescribe medical marijuana and for patients to use it, the actual sale of the drug will remain illegal under federal law because rescheduling only changes prescribing under the CSA, Mr. Mikos said.
“If you’re a dispensary and you sell it, even if it’s to somebody who’s got a prescription, you’re still probably violating the Food, Drug and Cosmetics Act. Rescheduling doesn’t change that,” he said.
“Even assuming the DEA follows through with this and it doesn’t come undone at some future date, the industry is still going struggle to comply with the Controlled Substances Act post rescheduling because that statute is going to continue to impose a number of regulations on the industry,” Mr. Mikos added.
However, rescheduling would change the tax status of the estimated 12,000-15,000 state-licensed cannabis dispensaries in the United States, allowing access to certain tax deductions that are unavailable to sales involving Schedule I controlled substances, James Daily, JD, MS, with Center for Empirical Research in the Law at Washington University School of Law in St. Louis, told this news organization.
“Many cannabis businesses do in fact pay federal taxes, but the inability to take any federal tax credits or deductions means that their effective tax rate is much higher than it would otherwise be,” Mr. Daily said.
Although new federal tax deductions would likely available to cannabis businesses if marijuana were rescheduled to Schedule III, “their business would still be in violation of federal law,” he said.
“This creates a further tension between state and federal law, which could be resolved by further legalization or it could be resolved by extending the prohibition on tax deductions to include cannabis and not just Schedule I and II drugs,” he added.
Will Rescheduling Make It Easier to Conduct Cannabis-Related Research?
Research on medical cannabis has been stymied by FDA and DEA regulations regarding the study of Schedule I controlled substances. Although rescheduling could lift that barrier, other challenges would remain.
“Schedule III drugs can be more easily researched, but it’s unclear if, for example, a clinical trial could lawfully obtain the cannabis from a dispensary or if they would still have to go through the one legal federal supplier of cannabis,” Daily said.
The FDA reports having received more than 800 investigational new drug applications for and pre-investigational new drug applications related to cannabis and cannabis-derived products since the 1970s, the agency reports. To date, the FDA has not approved any marketing drug applications for cannabis for the treatment of any disease or condition.
In January 2023, the agency published updated guidelines for researchers and sponsors interested in developing drugs containing cannabis or cannabis-derived compounds.
It’s unclear whether those guidelines would be updated if the rescheduling moves forward.
Does Rescheduling Marijuana Pose Any Risk?
In its report to the DEA that marijuana be rescheduled, the FDA was careful to note that the agency’s recommendation is “not meant to imply that safety and effectiveness have been established for marijuana that would support FDA approval of a marijuana drug product for a particular indication.”
That’s a notation that clinicians and patients should take to heart, Dr. Strakowski said.
“It’s important to remind people that Schedule III drugs, by definition, have addiction and other side effect risks,” he said. “The celebrity marketing that sits behind a lot of this is incompletely informed. It’s portrayed as fun and harmless in almost every movie and conversation you see, and we know that’s not true.”
Previous studies have linked cannabis to increased risk for mania, anxiety disorders, and schizophrenia.
“It is increasingly clear that marijuana use is linked to poor outcomes in people who struggle with mental illness,” Dr. Strakowski said. “We have no evidence that it can help you but there is evidence that it can harm you.”
Dr. Strakowski likens cannabis use to alcohol, which is a known depressant that is associated with worse outcomes in people with mental illness.
“I think with cannabis, we don’t know enough about it yet, but we do know that it does have some anxiety risks,” he said. “The risks in people with mental illness are simply different than in people who don’t have mental illness.”
Dr. Strakowski, Mr. Mikos, and Mr. Daily report no relevant disclosures.
A version of this article appeared on Medscape.com.
Most Homeless People Have Mental Health Disorders
Most people experiencing homelessness have mental health disorders, according to a systematic review and meta-analysis.
In an examination of studies that included nearly 50,000 participants, the current prevalence of mental health disorders among people experiencing homelessness was 67% and the lifetime prevalence was 77%.
“The relationship is likely bidirectional, where experiencing homelessness may exacerbate mental health symptoms or where having a mental health disorder may increase an individual’s risk for experiencing homelessness,” lead author Rebecca Barry, PhD, a postdoctoral fellow at the University of Calgary in Calgary, Alberta, Canada, told this news organization.
“There are also likely stressors that increase both risk for homelessness and risk for developing mental health disorders. This study examines prevalence but does not examine causal relationships,” she said.
The findings were published in JAMA Psychiatry.
A Growing Problem
To determine the current and lifetime prevalence of mental health disorders among the homeless population, the researchers analyzed 85 studies that examined this question in participants aged ≥ 18 years. The review included 48,414 participants, including 11,154 (23%) women and 37,260 (77%) men.
The lifetime prevalence of mental health disorders was significantly higher in men experiencing homelessness (86%) than in women (69%). The most common mental health disorder was substance use disorder (44%), followed by antisocial personality disorder (26%), major depression (19%), bipolar disorder (8%), and schizophrenia (7%).
The prevalence of current and lifetime mental health disorders among the homeless population was higher than that that observed in the general population (13%-15% and 12%-47%, respectively).
The results resembled those of a previous review that estimated that 76% of people experiencing homelessness living in high-income countries have mental health disorders.
“Even though our results are not surprising, they still are drawing attention to this issue because it is a big problem in Canada, the United States, Europe, and other places,” senior author Dallas Seitz, MD, PhD, professor of psychiatry at the University of Calgary’s Cumming School of Medicine, told this news organization. “The problem is concerning, and it’s not getting better. Addiction and mental health problems are becoming more common among people who are homeless.”
The bottom line is that people need affordable housing and mental health support, said Dr. Seitz. “It’s a housing problem and a health problem, and we need adequate resources to find better ways for those two systems to collaborate. There are public safety concerns, and we have to try and bring services to people experiencing homelessness. You have to come and meet people where they’re at. You have to try and establish a trusting relationship so that we can get people on the path to recovery.”
‘It’s Really About Income’
Commenting on the findings for this news organization, Stephen Hwang, MD, professor of medicine at the University of Toronto, Toronto, Ontario, Canada, said, “There have been previous studies of this type, but it is good to have an updated one.” Dr. Hwang, who is also chair in Homelessness, Housing, and Health at St. Michael’s Hospital, did not participate in the research.
The findings must be understood in the proper context, he added. For one thing, grouping together all mental health disorders and giving a single prevalence figure can be misleading. “They are including in that category a diverse group of conditions. Substance use disorder, personality disorder, schizophrenia, and depression are all lumped together. The 67% prevalence seems very high, but it is a combination of many different conditions. I just don’t want people to look at that number and think that this means that everyone is a substance user or everyone has schizophrenia,” said Dr. Hwang.
Also, some readers might interpret the findings to mean that mental problems are the reason people are homeless, he added. “That would be an incorrect interpretation because what this study is showing is that people with mental health disorders have a higher risk for becoming homeless. It doesn’t mean that it caused their homelessness. What really causes homelessness is a lack of affordable housing,” said Dr. Hwang.
“In a city or community where housing is very expensive, there’s not enough for everyone to be housed, there is a lot of competition for housing, and there’s not enough affordable housing for a number of reasons, we know that people with mental health conditions and substance use disorders will be among the first to lose their housing,” he said.
“It’s really about income. There are many reasons why a person cannot afford housing. So, not being able to earn enough money to afford it because you have a mental health disorder or substance use disorder is a common underlying reason for homelessness.”
Dr. Hwang also pointed out that people with mental illness who can access support, either through family members or through mental health care, and who also have the income to afford such services do not become homeless.
“Schizophrenia is seen in every population of the world at a rate of 1%. But you travel to certain cities and you see people who appear to have schizophrenia wandering the streets, and you go to other cities in the world and you don’t see anyone who looks like they’re homeless and have schizophrenia,” he said.
“It’s not because there are fewer people with schizophrenia in those cities or countries; it’s because people with schizophrenia are treated differently. The rate of homelessness is determined not by how many people have that condition [eg, schizophrenia] but by how we treat those people and how we set up our society to either support or not support people who have disabilities.”
The study was funded by the Precision Care With Information, Science and Experience – Mental Health grant funded by the Calgary Health Foundation. Dr. Barry is supported by the Harley Hotchkiss Samuel Weiss Postdoctoral Fellowship awarded by the Hotchkiss Brain Institute at the University of Calgary. Dr. Barry reported having no relevant financial relationships. Dr. Seitz reported grants from Calgary Health Foundation during the conduct of the study as well as grants from University Health Foundation, the Canadian Institutes of Health Research, the Public Health Agency of Canada, the Alzheimer’s Association, and the Hotchkiss Brain Institute. He received honoraria for guideline development from the Canadian Coalition for Seniors Mental Health outside the submitted work. Dr. Hwang reported no relevant financial relationships.
A version of this article appeared on Medscape.com.
Most people experiencing homelessness have mental health disorders, according to a systematic review and meta-analysis.
In an examination of studies that included nearly 50,000 participants, the current prevalence of mental health disorders among people experiencing homelessness was 67% and the lifetime prevalence was 77%.
“The relationship is likely bidirectional, where experiencing homelessness may exacerbate mental health symptoms or where having a mental health disorder may increase an individual’s risk for experiencing homelessness,” lead author Rebecca Barry, PhD, a postdoctoral fellow at the University of Calgary in Calgary, Alberta, Canada, told this news organization.
“There are also likely stressors that increase both risk for homelessness and risk for developing mental health disorders. This study examines prevalence but does not examine causal relationships,” she said.
The findings were published in JAMA Psychiatry.
A Growing Problem
To determine the current and lifetime prevalence of mental health disorders among the homeless population, the researchers analyzed 85 studies that examined this question in participants aged ≥ 18 years. The review included 48,414 participants, including 11,154 (23%) women and 37,260 (77%) men.
The lifetime prevalence of mental health disorders was significantly higher in men experiencing homelessness (86%) than in women (69%). The most common mental health disorder was substance use disorder (44%), followed by antisocial personality disorder (26%), major depression (19%), bipolar disorder (8%), and schizophrenia (7%).
The prevalence of current and lifetime mental health disorders among the homeless population was higher than that that observed in the general population (13%-15% and 12%-47%, respectively).
The results resembled those of a previous review that estimated that 76% of people experiencing homelessness living in high-income countries have mental health disorders.
“Even though our results are not surprising, they still are drawing attention to this issue because it is a big problem in Canada, the United States, Europe, and other places,” senior author Dallas Seitz, MD, PhD, professor of psychiatry at the University of Calgary’s Cumming School of Medicine, told this news organization. “The problem is concerning, and it’s not getting better. Addiction and mental health problems are becoming more common among people who are homeless.”
The bottom line is that people need affordable housing and mental health support, said Dr. Seitz. “It’s a housing problem and a health problem, and we need adequate resources to find better ways for those two systems to collaborate. There are public safety concerns, and we have to try and bring services to people experiencing homelessness. You have to come and meet people where they’re at. You have to try and establish a trusting relationship so that we can get people on the path to recovery.”
‘It’s Really About Income’
Commenting on the findings for this news organization, Stephen Hwang, MD, professor of medicine at the University of Toronto, Toronto, Ontario, Canada, said, “There have been previous studies of this type, but it is good to have an updated one.” Dr. Hwang, who is also chair in Homelessness, Housing, and Health at St. Michael’s Hospital, did not participate in the research.
The findings must be understood in the proper context, he added. For one thing, grouping together all mental health disorders and giving a single prevalence figure can be misleading. “They are including in that category a diverse group of conditions. Substance use disorder, personality disorder, schizophrenia, and depression are all lumped together. The 67% prevalence seems very high, but it is a combination of many different conditions. I just don’t want people to look at that number and think that this means that everyone is a substance user or everyone has schizophrenia,” said Dr. Hwang.
Also, some readers might interpret the findings to mean that mental problems are the reason people are homeless, he added. “That would be an incorrect interpretation because what this study is showing is that people with mental health disorders have a higher risk for becoming homeless. It doesn’t mean that it caused their homelessness. What really causes homelessness is a lack of affordable housing,” said Dr. Hwang.
“In a city or community where housing is very expensive, there’s not enough for everyone to be housed, there is a lot of competition for housing, and there’s not enough affordable housing for a number of reasons, we know that people with mental health conditions and substance use disorders will be among the first to lose their housing,” he said.
“It’s really about income. There are many reasons why a person cannot afford housing. So, not being able to earn enough money to afford it because you have a mental health disorder or substance use disorder is a common underlying reason for homelessness.”
Dr. Hwang also pointed out that people with mental illness who can access support, either through family members or through mental health care, and who also have the income to afford such services do not become homeless.
“Schizophrenia is seen in every population of the world at a rate of 1%. But you travel to certain cities and you see people who appear to have schizophrenia wandering the streets, and you go to other cities in the world and you don’t see anyone who looks like they’re homeless and have schizophrenia,” he said.
“It’s not because there are fewer people with schizophrenia in those cities or countries; it’s because people with schizophrenia are treated differently. The rate of homelessness is determined not by how many people have that condition [eg, schizophrenia] but by how we treat those people and how we set up our society to either support or not support people who have disabilities.”
The study was funded by the Precision Care With Information, Science and Experience – Mental Health grant funded by the Calgary Health Foundation. Dr. Barry is supported by the Harley Hotchkiss Samuel Weiss Postdoctoral Fellowship awarded by the Hotchkiss Brain Institute at the University of Calgary. Dr. Barry reported having no relevant financial relationships. Dr. Seitz reported grants from Calgary Health Foundation during the conduct of the study as well as grants from University Health Foundation, the Canadian Institutes of Health Research, the Public Health Agency of Canada, the Alzheimer’s Association, and the Hotchkiss Brain Institute. He received honoraria for guideline development from the Canadian Coalition for Seniors Mental Health outside the submitted work. Dr. Hwang reported no relevant financial relationships.
A version of this article appeared on Medscape.com.
Most people experiencing homelessness have mental health disorders, according to a systematic review and meta-analysis.
In an examination of studies that included nearly 50,000 participants, the current prevalence of mental health disorders among people experiencing homelessness was 67% and the lifetime prevalence was 77%.
“The relationship is likely bidirectional, where experiencing homelessness may exacerbate mental health symptoms or where having a mental health disorder may increase an individual’s risk for experiencing homelessness,” lead author Rebecca Barry, PhD, a postdoctoral fellow at the University of Calgary in Calgary, Alberta, Canada, told this news organization.
“There are also likely stressors that increase both risk for homelessness and risk for developing mental health disorders. This study examines prevalence but does not examine causal relationships,” she said.
The findings were published in JAMA Psychiatry.
A Growing Problem
To determine the current and lifetime prevalence of mental health disorders among the homeless population, the researchers analyzed 85 studies that examined this question in participants aged ≥ 18 years. The review included 48,414 participants, including 11,154 (23%) women and 37,260 (77%) men.
The lifetime prevalence of mental health disorders was significantly higher in men experiencing homelessness (86%) than in women (69%). The most common mental health disorder was substance use disorder (44%), followed by antisocial personality disorder (26%), major depression (19%), bipolar disorder (8%), and schizophrenia (7%).
The prevalence of current and lifetime mental health disorders among the homeless population was higher than that that observed in the general population (13%-15% and 12%-47%, respectively).
The results resembled those of a previous review that estimated that 76% of people experiencing homelessness living in high-income countries have mental health disorders.
“Even though our results are not surprising, they still are drawing attention to this issue because it is a big problem in Canada, the United States, Europe, and other places,” senior author Dallas Seitz, MD, PhD, professor of psychiatry at the University of Calgary’s Cumming School of Medicine, told this news organization. “The problem is concerning, and it’s not getting better. Addiction and mental health problems are becoming more common among people who are homeless.”
The bottom line is that people need affordable housing and mental health support, said Dr. Seitz. “It’s a housing problem and a health problem, and we need adequate resources to find better ways for those two systems to collaborate. There are public safety concerns, and we have to try and bring services to people experiencing homelessness. You have to come and meet people where they’re at. You have to try and establish a trusting relationship so that we can get people on the path to recovery.”
‘It’s Really About Income’
Commenting on the findings for this news organization, Stephen Hwang, MD, professor of medicine at the University of Toronto, Toronto, Ontario, Canada, said, “There have been previous studies of this type, but it is good to have an updated one.” Dr. Hwang, who is also chair in Homelessness, Housing, and Health at St. Michael’s Hospital, did not participate in the research.
The findings must be understood in the proper context, he added. For one thing, grouping together all mental health disorders and giving a single prevalence figure can be misleading. “They are including in that category a diverse group of conditions. Substance use disorder, personality disorder, schizophrenia, and depression are all lumped together. The 67% prevalence seems very high, but it is a combination of many different conditions. I just don’t want people to look at that number and think that this means that everyone is a substance user or everyone has schizophrenia,” said Dr. Hwang.
Also, some readers might interpret the findings to mean that mental problems are the reason people are homeless, he added. “That would be an incorrect interpretation because what this study is showing is that people with mental health disorders have a higher risk for becoming homeless. It doesn’t mean that it caused their homelessness. What really causes homelessness is a lack of affordable housing,” said Dr. Hwang.
“In a city or community where housing is very expensive, there’s not enough for everyone to be housed, there is a lot of competition for housing, and there’s not enough affordable housing for a number of reasons, we know that people with mental health conditions and substance use disorders will be among the first to lose their housing,” he said.
“It’s really about income. There are many reasons why a person cannot afford housing. So, not being able to earn enough money to afford it because you have a mental health disorder or substance use disorder is a common underlying reason for homelessness.”
Dr. Hwang also pointed out that people with mental illness who can access support, either through family members or through mental health care, and who also have the income to afford such services do not become homeless.
“Schizophrenia is seen in every population of the world at a rate of 1%. But you travel to certain cities and you see people who appear to have schizophrenia wandering the streets, and you go to other cities in the world and you don’t see anyone who looks like they’re homeless and have schizophrenia,” he said.
“It’s not because there are fewer people with schizophrenia in those cities or countries; it’s because people with schizophrenia are treated differently. The rate of homelessness is determined not by how many people have that condition [eg, schizophrenia] but by how we treat those people and how we set up our society to either support or not support people who have disabilities.”
The study was funded by the Precision Care With Information, Science and Experience – Mental Health grant funded by the Calgary Health Foundation. Dr. Barry is supported by the Harley Hotchkiss Samuel Weiss Postdoctoral Fellowship awarded by the Hotchkiss Brain Institute at the University of Calgary. Dr. Barry reported having no relevant financial relationships. Dr. Seitz reported grants from Calgary Health Foundation during the conduct of the study as well as grants from University Health Foundation, the Canadian Institutes of Health Research, the Public Health Agency of Canada, the Alzheimer’s Association, and the Hotchkiss Brain Institute. He received honoraria for guideline development from the Canadian Coalition for Seniors Mental Health outside the submitted work. Dr. Hwang reported no relevant financial relationships.
A version of this article appeared on Medscape.com.
Girls Catching Up With Boys in Substance Use
, warned the authors of a new report detailing trends across several regions between 2018 and 2022. The latest 4-yearly Health Behaviour in School-Aged Children study, in collaboration with the World Health Organization (WHO) Regional Office for Europe, concluded that substance use remains “a crucial public health problem among adolescents” despite overall declines in smoking, alcohol, and cannabis use.
The new report: A focus on adolescent substance use in Europe, central Asia, and Canada, detailed substance use among adolescents aged 11, 13, and 15 years across 44 countries and regions in Europe, Central Asia, and Canada in the 2021-2022 school-based survey.
Principal findings included:
- Cigarette smoking: Lifetime smoking declined between 2018 and 2022, particularly among 13-year-old boys and 15-year-old boys and girls. There was also a small but significant decrease in current smoking among 15-year-old boys.
- Alcohol use: Lifetime use decreased overall in boys between 2018 and 2022, particularly among 15-year-olds. An increase was observed among 11- and 13-year-old girls but not 15-year-old girls. There was a small but significant decrease in the proportion of current drinkers among 15-year-old boys, with no change among 11- and 13-year-old boys. Current alcohol use increased among girls in all age groups.
- Cannabis use: Lifetime use among 15-year-olds decreased slightly from 14% to 12% between 2018 and 2022, while 6% of 15-year-olds reported having used cannabis in the previous 30 days.
- Vaping: In 2022 vapes (e-cigarettes) were more popular among adolescents than conventional tobacco cigarettes.
Traditional Gender Gap Narrowing or Reversing
Report coauthor Judith Brown from the University of Glasgow, Glasgow, Scotland, and a project manager for the Scottish survey, said that “there was an overall increase in current alcohol use and drunkenness among older girls” despite the overall decrease in boys’ alcohol use.
She explained: “Substance use has traditionally been more prevalent among boys, and the survey findings confirm a well-established gender difference, with higher prevalence in boys than in girls among 11-year-olds. By the age of 13, however, gender differences diminish or even disappear in many countries and regions.”
“Among 15-year-olds, girls often reported more frequent substance use than boys. While this pattern has been known for cigarette smoking in many countries and regions for about two decades, especially among 15-year-olds, it is a new phenomenon for behaviors related to other substances (such as alcohol consumption and drunkenness) in most countries and regions. Historically, prevalence for these behaviors has been higher among boys than girls.”
The new survey results highlight this gender reversal for several substances, she said. “Cannabis is the only substance for which both lifetime and current use is consistently higher in boys.”
Vaping Is an Emerging Public Health Concern
Dr. Brown added that the 2022 survey was the first time that vaping data had been collected from all countries. Although this is against the background of continuing decreases in smoking rates, “researchers suggest the transition to e-cigarettes, as a more popular choice than conventional cigarettes, highlights an urgent need for more targeted interventions to address this emerging public health concern.”
The report authors commented that because young people’s brains are still developing, they are “very sensitive to substances such as nicotine,” making it “easier for them to get hooked.”
Margreet de Looze, PhD, assistant professor of interdisciplinary social science at Utrecht University in Utrecht, the Netherlands, agreed with the authors’ concerns. “Vaping is extremely attractive for young people,” she said, “because the taste is more attractive than that of traditional cigarettes.” Until recently, many people were not aware of health hazards attached to vaping. “While more research is needed, vaping may function as a first step toward tobacco use and is hazardous for young people’s health. Therefore, it should be strongly discouraged.”
Substance Use Trends May Be Stabilizing or Rising Again
Increased awareness of the harmful effects of alcohol for adolescent development is also one postulated reason for declining adolescent alcohol consumption in both Europe and North America over the past two decades, which Dr. de Looze’s research has explored. Her work has also noted the “growing trend” of young people abstaining from alcohol altogether and some evidence of reductions in adolescent risk behaviors more generally, including early sexual initiation and juvenile crime.
“It may be good to realize that, in fact, the current generation of youth in many respects is healthier and reports less risky health behaviors as compared to previous generations,” she said.
However, “The declining trend in adolescent substance use that took place in many countries since the beginning of the 21st century seems to have stabilized, and moreover, in some countries and subgroups of adolescents, substance use appears to be on the rise again.” She cited particularly an overall increase in current alcohol use and drunkenness among older girls between 2018 and 2022. “It appears that, especially for girls, recent trends over time are less favorable as compared with boys.”
Multiple Influences on Adolescent Substance Abuse
Peer group influences are known to come to the fore during adolescence, and Dr. de Looze added that the early 21st century saw marked reductions in adolescent face-to-face contacts with their peers due to the rise in digital communications. “Adolescents typically use substances in the presence of peers (and in the absence of adults/parents), as it increases their status in their peer group.” Reduced in person interactions with friends may therefore have contributed to the earlier decline in substance use.
However, her team had found that adolescents who spend much time online with friends often also spend much time with friends offline. “They are what you could call the ‘social’ youth, who just spend much time with peers, be it offline or online,” she said. “More research is needed to disentangle exactly how, what kind, for whom the digital environment may be related to young people’s substance use,” she said.
“We also see that young people actively select their friends. So, if you are curious and a bit of a sensation-seeker yourself, you are more likely to become friends with youth who are just like you, and together, you may be more likely to try out substances.”
Factors underlying adolescent substance use and differences between countries are influenced by a complex interplay of factors, said Carina Ferreira-Borges, PhD, regional adviser for alcohol, illicit drugs, and prison health at the WHO Regional Office for Europe.
“Prevention measures definitely play a critical role in reducing substance use,” she said, “but other factors, such as cultural norms and socioeconomic conditions, also significantly impact these patterns.”
“Variations in substance use among countries can be attributed to different levels of implemented polices, public health initiatives, and the extent to which substance use is normalized or stigmatized within each society.”
Policy Efforts Must Be Targeted
“To address these disparities effectively, interventions and population-level policies need to be culturally adapted and target the specific environments where substance use is normalized among adolescents. By understanding and modifying the broader context in which young people make choices about substance use, we can better influence their behavior and health outcomes.”
Dr. de Looze cautioned, “In the past two decades, public health efforts in many countries have focused on reducing young people’s engagement in substance use. It is important that these efforts continue, as every year a new generation of youth is born. If public health efforts do not continue to focus on supporting a healthy lifestyle among young people, it should not come as a surprise that rates start or continue to rise again.”
A version of this article appeared on Medscape.com.
, warned the authors of a new report detailing trends across several regions between 2018 and 2022. The latest 4-yearly Health Behaviour in School-Aged Children study, in collaboration with the World Health Organization (WHO) Regional Office for Europe, concluded that substance use remains “a crucial public health problem among adolescents” despite overall declines in smoking, alcohol, and cannabis use.
The new report: A focus on adolescent substance use in Europe, central Asia, and Canada, detailed substance use among adolescents aged 11, 13, and 15 years across 44 countries and regions in Europe, Central Asia, and Canada in the 2021-2022 school-based survey.
Principal findings included:
- Cigarette smoking: Lifetime smoking declined between 2018 and 2022, particularly among 13-year-old boys and 15-year-old boys and girls. There was also a small but significant decrease in current smoking among 15-year-old boys.
- Alcohol use: Lifetime use decreased overall in boys between 2018 and 2022, particularly among 15-year-olds. An increase was observed among 11- and 13-year-old girls but not 15-year-old girls. There was a small but significant decrease in the proportion of current drinkers among 15-year-old boys, with no change among 11- and 13-year-old boys. Current alcohol use increased among girls in all age groups.
- Cannabis use: Lifetime use among 15-year-olds decreased slightly from 14% to 12% between 2018 and 2022, while 6% of 15-year-olds reported having used cannabis in the previous 30 days.
- Vaping: In 2022 vapes (e-cigarettes) were more popular among adolescents than conventional tobacco cigarettes.
Traditional Gender Gap Narrowing or Reversing
Report coauthor Judith Brown from the University of Glasgow, Glasgow, Scotland, and a project manager for the Scottish survey, said that “there was an overall increase in current alcohol use and drunkenness among older girls” despite the overall decrease in boys’ alcohol use.
She explained: “Substance use has traditionally been more prevalent among boys, and the survey findings confirm a well-established gender difference, with higher prevalence in boys than in girls among 11-year-olds. By the age of 13, however, gender differences diminish or even disappear in many countries and regions.”
“Among 15-year-olds, girls often reported more frequent substance use than boys. While this pattern has been known for cigarette smoking in many countries and regions for about two decades, especially among 15-year-olds, it is a new phenomenon for behaviors related to other substances (such as alcohol consumption and drunkenness) in most countries and regions. Historically, prevalence for these behaviors has been higher among boys than girls.”
The new survey results highlight this gender reversal for several substances, she said. “Cannabis is the only substance for which both lifetime and current use is consistently higher in boys.”
Vaping Is an Emerging Public Health Concern
Dr. Brown added that the 2022 survey was the first time that vaping data had been collected from all countries. Although this is against the background of continuing decreases in smoking rates, “researchers suggest the transition to e-cigarettes, as a more popular choice than conventional cigarettes, highlights an urgent need for more targeted interventions to address this emerging public health concern.”
The report authors commented that because young people’s brains are still developing, they are “very sensitive to substances such as nicotine,” making it “easier for them to get hooked.”
Margreet de Looze, PhD, assistant professor of interdisciplinary social science at Utrecht University in Utrecht, the Netherlands, agreed with the authors’ concerns. “Vaping is extremely attractive for young people,” she said, “because the taste is more attractive than that of traditional cigarettes.” Until recently, many people were not aware of health hazards attached to vaping. “While more research is needed, vaping may function as a first step toward tobacco use and is hazardous for young people’s health. Therefore, it should be strongly discouraged.”
Substance Use Trends May Be Stabilizing or Rising Again
Increased awareness of the harmful effects of alcohol for adolescent development is also one postulated reason for declining adolescent alcohol consumption in both Europe and North America over the past two decades, which Dr. de Looze’s research has explored. Her work has also noted the “growing trend” of young people abstaining from alcohol altogether and some evidence of reductions in adolescent risk behaviors more generally, including early sexual initiation and juvenile crime.
“It may be good to realize that, in fact, the current generation of youth in many respects is healthier and reports less risky health behaviors as compared to previous generations,” she said.
However, “The declining trend in adolescent substance use that took place in many countries since the beginning of the 21st century seems to have stabilized, and moreover, in some countries and subgroups of adolescents, substance use appears to be on the rise again.” She cited particularly an overall increase in current alcohol use and drunkenness among older girls between 2018 and 2022. “It appears that, especially for girls, recent trends over time are less favorable as compared with boys.”
Multiple Influences on Adolescent Substance Abuse
Peer group influences are known to come to the fore during adolescence, and Dr. de Looze added that the early 21st century saw marked reductions in adolescent face-to-face contacts with their peers due to the rise in digital communications. “Adolescents typically use substances in the presence of peers (and in the absence of adults/parents), as it increases their status in their peer group.” Reduced in person interactions with friends may therefore have contributed to the earlier decline in substance use.
However, her team had found that adolescents who spend much time online with friends often also spend much time with friends offline. “They are what you could call the ‘social’ youth, who just spend much time with peers, be it offline or online,” she said. “More research is needed to disentangle exactly how, what kind, for whom the digital environment may be related to young people’s substance use,” she said.
“We also see that young people actively select their friends. So, if you are curious and a bit of a sensation-seeker yourself, you are more likely to become friends with youth who are just like you, and together, you may be more likely to try out substances.”
Factors underlying adolescent substance use and differences between countries are influenced by a complex interplay of factors, said Carina Ferreira-Borges, PhD, regional adviser for alcohol, illicit drugs, and prison health at the WHO Regional Office for Europe.
“Prevention measures definitely play a critical role in reducing substance use,” she said, “but other factors, such as cultural norms and socioeconomic conditions, also significantly impact these patterns.”
“Variations in substance use among countries can be attributed to different levels of implemented polices, public health initiatives, and the extent to which substance use is normalized or stigmatized within each society.”
Policy Efforts Must Be Targeted
“To address these disparities effectively, interventions and population-level policies need to be culturally adapted and target the specific environments where substance use is normalized among adolescents. By understanding and modifying the broader context in which young people make choices about substance use, we can better influence their behavior and health outcomes.”
Dr. de Looze cautioned, “In the past two decades, public health efforts in many countries have focused on reducing young people’s engagement in substance use. It is important that these efforts continue, as every year a new generation of youth is born. If public health efforts do not continue to focus on supporting a healthy lifestyle among young people, it should not come as a surprise that rates start or continue to rise again.”
A version of this article appeared on Medscape.com.
, warned the authors of a new report detailing trends across several regions between 2018 and 2022. The latest 4-yearly Health Behaviour in School-Aged Children study, in collaboration with the World Health Organization (WHO) Regional Office for Europe, concluded that substance use remains “a crucial public health problem among adolescents” despite overall declines in smoking, alcohol, and cannabis use.
The new report: A focus on adolescent substance use in Europe, central Asia, and Canada, detailed substance use among adolescents aged 11, 13, and 15 years across 44 countries and regions in Europe, Central Asia, and Canada in the 2021-2022 school-based survey.
Principal findings included:
- Cigarette smoking: Lifetime smoking declined between 2018 and 2022, particularly among 13-year-old boys and 15-year-old boys and girls. There was also a small but significant decrease in current smoking among 15-year-old boys.
- Alcohol use: Lifetime use decreased overall in boys between 2018 and 2022, particularly among 15-year-olds. An increase was observed among 11- and 13-year-old girls but not 15-year-old girls. There was a small but significant decrease in the proportion of current drinkers among 15-year-old boys, with no change among 11- and 13-year-old boys. Current alcohol use increased among girls in all age groups.
- Cannabis use: Lifetime use among 15-year-olds decreased slightly from 14% to 12% between 2018 and 2022, while 6% of 15-year-olds reported having used cannabis in the previous 30 days.
- Vaping: In 2022 vapes (e-cigarettes) were more popular among adolescents than conventional tobacco cigarettes.
Traditional Gender Gap Narrowing or Reversing
Report coauthor Judith Brown from the University of Glasgow, Glasgow, Scotland, and a project manager for the Scottish survey, said that “there was an overall increase in current alcohol use and drunkenness among older girls” despite the overall decrease in boys’ alcohol use.
She explained: “Substance use has traditionally been more prevalent among boys, and the survey findings confirm a well-established gender difference, with higher prevalence in boys than in girls among 11-year-olds. By the age of 13, however, gender differences diminish or even disappear in many countries and regions.”
“Among 15-year-olds, girls often reported more frequent substance use than boys. While this pattern has been known for cigarette smoking in many countries and regions for about two decades, especially among 15-year-olds, it is a new phenomenon for behaviors related to other substances (such as alcohol consumption and drunkenness) in most countries and regions. Historically, prevalence for these behaviors has been higher among boys than girls.”
The new survey results highlight this gender reversal for several substances, she said. “Cannabis is the only substance for which both lifetime and current use is consistently higher in boys.”
Vaping Is an Emerging Public Health Concern
Dr. Brown added that the 2022 survey was the first time that vaping data had been collected from all countries. Although this is against the background of continuing decreases in smoking rates, “researchers suggest the transition to e-cigarettes, as a more popular choice than conventional cigarettes, highlights an urgent need for more targeted interventions to address this emerging public health concern.”
The report authors commented that because young people’s brains are still developing, they are “very sensitive to substances such as nicotine,” making it “easier for them to get hooked.”
Margreet de Looze, PhD, assistant professor of interdisciplinary social science at Utrecht University in Utrecht, the Netherlands, agreed with the authors’ concerns. “Vaping is extremely attractive for young people,” she said, “because the taste is more attractive than that of traditional cigarettes.” Until recently, many people were not aware of health hazards attached to vaping. “While more research is needed, vaping may function as a first step toward tobacco use and is hazardous for young people’s health. Therefore, it should be strongly discouraged.”
Substance Use Trends May Be Stabilizing or Rising Again
Increased awareness of the harmful effects of alcohol for adolescent development is also one postulated reason for declining adolescent alcohol consumption in both Europe and North America over the past two decades, which Dr. de Looze’s research has explored. Her work has also noted the “growing trend” of young people abstaining from alcohol altogether and some evidence of reductions in adolescent risk behaviors more generally, including early sexual initiation and juvenile crime.
“It may be good to realize that, in fact, the current generation of youth in many respects is healthier and reports less risky health behaviors as compared to previous generations,” she said.
However, “The declining trend in adolescent substance use that took place in many countries since the beginning of the 21st century seems to have stabilized, and moreover, in some countries and subgroups of adolescents, substance use appears to be on the rise again.” She cited particularly an overall increase in current alcohol use and drunkenness among older girls between 2018 and 2022. “It appears that, especially for girls, recent trends over time are less favorable as compared with boys.”
Multiple Influences on Adolescent Substance Abuse
Peer group influences are known to come to the fore during adolescence, and Dr. de Looze added that the early 21st century saw marked reductions in adolescent face-to-face contacts with their peers due to the rise in digital communications. “Adolescents typically use substances in the presence of peers (and in the absence of adults/parents), as it increases their status in their peer group.” Reduced in person interactions with friends may therefore have contributed to the earlier decline in substance use.
However, her team had found that adolescents who spend much time online with friends often also spend much time with friends offline. “They are what you could call the ‘social’ youth, who just spend much time with peers, be it offline or online,” she said. “More research is needed to disentangle exactly how, what kind, for whom the digital environment may be related to young people’s substance use,” she said.
“We also see that young people actively select their friends. So, if you are curious and a bit of a sensation-seeker yourself, you are more likely to become friends with youth who are just like you, and together, you may be more likely to try out substances.”
Factors underlying adolescent substance use and differences between countries are influenced by a complex interplay of factors, said Carina Ferreira-Borges, PhD, regional adviser for alcohol, illicit drugs, and prison health at the WHO Regional Office for Europe.
“Prevention measures definitely play a critical role in reducing substance use,” she said, “but other factors, such as cultural norms and socioeconomic conditions, also significantly impact these patterns.”
“Variations in substance use among countries can be attributed to different levels of implemented polices, public health initiatives, and the extent to which substance use is normalized or stigmatized within each society.”
Policy Efforts Must Be Targeted
“To address these disparities effectively, interventions and population-level policies need to be culturally adapted and target the specific environments where substance use is normalized among adolescents. By understanding and modifying the broader context in which young people make choices about substance use, we can better influence their behavior and health outcomes.”
Dr. de Looze cautioned, “In the past two decades, public health efforts in many countries have focused on reducing young people’s engagement in substance use. It is important that these efforts continue, as every year a new generation of youth is born. If public health efforts do not continue to focus on supporting a healthy lifestyle among young people, it should not come as a surprise that rates start or continue to rise again.”
A version of this article appeared on Medscape.com.
Getting Patients With Opioid Use Disorder Started on Buprenorphine in Primary Care
*The first thing Ann Garment, MD, wants all clinicians to know about buprenorphine is that [where state law permits] any prescriber with a DEA registration number “is able to prescribe buprenorphine and should be ready and willing to prescribe” the medication.
*A change in federal law means that for most providers “there is no longer any extra paperwork or training required to prescribe buprenorphine,” said Dr. Garment, clinical associate professor at New York University and chief of general internal medicine at Bellevue Hospital in New York City, during a presentation on April 19 at the American College of Physicians (ACP-IM) Internal Medicine Meeting 2024.
Dr. Garment, who specializes in opioid use disorder (OUD), described the current “third wave” of increasing opioid overdose deaths fueled by the increase of synthetic opioids in the drug supply. The third wave started in 2013 with the rise in use of fentanyl and tramadol. The 107,000 number of overdose deaths in the United States in 2021 was more than six times that in 1999, and 75% involved opioids.
“Now, more than ever,” Dr. Garment said, “opioid use disorder should be treated from the primary care setting.”
How to Identify OUD
“It’s less sensitive for picking up on people who have a prior opioid use disorder history or are only exhibiting risky opioid use that wouldn’t constitute opioid use disorder yet,” she said.
If someone screens positive, to verify OUD, the Diagnostic and Statistical Manual of Mental Disorders identifies criteria for any substance abuse disorder with two general themes: Loss of control and continued use despite negative consequences.
“If you have a patient who is getting prescribed opioids and they have opioid tolerance or withdrawal, that does not mean they have opioid use disorder,” she said.
Medication for OUD
Medication is the top treatment for OUD, according to Dr. Garment. Psychosocial treatments can help some but not all people with OUD, she said. “It is not a requirement for a patient to engage in psychosocial treatment in order to get a medication for opioid use disorder, so please do not let that be a barrier for your patients,” she said.
Buprenorphine has advantages over other medications for OUD, including methadone and naltrexone.
Methadone must be obtained daily at a methadone clinic instead of at a local pharmacy. And escalating doses of methadone carry an increased risk for overdose and respiratory problems and potential drug-drug interactions, Dr. Garment added.
One downside with naltrexone is loss of tolerance, she said. If a patient has been using naltrexone to treat OUD and they decide to resume taking opioids, “they no longer can use the same amount of opioids that they were using before” because they have lost their tolerance and now are at a risk for overdose with their usual amount, she said. What’s more, naltrexone has not been shown to reduce overdose deaths.
Finally, she said, buprenorphine, “is an incredibly safe medication. If anyone in this room has ever prescribed coumadin or insulin, I’m going to tell you: This is much safer.”
Dr. Garment offered three reasons for buprenorphine’s safety:
- The drug is a partial, as opposed to full, opioid agonist, so as the dose increases, the patient experiences less withdrawal and fewer opioid cravings. As a result, they will hit a ceiling effect that avoids euphoria, respiratory depression, or overdose.
- Buprenorphine is “stickier” than other OUD medications: “If I’m taking buprenorphine and I decide to use some [oxycodone], what’s going to happen is that very little of that, if any, is going to get bound to my opioid receptors because buprenorphine is so sticky and adherent, it’s not going to let other opioids on.”
- Most buprenorphine is co-formulated with naloxone, an opioid antagonist. If a patient tries to get high from buprenorphine and tries to snort or inject it, naloxone will kick in and cancel out the buprenorphine.
Dr. Garment said she obtains urine screens ideally twice a year. If other drugs show up on the test, she said, she speaks with the patient about their drug use. “It’s never a reason to discharge someone from a practice,” she said.
Dr. Garment reported no relevant financial conflicts of interest.
*This story was updated on April 29, 2024.
A version of this article appeared on Medscape.com.
*The first thing Ann Garment, MD, wants all clinicians to know about buprenorphine is that [where state law permits] any prescriber with a DEA registration number “is able to prescribe buprenorphine and should be ready and willing to prescribe” the medication.
*A change in federal law means that for most providers “there is no longer any extra paperwork or training required to prescribe buprenorphine,” said Dr. Garment, clinical associate professor at New York University and chief of general internal medicine at Bellevue Hospital in New York City, during a presentation on April 19 at the American College of Physicians (ACP-IM) Internal Medicine Meeting 2024.
Dr. Garment, who specializes in opioid use disorder (OUD), described the current “third wave” of increasing opioid overdose deaths fueled by the increase of synthetic opioids in the drug supply. The third wave started in 2013 with the rise in use of fentanyl and tramadol. The 107,000 number of overdose deaths in the United States in 2021 was more than six times that in 1999, and 75% involved opioids.
“Now, more than ever,” Dr. Garment said, “opioid use disorder should be treated from the primary care setting.”
How to Identify OUD
“It’s less sensitive for picking up on people who have a prior opioid use disorder history or are only exhibiting risky opioid use that wouldn’t constitute opioid use disorder yet,” she said.
If someone screens positive, to verify OUD, the Diagnostic and Statistical Manual of Mental Disorders identifies criteria for any substance abuse disorder with two general themes: Loss of control and continued use despite negative consequences.
“If you have a patient who is getting prescribed opioids and they have opioid tolerance or withdrawal, that does not mean they have opioid use disorder,” she said.
Medication for OUD
Medication is the top treatment for OUD, according to Dr. Garment. Psychosocial treatments can help some but not all people with OUD, she said. “It is not a requirement for a patient to engage in psychosocial treatment in order to get a medication for opioid use disorder, so please do not let that be a barrier for your patients,” she said.
Buprenorphine has advantages over other medications for OUD, including methadone and naltrexone.
Methadone must be obtained daily at a methadone clinic instead of at a local pharmacy. And escalating doses of methadone carry an increased risk for overdose and respiratory problems and potential drug-drug interactions, Dr. Garment added.
One downside with naltrexone is loss of tolerance, she said. If a patient has been using naltrexone to treat OUD and they decide to resume taking opioids, “they no longer can use the same amount of opioids that they were using before” because they have lost their tolerance and now are at a risk for overdose with their usual amount, she said. What’s more, naltrexone has not been shown to reduce overdose deaths.
Finally, she said, buprenorphine, “is an incredibly safe medication. If anyone in this room has ever prescribed coumadin or insulin, I’m going to tell you: This is much safer.”
Dr. Garment offered three reasons for buprenorphine’s safety:
- The drug is a partial, as opposed to full, opioid agonist, so as the dose increases, the patient experiences less withdrawal and fewer opioid cravings. As a result, they will hit a ceiling effect that avoids euphoria, respiratory depression, or overdose.
- Buprenorphine is “stickier” than other OUD medications: “If I’m taking buprenorphine and I decide to use some [oxycodone], what’s going to happen is that very little of that, if any, is going to get bound to my opioid receptors because buprenorphine is so sticky and adherent, it’s not going to let other opioids on.”
- Most buprenorphine is co-formulated with naloxone, an opioid antagonist. If a patient tries to get high from buprenorphine and tries to snort or inject it, naloxone will kick in and cancel out the buprenorphine.
Dr. Garment said she obtains urine screens ideally twice a year. If other drugs show up on the test, she said, she speaks with the patient about their drug use. “It’s never a reason to discharge someone from a practice,” she said.
Dr. Garment reported no relevant financial conflicts of interest.
*This story was updated on April 29, 2024.
A version of this article appeared on Medscape.com.
*The first thing Ann Garment, MD, wants all clinicians to know about buprenorphine is that [where state law permits] any prescriber with a DEA registration number “is able to prescribe buprenorphine and should be ready and willing to prescribe” the medication.
*A change in federal law means that for most providers “there is no longer any extra paperwork or training required to prescribe buprenorphine,” said Dr. Garment, clinical associate professor at New York University and chief of general internal medicine at Bellevue Hospital in New York City, during a presentation on April 19 at the American College of Physicians (ACP-IM) Internal Medicine Meeting 2024.
Dr. Garment, who specializes in opioid use disorder (OUD), described the current “third wave” of increasing opioid overdose deaths fueled by the increase of synthetic opioids in the drug supply. The third wave started in 2013 with the rise in use of fentanyl and tramadol. The 107,000 number of overdose deaths in the United States in 2021 was more than six times that in 1999, and 75% involved opioids.
“Now, more than ever,” Dr. Garment said, “opioid use disorder should be treated from the primary care setting.”
How to Identify OUD
“It’s less sensitive for picking up on people who have a prior opioid use disorder history or are only exhibiting risky opioid use that wouldn’t constitute opioid use disorder yet,” she said.
If someone screens positive, to verify OUD, the Diagnostic and Statistical Manual of Mental Disorders identifies criteria for any substance abuse disorder with two general themes: Loss of control and continued use despite negative consequences.
“If you have a patient who is getting prescribed opioids and they have opioid tolerance or withdrawal, that does not mean they have opioid use disorder,” she said.
Medication for OUD
Medication is the top treatment for OUD, according to Dr. Garment. Psychosocial treatments can help some but not all people with OUD, she said. “It is not a requirement for a patient to engage in psychosocial treatment in order to get a medication for opioid use disorder, so please do not let that be a barrier for your patients,” she said.
Buprenorphine has advantages over other medications for OUD, including methadone and naltrexone.
Methadone must be obtained daily at a methadone clinic instead of at a local pharmacy. And escalating doses of methadone carry an increased risk for overdose and respiratory problems and potential drug-drug interactions, Dr. Garment added.
One downside with naltrexone is loss of tolerance, she said. If a patient has been using naltrexone to treat OUD and they decide to resume taking opioids, “they no longer can use the same amount of opioids that they were using before” because they have lost their tolerance and now are at a risk for overdose with their usual amount, she said. What’s more, naltrexone has not been shown to reduce overdose deaths.
Finally, she said, buprenorphine, “is an incredibly safe medication. If anyone in this room has ever prescribed coumadin or insulin, I’m going to tell you: This is much safer.”
Dr. Garment offered three reasons for buprenorphine’s safety:
- The drug is a partial, as opposed to full, opioid agonist, so as the dose increases, the patient experiences less withdrawal and fewer opioid cravings. As a result, they will hit a ceiling effect that avoids euphoria, respiratory depression, or overdose.
- Buprenorphine is “stickier” than other OUD medications: “If I’m taking buprenorphine and I decide to use some [oxycodone], what’s going to happen is that very little of that, if any, is going to get bound to my opioid receptors because buprenorphine is so sticky and adherent, it’s not going to let other opioids on.”
- Most buprenorphine is co-formulated with naloxone, an opioid antagonist. If a patient tries to get high from buprenorphine and tries to snort or inject it, naloxone will kick in and cancel out the buprenorphine.
Dr. Garment said she obtains urine screens ideally twice a year. If other drugs show up on the test, she said, she speaks with the patient about their drug use. “It’s never a reason to discharge someone from a practice,” she said.
Dr. Garment reported no relevant financial conflicts of interest.
*This story was updated on April 29, 2024.
A version of this article appeared on Medscape.com.
Integrating Telemedicine for HCV With Opioid Use Disorder Treatment Works
People with opioid use disorder (OUD) who have hepatitis C virus (HCV) were twice as likely to be treated and cured of HCV if they received facilitated telemedicine treatment within their opioid treatment program than if they were referred for off-site treatment, the results of a new study showed.
In addition, among cured patients, illicit drug use fell significantly, and there were few reinfections, reported the researchers, led by Andrew Talal, MD, MPH, with the University at Buffalo, State University of New York, Buffalo.
The study was published online in JAMA.
HCV is a major public health concern, especially among people with OUD. Geographic and logistical barriers often prevent this underserved population from accessing treatment; however, telemedicine has the potential to overcome these obstacles.
In a prospective cluster randomized clinical trial, Dr. Talal and colleagues assessed the impact of embedding facilitated telemedicine for HCV care into 12 opioid treatment programs in New York State.
They studied 602 HCV-infected adults (61% male; 51% White) with OUD. Of these, 290 (mean age, 47.1 years) were enrolled in facilitated telemedicine programs onsite, and 312 (mean age, 48.9 years) received an off-site referral (usual care).
Telemedicine participants had an initial telemedicine encounter facilitated by study case managers onsite who also administered a blood test. The telemedicine clinician subsequently evaluated participants and ordered direct-acting antiviral (DAA) medication that was delivered to the opioid treatment program monthly (as refills required) and dispensed along with methadone.
In the telemedicine group, 268 of 290 individuals (92.4%) initiated HCV treatment compared with 126 of 312 (40.4%) in the referral group.
Participants in the telemedicine group were also seen sooner and started treatment faster.
The interval between screening and initial appointments was 14 days with telemedicine vs 18 days with a referral (P = .04). The time between the initial visit and DAA initiation was 49.9 days with telemedicine vs 123.5 days with a referral (P < .001).
Intention-to-treat analysis showed significantly higher HCV cure rates with telemedicine than with referral (90.3% vs 39.4%, respectively). Similarly, the observed cure rates were also higher in the telemedicine group (84.8% vs 34.0%).
Sustained virologic response was durable, with only 13 reinfections (incidence, 2.5 per 100 person-years) occurring during the 2-year follow-up period, the researchers reported.
In addition, illicit drug use decreased significantly among cured patients in both the telemedicine group (P < .001) and the referral group (P = .001). Adults in both groups rated healthcare delivery satisfaction as high or very high.
“Our study demonstrates how telemedicine successfully integrates medical and behavioral treatment,” Dr. Talal said in a statement.
The intervention “builds patient-clinician trust across the screen, and significant decreases in substance use were observed in cured participants with minimal HCV reinfections,” the study team wrote.
Support for this research was provided by the Patient-Centered Outcomes Research Institute and by the Troup Fund of the Kaleida Health Foundation.
A version of this article appeared on Medscape.com .
People with opioid use disorder (OUD) who have hepatitis C virus (HCV) were twice as likely to be treated and cured of HCV if they received facilitated telemedicine treatment within their opioid treatment program than if they were referred for off-site treatment, the results of a new study showed.
In addition, among cured patients, illicit drug use fell significantly, and there were few reinfections, reported the researchers, led by Andrew Talal, MD, MPH, with the University at Buffalo, State University of New York, Buffalo.
The study was published online in JAMA.
HCV is a major public health concern, especially among people with OUD. Geographic and logistical barriers often prevent this underserved population from accessing treatment; however, telemedicine has the potential to overcome these obstacles.
In a prospective cluster randomized clinical trial, Dr. Talal and colleagues assessed the impact of embedding facilitated telemedicine for HCV care into 12 opioid treatment programs in New York State.
They studied 602 HCV-infected adults (61% male; 51% White) with OUD. Of these, 290 (mean age, 47.1 years) were enrolled in facilitated telemedicine programs onsite, and 312 (mean age, 48.9 years) received an off-site referral (usual care).
Telemedicine participants had an initial telemedicine encounter facilitated by study case managers onsite who also administered a blood test. The telemedicine clinician subsequently evaluated participants and ordered direct-acting antiviral (DAA) medication that was delivered to the opioid treatment program monthly (as refills required) and dispensed along with methadone.
In the telemedicine group, 268 of 290 individuals (92.4%) initiated HCV treatment compared with 126 of 312 (40.4%) in the referral group.
Participants in the telemedicine group were also seen sooner and started treatment faster.
The interval between screening and initial appointments was 14 days with telemedicine vs 18 days with a referral (P = .04). The time between the initial visit and DAA initiation was 49.9 days with telemedicine vs 123.5 days with a referral (P < .001).
Intention-to-treat analysis showed significantly higher HCV cure rates with telemedicine than with referral (90.3% vs 39.4%, respectively). Similarly, the observed cure rates were also higher in the telemedicine group (84.8% vs 34.0%).
Sustained virologic response was durable, with only 13 reinfections (incidence, 2.5 per 100 person-years) occurring during the 2-year follow-up period, the researchers reported.
In addition, illicit drug use decreased significantly among cured patients in both the telemedicine group (P < .001) and the referral group (P = .001). Adults in both groups rated healthcare delivery satisfaction as high or very high.
“Our study demonstrates how telemedicine successfully integrates medical and behavioral treatment,” Dr. Talal said in a statement.
The intervention “builds patient-clinician trust across the screen, and significant decreases in substance use were observed in cured participants with minimal HCV reinfections,” the study team wrote.
Support for this research was provided by the Patient-Centered Outcomes Research Institute and by the Troup Fund of the Kaleida Health Foundation.
A version of this article appeared on Medscape.com .
People with opioid use disorder (OUD) who have hepatitis C virus (HCV) were twice as likely to be treated and cured of HCV if they received facilitated telemedicine treatment within their opioid treatment program than if they were referred for off-site treatment, the results of a new study showed.
In addition, among cured patients, illicit drug use fell significantly, and there were few reinfections, reported the researchers, led by Andrew Talal, MD, MPH, with the University at Buffalo, State University of New York, Buffalo.
The study was published online in JAMA.
HCV is a major public health concern, especially among people with OUD. Geographic and logistical barriers often prevent this underserved population from accessing treatment; however, telemedicine has the potential to overcome these obstacles.
In a prospective cluster randomized clinical trial, Dr. Talal and colleagues assessed the impact of embedding facilitated telemedicine for HCV care into 12 opioid treatment programs in New York State.
They studied 602 HCV-infected adults (61% male; 51% White) with OUD. Of these, 290 (mean age, 47.1 years) were enrolled in facilitated telemedicine programs onsite, and 312 (mean age, 48.9 years) received an off-site referral (usual care).
Telemedicine participants had an initial telemedicine encounter facilitated by study case managers onsite who also administered a blood test. The telemedicine clinician subsequently evaluated participants and ordered direct-acting antiviral (DAA) medication that was delivered to the opioid treatment program monthly (as refills required) and dispensed along with methadone.
In the telemedicine group, 268 of 290 individuals (92.4%) initiated HCV treatment compared with 126 of 312 (40.4%) in the referral group.
Participants in the telemedicine group were also seen sooner and started treatment faster.
The interval between screening and initial appointments was 14 days with telemedicine vs 18 days with a referral (P = .04). The time between the initial visit and DAA initiation was 49.9 days with telemedicine vs 123.5 days with a referral (P < .001).
Intention-to-treat analysis showed significantly higher HCV cure rates with telemedicine than with referral (90.3% vs 39.4%, respectively). Similarly, the observed cure rates were also higher in the telemedicine group (84.8% vs 34.0%).
Sustained virologic response was durable, with only 13 reinfections (incidence, 2.5 per 100 person-years) occurring during the 2-year follow-up period, the researchers reported.
In addition, illicit drug use decreased significantly among cured patients in both the telemedicine group (P < .001) and the referral group (P = .001). Adults in both groups rated healthcare delivery satisfaction as high or very high.
“Our study demonstrates how telemedicine successfully integrates medical and behavioral treatment,” Dr. Talal said in a statement.
The intervention “builds patient-clinician trust across the screen, and significant decreases in substance use were observed in cured participants with minimal HCV reinfections,” the study team wrote.
Support for this research was provided by the Patient-Centered Outcomes Research Institute and by the Troup Fund of the Kaleida Health Foundation.
A version of this article appeared on Medscape.com .
FROM JAMA
MAUD Medication at Discharge Dramatically Cuts Rehospitalization Rates
Adults with alcohol-related hospitalization who were discharged from the hospital with medication for alcohol use disorder (MAUD) were 51% less likely to be rehospitalized for an alcohol-related issue, new research suggested.
Despite the link to better outcomes, the analysis of 6500 Medicare Part D beneficiaries hospitalized for alcohol-related causes revealed that only 2% of patients were discharged with an MAUD prescription.
“Despite known efficacy, medication treatment for alcohol use disorder is underutilized and rarely initiated in the post-hospitalization setting,” lead author Eden Y. Bernstein, MD, a physician scientist in the Division of General Internal Medicine at Massachusetts General Hospital, Boston, said in a news release.
“Our findings highlight the potential clinical benefit associated with increased uptake of these medications in this setting and suggest a need to support and expand ongoing efforts to improve access to these medications upon hospital discharge,” Dr. Bernstein added.
The study was published online in JAMA Network Open.
MAUD prescribing or referral to addiction treatment at hospital discharge is widely recommended, investigators noted, making hospitalizations “important touch points” for alcohol use disorder (AUD) treatment engagement.
To study the association between discharge MAUD and 30-day rehospitalization, the researchers analyzed Medicare claims data from 2015 to 2017 in a retrospective study designed to emulate a randomized clinical trial of hospitalized patients with AUD.
The analysis included data on 6794 beneficiaries with 9834 hospitalizations for alcohol-related causes (median age, 54 years; 33% female; 72% White).
Researchers controlled for several covariates, including sociodemographic, clinical, and rehospitalization factors.
‘Sobering’ Findings
After propensity matching, discharge MAUD initiation was associated with a 42% decreased incidence of rehospitalization within 30 days of discharge (including emergency department visits and readmissions) or death within 30 days (incident rate ratio [IRR], 0.58; 95% CI, 0.45-0.76).
These findings remained consistent among secondary outcomes as well. Mortality was rare in both groups.
MAUD initiation at discharge was associated with a 51% decrease in incidence of alcohol-related return to the hospital (IRR, 0.49; 95% CI, 0.34-0.71).
Patients who received discharge MAUD were 22% more likely to have primary care or mental health follow-up visits (IRR, 1.22; 95% CI, 1.04-1.44).
Limitations noted by the authors include the observational study design and lack of information of nonpharmacologic treatment, such as 12-step facilitation or behavioral interventions.
In an accompanying editorial, Wid Yaseen, MD, of the Department of Medicine, University of Toronto, and coauthors noted that at present, most patients with AUD do not receive evidence-based treatment.
“An important first step might be reframing our mindset to consider AUD as a chronic disease,” they wrote. “We should also ask ourselves: Would we accept the status quo if only 2% of our patients with diabetes were prescribed evidence-based therapy?”
They added, “The insufficient use of MAUD is sobering and is also an enormous opportunity to do better for our patients.”
The study was funded by the Institutional National Research Service Award, Massachusetts General Hospital, the Agency for Healthcare Research and Quality, and the National Institute on Aging. Dr. Bernstein received personal fees from Alosa Health outside the submitted work, and Dr. Yaseen reported no relevant financial relationships. Full disclosures are included in the original articles.
A version of this article appeared on Medscape.com.
Adults with alcohol-related hospitalization who were discharged from the hospital with medication for alcohol use disorder (MAUD) were 51% less likely to be rehospitalized for an alcohol-related issue, new research suggested.
Despite the link to better outcomes, the analysis of 6500 Medicare Part D beneficiaries hospitalized for alcohol-related causes revealed that only 2% of patients were discharged with an MAUD prescription.
“Despite known efficacy, medication treatment for alcohol use disorder is underutilized and rarely initiated in the post-hospitalization setting,” lead author Eden Y. Bernstein, MD, a physician scientist in the Division of General Internal Medicine at Massachusetts General Hospital, Boston, said in a news release.
“Our findings highlight the potential clinical benefit associated with increased uptake of these medications in this setting and suggest a need to support and expand ongoing efforts to improve access to these medications upon hospital discharge,” Dr. Bernstein added.
The study was published online in JAMA Network Open.
MAUD prescribing or referral to addiction treatment at hospital discharge is widely recommended, investigators noted, making hospitalizations “important touch points” for alcohol use disorder (AUD) treatment engagement.
To study the association between discharge MAUD and 30-day rehospitalization, the researchers analyzed Medicare claims data from 2015 to 2017 in a retrospective study designed to emulate a randomized clinical trial of hospitalized patients with AUD.
The analysis included data on 6794 beneficiaries with 9834 hospitalizations for alcohol-related causes (median age, 54 years; 33% female; 72% White).
Researchers controlled for several covariates, including sociodemographic, clinical, and rehospitalization factors.
‘Sobering’ Findings
After propensity matching, discharge MAUD initiation was associated with a 42% decreased incidence of rehospitalization within 30 days of discharge (including emergency department visits and readmissions) or death within 30 days (incident rate ratio [IRR], 0.58; 95% CI, 0.45-0.76).
These findings remained consistent among secondary outcomes as well. Mortality was rare in both groups.
MAUD initiation at discharge was associated with a 51% decrease in incidence of alcohol-related return to the hospital (IRR, 0.49; 95% CI, 0.34-0.71).
Patients who received discharge MAUD were 22% more likely to have primary care or mental health follow-up visits (IRR, 1.22; 95% CI, 1.04-1.44).
Limitations noted by the authors include the observational study design and lack of information of nonpharmacologic treatment, such as 12-step facilitation or behavioral interventions.
In an accompanying editorial, Wid Yaseen, MD, of the Department of Medicine, University of Toronto, and coauthors noted that at present, most patients with AUD do not receive evidence-based treatment.
“An important first step might be reframing our mindset to consider AUD as a chronic disease,” they wrote. “We should also ask ourselves: Would we accept the status quo if only 2% of our patients with diabetes were prescribed evidence-based therapy?”
They added, “The insufficient use of MAUD is sobering and is also an enormous opportunity to do better for our patients.”
The study was funded by the Institutional National Research Service Award, Massachusetts General Hospital, the Agency for Healthcare Research and Quality, and the National Institute on Aging. Dr. Bernstein received personal fees from Alosa Health outside the submitted work, and Dr. Yaseen reported no relevant financial relationships. Full disclosures are included in the original articles.
A version of this article appeared on Medscape.com.
Adults with alcohol-related hospitalization who were discharged from the hospital with medication for alcohol use disorder (MAUD) were 51% less likely to be rehospitalized for an alcohol-related issue, new research suggested.
Despite the link to better outcomes, the analysis of 6500 Medicare Part D beneficiaries hospitalized for alcohol-related causes revealed that only 2% of patients were discharged with an MAUD prescription.
“Despite known efficacy, medication treatment for alcohol use disorder is underutilized and rarely initiated in the post-hospitalization setting,” lead author Eden Y. Bernstein, MD, a physician scientist in the Division of General Internal Medicine at Massachusetts General Hospital, Boston, said in a news release.
“Our findings highlight the potential clinical benefit associated with increased uptake of these medications in this setting and suggest a need to support and expand ongoing efforts to improve access to these medications upon hospital discharge,” Dr. Bernstein added.
The study was published online in JAMA Network Open.
MAUD prescribing or referral to addiction treatment at hospital discharge is widely recommended, investigators noted, making hospitalizations “important touch points” for alcohol use disorder (AUD) treatment engagement.
To study the association between discharge MAUD and 30-day rehospitalization, the researchers analyzed Medicare claims data from 2015 to 2017 in a retrospective study designed to emulate a randomized clinical trial of hospitalized patients with AUD.
The analysis included data on 6794 beneficiaries with 9834 hospitalizations for alcohol-related causes (median age, 54 years; 33% female; 72% White).
Researchers controlled for several covariates, including sociodemographic, clinical, and rehospitalization factors.
‘Sobering’ Findings
After propensity matching, discharge MAUD initiation was associated with a 42% decreased incidence of rehospitalization within 30 days of discharge (including emergency department visits and readmissions) or death within 30 days (incident rate ratio [IRR], 0.58; 95% CI, 0.45-0.76).
These findings remained consistent among secondary outcomes as well. Mortality was rare in both groups.
MAUD initiation at discharge was associated with a 51% decrease in incidence of alcohol-related return to the hospital (IRR, 0.49; 95% CI, 0.34-0.71).
Patients who received discharge MAUD were 22% more likely to have primary care or mental health follow-up visits (IRR, 1.22; 95% CI, 1.04-1.44).
Limitations noted by the authors include the observational study design and lack of information of nonpharmacologic treatment, such as 12-step facilitation or behavioral interventions.
In an accompanying editorial, Wid Yaseen, MD, of the Department of Medicine, University of Toronto, and coauthors noted that at present, most patients with AUD do not receive evidence-based treatment.
“An important first step might be reframing our mindset to consider AUD as a chronic disease,” they wrote. “We should also ask ourselves: Would we accept the status quo if only 2% of our patients with diabetes were prescribed evidence-based therapy?”
They added, “The insufficient use of MAUD is sobering and is also an enormous opportunity to do better for our patients.”
The study was funded by the Institutional National Research Service Award, Massachusetts General Hospital, the Agency for Healthcare Research and Quality, and the National Institute on Aging. Dr. Bernstein received personal fees from Alosa Health outside the submitted work, and Dr. Yaseen reported no relevant financial relationships. Full disclosures are included in the original articles.
A version of this article appeared on Medscape.com.
Cannabis Constituent May Be Key to Easing THC-Induced Anxiety
, new data from a small study suggested.
Participants who inhaled vaporized D-limonene and THC reported significantly greater decreases in anxiogenic effects than did people who received either component alone or a placebo. Reductions were greater as the dose of the D-limonene was increased.
Investigators noted that the findings could have implications for the use of medicinal or recreational cannabis, which has increased in recent years due to state legalization efforts.
“People use cannabis to help reduce anxiety, depression, and posttraumatic stress disorder, but since THC levels vary widely, if a person overshoots their tolerance of THC, cannabis can induce anxiety rather than relieve it,” senior investigator Ryan Vandrey, PhD, professor of psychiatry and behavioral sciences, Johns Hopkins School of Medicine, Baltimore, said in a news release.
“Our study demonstrates that D-limonene can modulate the effects of THC in a meaningful way and make THC more tolerable to people using it for both therapeutic and non-therapeutic purposes,” he added.
The study was published online in Drug and Alcohol Dependence.
Entourage Theory
Cannabis legalization has opened the door to an increased range of medicinal and nonmedicinal uses, but its benefits can be limited by the anxiety and panic some people experience with its use, investigators noted.
Many cannabis plants have been bred to contain higher concentrations of THC, with some dispensaries selling cannabis with more than 20%-30% THC. The plants often include cannabidiol, “minor” cannabinoids, and terpenes, such as D-limonene.
Prior studies pointed to THC as the cause of acute behavioral and psychoactive effects some cannabis users experience. However, a new, untested theory, the “cannabis entourage effect theory,” suggested other components in cannabis, including D-limonene, may contribute to the anxiogenic symptoms.
“We were motivated by scientific publications that hypothesized D-limonene can attenuate the acute anxiogenic effects of cannabis, but for which empirical data did not exist,” Dr. Vandrey said.
Investigators designed a small double-blind, within-subjects crossover study of 20 healthy adults (median age, 26 years; 50% men). About half of participants were Caucasian/non-Hispanic, 30% African American/non-Hispanic, 10% Caucasian/Hispanic, and 10% Asian/non-Hispanic.
All participants completed nine outpatient drug administration sessions, during which they inhaled vaporized D-limonene alone (1 or 5 mg), THC alone (15 or 30 mg), the same doses of THC and D-limonene together, or placebo.
Primary outcomes included subjective drug effects, measured with the Drug Effect Questionnaire (DEQ) and the 20-item state subscale of the State-Trait Anxiety Inventory (STAI-S). Investigators also measured cognitive/psychomotor performance with the Digit Symbol Substitution Task (DSST) and the Paced Serial Addition Task.
Vital signs such as heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), and plasma D-limonene and THC concentrations were also tracked.
Participants’ responses were measured at baseline and then an additional nine times after initial exposure over the course of each 6-hour test session. Blood and urine samples were collected from participants before, during, and after each session.
First Evidence
There were no significant differences in outcomes between the D-limonene alone and placebo groups.
Receipt of 15- and 30-mg doses of THC alone was associated with subjective reports of acute cannabis exposure, including cognitive and physiological effects.
A treatment effect was observed for “anxious/nervous” (P < .01), “paranoid” (P < .01), and “heart racing” (P < .0001).
In planned comparisons, ratings of anxiety-like subjective effects qualitatively decreased as D-limonene dose increased, and concurrent administration of 30-mg THC plus 15-mg D-limonene significantly reduced ratings of “anxious/nervous” and “paranoid” on the DEQ compared to 30 mg of THC alone (P < .05).
Findings were similar on the composite score of the STAI-S, and although planned comparisons did not reach the threshold for statistical significance, reductions in anxiety approached significance in the THC plus D-limonene group compared with the THC alone condition (P = .08). The combination group also reported significantly lower subjective ratings of unpleasant drug effects than the THC alone group (P = .03).
In particular, a main effect of treatment was found for the anxious/nervous category on the DEQ (P < .01), as well as the “paranoid” (P < .01) and heart racing (P < .0001) categories.
On the other hand, ratings of anxious/nervous and paranoid categories were significantly lower in the 30-mg THC plus 15-mg D-limonene vs the 30-mg THC alone condition (P < .05, for all).
As for cognition, following drug administration, a significant main effect of treatment was observed for the DSST (P < .05), but no significant differences between THC and THC plus D-limonene combination conditions or between D-limonene alone and placebo were detected.
There were no differences within each THC dose and between D-limonene alone versus placebo conditions. Moreover, there were no main effects of treatment found for SBP or DBP.
The combination condition produced significantly greater concentrations of THC than the THC alone condition (P < .05).
“This study provides the first evidence that there are chemical constituents found naturally in the cannabis plant that can reduce some of the adverse effects of using delta-9-THC,” Dr. Vandrey said.
Although the exact mechanism by which vaporized D-limonene counters the anxiogenic effects of THC is unclear, “our best guess is that D-limonene is producing an anxiolytic effect on its own that is not mediated by cannabinoid receptors,” Dr. Vandrey said.
Significant Impact
Commenting on the research, Joshua Lile, PhD, professor, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, noted that the study seems to be the first of its kind to study the influence of terpene on THC response.
The research “makes a significant impact on our field,” and is “among the few controlled clinical studies that have demonstrated interactions between THC and other cannabis constituents, supporting the validity of the ‘entourage’ effect,” said Dr. Lile, who was not involved with the current research.
“This work is particularly important, given the unfounded claims sometimes made by the cannabis industry regarding the effects of different cannabis products,” he added.
Also commenting on the study, Ziva Cooper, PhD, professor and director of the UCLA Center for Cannabis and Cannabinoids, University of California Los Angeles, said the findings “have direct implications for improving the safety of cannabis, whether it’s being used for medical or nonmedical purposes, especially in people and patients who do not have experience with cannabis, a group that is at high risk for experiencing anxiety after using cannabis.”
In addition, “an important aspect to this study is that the effects of limonene in reducing anxiety attributed to delta-9-THC were observed at higher concentrations (or doses) than those usually present in the plant,” Dr. Copper said. “This calls for further investigation into new cannabis formulations specifically designed to leverage the potential protective effects of the terpene.”
This research was supported by the National Institute on Drug Abuse. Dr. Vandrey served as a consultant or received honoraria from Mira1a Therapeutics, Inc.; Jazz Pharmaceuticals; Charlotte’s Web; Syqe Medical Ltd.; and WebMD. The other authors’ disclosures are listed on the original paper. Dr. Lile declared no relevant financial relationships. Dr. Cooper reported receiving study drug from Canopy Growth Corp and True Terpenes, study-related materials from Storz & Bickel, and research support from the National Institute on Drug Abuse, National Center for Complementary and Integrative Health, California Department of Cannabis Control, Center for Medicinal Cannabis Research, and California Highway Patrol.
A version of this article appeared on Medscape.com.
, new data from a small study suggested.
Participants who inhaled vaporized D-limonene and THC reported significantly greater decreases in anxiogenic effects than did people who received either component alone or a placebo. Reductions were greater as the dose of the D-limonene was increased.
Investigators noted that the findings could have implications for the use of medicinal or recreational cannabis, which has increased in recent years due to state legalization efforts.
“People use cannabis to help reduce anxiety, depression, and posttraumatic stress disorder, but since THC levels vary widely, if a person overshoots their tolerance of THC, cannabis can induce anxiety rather than relieve it,” senior investigator Ryan Vandrey, PhD, professor of psychiatry and behavioral sciences, Johns Hopkins School of Medicine, Baltimore, said in a news release.
“Our study demonstrates that D-limonene can modulate the effects of THC in a meaningful way and make THC more tolerable to people using it for both therapeutic and non-therapeutic purposes,” he added.
The study was published online in Drug and Alcohol Dependence.
Entourage Theory
Cannabis legalization has opened the door to an increased range of medicinal and nonmedicinal uses, but its benefits can be limited by the anxiety and panic some people experience with its use, investigators noted.
Many cannabis plants have been bred to contain higher concentrations of THC, with some dispensaries selling cannabis with more than 20%-30% THC. The plants often include cannabidiol, “minor” cannabinoids, and terpenes, such as D-limonene.
Prior studies pointed to THC as the cause of acute behavioral and psychoactive effects some cannabis users experience. However, a new, untested theory, the “cannabis entourage effect theory,” suggested other components in cannabis, including D-limonene, may contribute to the anxiogenic symptoms.
“We were motivated by scientific publications that hypothesized D-limonene can attenuate the acute anxiogenic effects of cannabis, but for which empirical data did not exist,” Dr. Vandrey said.
Investigators designed a small double-blind, within-subjects crossover study of 20 healthy adults (median age, 26 years; 50% men). About half of participants were Caucasian/non-Hispanic, 30% African American/non-Hispanic, 10% Caucasian/Hispanic, and 10% Asian/non-Hispanic.
All participants completed nine outpatient drug administration sessions, during which they inhaled vaporized D-limonene alone (1 or 5 mg), THC alone (15 or 30 mg), the same doses of THC and D-limonene together, or placebo.
Primary outcomes included subjective drug effects, measured with the Drug Effect Questionnaire (DEQ) and the 20-item state subscale of the State-Trait Anxiety Inventory (STAI-S). Investigators also measured cognitive/psychomotor performance with the Digit Symbol Substitution Task (DSST) and the Paced Serial Addition Task.
Vital signs such as heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), and plasma D-limonene and THC concentrations were also tracked.
Participants’ responses were measured at baseline and then an additional nine times after initial exposure over the course of each 6-hour test session. Blood and urine samples were collected from participants before, during, and after each session.
First Evidence
There were no significant differences in outcomes between the D-limonene alone and placebo groups.
Receipt of 15- and 30-mg doses of THC alone was associated with subjective reports of acute cannabis exposure, including cognitive and physiological effects.
A treatment effect was observed for “anxious/nervous” (P < .01), “paranoid” (P < .01), and “heart racing” (P < .0001).
In planned comparisons, ratings of anxiety-like subjective effects qualitatively decreased as D-limonene dose increased, and concurrent administration of 30-mg THC plus 15-mg D-limonene significantly reduced ratings of “anxious/nervous” and “paranoid” on the DEQ compared to 30 mg of THC alone (P < .05).
Findings were similar on the composite score of the STAI-S, and although planned comparisons did not reach the threshold for statistical significance, reductions in anxiety approached significance in the THC plus D-limonene group compared with the THC alone condition (P = .08). The combination group also reported significantly lower subjective ratings of unpleasant drug effects than the THC alone group (P = .03).
In particular, a main effect of treatment was found for the anxious/nervous category on the DEQ (P < .01), as well as the “paranoid” (P < .01) and heart racing (P < .0001) categories.
On the other hand, ratings of anxious/nervous and paranoid categories were significantly lower in the 30-mg THC plus 15-mg D-limonene vs the 30-mg THC alone condition (P < .05, for all).
As for cognition, following drug administration, a significant main effect of treatment was observed for the DSST (P < .05), but no significant differences between THC and THC plus D-limonene combination conditions or between D-limonene alone and placebo were detected.
There were no differences within each THC dose and between D-limonene alone versus placebo conditions. Moreover, there were no main effects of treatment found for SBP or DBP.
The combination condition produced significantly greater concentrations of THC than the THC alone condition (P < .05).
“This study provides the first evidence that there are chemical constituents found naturally in the cannabis plant that can reduce some of the adverse effects of using delta-9-THC,” Dr. Vandrey said.
Although the exact mechanism by which vaporized D-limonene counters the anxiogenic effects of THC is unclear, “our best guess is that D-limonene is producing an anxiolytic effect on its own that is not mediated by cannabinoid receptors,” Dr. Vandrey said.
Significant Impact
Commenting on the research, Joshua Lile, PhD, professor, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, noted that the study seems to be the first of its kind to study the influence of terpene on THC response.
The research “makes a significant impact on our field,” and is “among the few controlled clinical studies that have demonstrated interactions between THC and other cannabis constituents, supporting the validity of the ‘entourage’ effect,” said Dr. Lile, who was not involved with the current research.
“This work is particularly important, given the unfounded claims sometimes made by the cannabis industry regarding the effects of different cannabis products,” he added.
Also commenting on the study, Ziva Cooper, PhD, professor and director of the UCLA Center for Cannabis and Cannabinoids, University of California Los Angeles, said the findings “have direct implications for improving the safety of cannabis, whether it’s being used for medical or nonmedical purposes, especially in people and patients who do not have experience with cannabis, a group that is at high risk for experiencing anxiety after using cannabis.”
In addition, “an important aspect to this study is that the effects of limonene in reducing anxiety attributed to delta-9-THC were observed at higher concentrations (or doses) than those usually present in the plant,” Dr. Copper said. “This calls for further investigation into new cannabis formulations specifically designed to leverage the potential protective effects of the terpene.”
This research was supported by the National Institute on Drug Abuse. Dr. Vandrey served as a consultant or received honoraria from Mira1a Therapeutics, Inc.; Jazz Pharmaceuticals; Charlotte’s Web; Syqe Medical Ltd.; and WebMD. The other authors’ disclosures are listed on the original paper. Dr. Lile declared no relevant financial relationships. Dr. Cooper reported receiving study drug from Canopy Growth Corp and True Terpenes, study-related materials from Storz & Bickel, and research support from the National Institute on Drug Abuse, National Center for Complementary and Integrative Health, California Department of Cannabis Control, Center for Medicinal Cannabis Research, and California Highway Patrol.
A version of this article appeared on Medscape.com.
, new data from a small study suggested.
Participants who inhaled vaporized D-limonene and THC reported significantly greater decreases in anxiogenic effects than did people who received either component alone or a placebo. Reductions were greater as the dose of the D-limonene was increased.
Investigators noted that the findings could have implications for the use of medicinal or recreational cannabis, which has increased in recent years due to state legalization efforts.
“People use cannabis to help reduce anxiety, depression, and posttraumatic stress disorder, but since THC levels vary widely, if a person overshoots their tolerance of THC, cannabis can induce anxiety rather than relieve it,” senior investigator Ryan Vandrey, PhD, professor of psychiatry and behavioral sciences, Johns Hopkins School of Medicine, Baltimore, said in a news release.
“Our study demonstrates that D-limonene can modulate the effects of THC in a meaningful way and make THC more tolerable to people using it for both therapeutic and non-therapeutic purposes,” he added.
The study was published online in Drug and Alcohol Dependence.
Entourage Theory
Cannabis legalization has opened the door to an increased range of medicinal and nonmedicinal uses, but its benefits can be limited by the anxiety and panic some people experience with its use, investigators noted.
Many cannabis plants have been bred to contain higher concentrations of THC, with some dispensaries selling cannabis with more than 20%-30% THC. The plants often include cannabidiol, “minor” cannabinoids, and terpenes, such as D-limonene.
Prior studies pointed to THC as the cause of acute behavioral and psychoactive effects some cannabis users experience. However, a new, untested theory, the “cannabis entourage effect theory,” suggested other components in cannabis, including D-limonene, may contribute to the anxiogenic symptoms.
“We were motivated by scientific publications that hypothesized D-limonene can attenuate the acute anxiogenic effects of cannabis, but for which empirical data did not exist,” Dr. Vandrey said.
Investigators designed a small double-blind, within-subjects crossover study of 20 healthy adults (median age, 26 years; 50% men). About half of participants were Caucasian/non-Hispanic, 30% African American/non-Hispanic, 10% Caucasian/Hispanic, and 10% Asian/non-Hispanic.
All participants completed nine outpatient drug administration sessions, during which they inhaled vaporized D-limonene alone (1 or 5 mg), THC alone (15 or 30 mg), the same doses of THC and D-limonene together, or placebo.
Primary outcomes included subjective drug effects, measured with the Drug Effect Questionnaire (DEQ) and the 20-item state subscale of the State-Trait Anxiety Inventory (STAI-S). Investigators also measured cognitive/psychomotor performance with the Digit Symbol Substitution Task (DSST) and the Paced Serial Addition Task.
Vital signs such as heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), and plasma D-limonene and THC concentrations were also tracked.
Participants’ responses were measured at baseline and then an additional nine times after initial exposure over the course of each 6-hour test session. Blood and urine samples were collected from participants before, during, and after each session.
First Evidence
There were no significant differences in outcomes between the D-limonene alone and placebo groups.
Receipt of 15- and 30-mg doses of THC alone was associated with subjective reports of acute cannabis exposure, including cognitive and physiological effects.
A treatment effect was observed for “anxious/nervous” (P < .01), “paranoid” (P < .01), and “heart racing” (P < .0001).
In planned comparisons, ratings of anxiety-like subjective effects qualitatively decreased as D-limonene dose increased, and concurrent administration of 30-mg THC plus 15-mg D-limonene significantly reduced ratings of “anxious/nervous” and “paranoid” on the DEQ compared to 30 mg of THC alone (P < .05).
Findings were similar on the composite score of the STAI-S, and although planned comparisons did not reach the threshold for statistical significance, reductions in anxiety approached significance in the THC plus D-limonene group compared with the THC alone condition (P = .08). The combination group also reported significantly lower subjective ratings of unpleasant drug effects than the THC alone group (P = .03).
In particular, a main effect of treatment was found for the anxious/nervous category on the DEQ (P < .01), as well as the “paranoid” (P < .01) and heart racing (P < .0001) categories.
On the other hand, ratings of anxious/nervous and paranoid categories were significantly lower in the 30-mg THC plus 15-mg D-limonene vs the 30-mg THC alone condition (P < .05, for all).
As for cognition, following drug administration, a significant main effect of treatment was observed for the DSST (P < .05), but no significant differences between THC and THC plus D-limonene combination conditions or between D-limonene alone and placebo were detected.
There were no differences within each THC dose and between D-limonene alone versus placebo conditions. Moreover, there were no main effects of treatment found for SBP or DBP.
The combination condition produced significantly greater concentrations of THC than the THC alone condition (P < .05).
“This study provides the first evidence that there are chemical constituents found naturally in the cannabis plant that can reduce some of the adverse effects of using delta-9-THC,” Dr. Vandrey said.
Although the exact mechanism by which vaporized D-limonene counters the anxiogenic effects of THC is unclear, “our best guess is that D-limonene is producing an anxiolytic effect on its own that is not mediated by cannabinoid receptors,” Dr. Vandrey said.
Significant Impact
Commenting on the research, Joshua Lile, PhD, professor, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, noted that the study seems to be the first of its kind to study the influence of terpene on THC response.
The research “makes a significant impact on our field,” and is “among the few controlled clinical studies that have demonstrated interactions between THC and other cannabis constituents, supporting the validity of the ‘entourage’ effect,” said Dr. Lile, who was not involved with the current research.
“This work is particularly important, given the unfounded claims sometimes made by the cannabis industry regarding the effects of different cannabis products,” he added.
Also commenting on the study, Ziva Cooper, PhD, professor and director of the UCLA Center for Cannabis and Cannabinoids, University of California Los Angeles, said the findings “have direct implications for improving the safety of cannabis, whether it’s being used for medical or nonmedical purposes, especially in people and patients who do not have experience with cannabis, a group that is at high risk for experiencing anxiety after using cannabis.”
In addition, “an important aspect to this study is that the effects of limonene in reducing anxiety attributed to delta-9-THC were observed at higher concentrations (or doses) than those usually present in the plant,” Dr. Copper said. “This calls for further investigation into new cannabis formulations specifically designed to leverage the potential protective effects of the terpene.”
This research was supported by the National Institute on Drug Abuse. Dr. Vandrey served as a consultant or received honoraria from Mira1a Therapeutics, Inc.; Jazz Pharmaceuticals; Charlotte’s Web; Syqe Medical Ltd.; and WebMD. The other authors’ disclosures are listed on the original paper. Dr. Lile declared no relevant financial relationships. Dr. Cooper reported receiving study drug from Canopy Growth Corp and True Terpenes, study-related materials from Storz & Bickel, and research support from the National Institute on Drug Abuse, National Center for Complementary and Integrative Health, California Department of Cannabis Control, Center for Medicinal Cannabis Research, and California Highway Patrol.
A version of this article appeared on Medscape.com.
From Drug and Alcohol Dependence
Remote CBT as Effective as In-Person Therapy for Mental Illness
Remote cognitive behavioral therapy (CBT) is just as effective as in-person CBT for a range of mental health and somatic disorders, a new review of more than 50 randomized clinical trials (RCTs) showed.
The RCTs included more than 5000 patients receiving CBT for conditions such as mood, anxiety, and body dysmorphic disorders, as well as chronic pain, insomnia, and alcohol use disorder.
“The World Health Organization has designated CBT as essential healthcare, but access remains an important barrier for many people in Canada. Our findings suggest that therapist-guided, remotely delivered CBT can be used to facilitate greater access to evidence-based care,” lead investigator Jason Busse, PhD, McMaster University, Hamilton, Ontario, Canada, said in a press release.
The findings were published online on March 18 in CMAJ.
Access Problematic
In Canada, CBT may be provided within existing government-funded healthcare services and by private providers such as registered psychotherapists, social worker, and psychologists who require out-of-pocket expenses.
Access to evidence-based mental healthcare such as CBT can be challenging in a country as geographically large, and as sparsely populated, as Canada. To increase access, some of the provinces have funded Internet-based CBT, but the efficacy of in-person vs remote CBT remains uncertain.
The investigators searched the medical literature for RCTs that enrolled adult patients randomized to receive either therapist-guided remote or in-person CBT.
The study included 52 RCTs with 5463 participants with a mean age of 43 years, and 3354 (61%) were female.
A total of 17 studies focused on the treatment of anxiety and related disorders, 14 on depression and mood disorders, seven on insomnia, six on chronic pain or fatigue syndromes, five on body image or eating disorders, three on tinnitus, and one on alcohol use disorder.
CBT was provided on an individual and group basis. Treatment duration ranged from 5 to 21 sessions, with the median follow-up of 180 days.
Investigators found little to no difference in effectiveness between in-person and therapist-guided remote CBT on primary outcomes (standardized mean difference [SMD], −0.02; 95% CI, −0.11 to 0.07).
Analysis using end scores also showed little to no difference in efficacy between in-person and remote CBT (SMD, −0.01; 95% CI, −0.11 to 0.08).
Policy Implications
The authors noted that remote CBT can potentially expand access to care as it is more convenient for patients and potentially more cost-effective.
“Our finding that remote CBT is an effective alternative to in-person delivery has potential policy implications,” they wrote.
The researchers recommended Canadian provinces and territories increase funding to boost access to therapist-guided remote CBT, thereby expanding access to evidence-based care.
Study limitations included the fact that most of the eligible RCTs reviewed in the analysis were conducted in high-income countries with middle-aged patients and followed them for a median 180 days, so generalizability of the findings to older patients living in lower-income patients or for longer follow-up periods was uncertain.
The study was partially funded by the Canadian Institutes of Health Research. Disclosures were noted in the original article.
A version of this article appeared on Medscape.com .
Remote cognitive behavioral therapy (CBT) is just as effective as in-person CBT for a range of mental health and somatic disorders, a new review of more than 50 randomized clinical trials (RCTs) showed.
The RCTs included more than 5000 patients receiving CBT for conditions such as mood, anxiety, and body dysmorphic disorders, as well as chronic pain, insomnia, and alcohol use disorder.
“The World Health Organization has designated CBT as essential healthcare, but access remains an important barrier for many people in Canada. Our findings suggest that therapist-guided, remotely delivered CBT can be used to facilitate greater access to evidence-based care,” lead investigator Jason Busse, PhD, McMaster University, Hamilton, Ontario, Canada, said in a press release.
The findings were published online on March 18 in CMAJ.
Access Problematic
In Canada, CBT may be provided within existing government-funded healthcare services and by private providers such as registered psychotherapists, social worker, and psychologists who require out-of-pocket expenses.
Access to evidence-based mental healthcare such as CBT can be challenging in a country as geographically large, and as sparsely populated, as Canada. To increase access, some of the provinces have funded Internet-based CBT, but the efficacy of in-person vs remote CBT remains uncertain.
The investigators searched the medical literature for RCTs that enrolled adult patients randomized to receive either therapist-guided remote or in-person CBT.
The study included 52 RCTs with 5463 participants with a mean age of 43 years, and 3354 (61%) were female.
A total of 17 studies focused on the treatment of anxiety and related disorders, 14 on depression and mood disorders, seven on insomnia, six on chronic pain or fatigue syndromes, five on body image or eating disorders, three on tinnitus, and one on alcohol use disorder.
CBT was provided on an individual and group basis. Treatment duration ranged from 5 to 21 sessions, with the median follow-up of 180 days.
Investigators found little to no difference in effectiveness between in-person and therapist-guided remote CBT on primary outcomes (standardized mean difference [SMD], −0.02; 95% CI, −0.11 to 0.07).
Analysis using end scores also showed little to no difference in efficacy between in-person and remote CBT (SMD, −0.01; 95% CI, −0.11 to 0.08).
Policy Implications
The authors noted that remote CBT can potentially expand access to care as it is more convenient for patients and potentially more cost-effective.
“Our finding that remote CBT is an effective alternative to in-person delivery has potential policy implications,” they wrote.
The researchers recommended Canadian provinces and territories increase funding to boost access to therapist-guided remote CBT, thereby expanding access to evidence-based care.
Study limitations included the fact that most of the eligible RCTs reviewed in the analysis were conducted in high-income countries with middle-aged patients and followed them for a median 180 days, so generalizability of the findings to older patients living in lower-income patients or for longer follow-up periods was uncertain.
The study was partially funded by the Canadian Institutes of Health Research. Disclosures were noted in the original article.
A version of this article appeared on Medscape.com .
Remote cognitive behavioral therapy (CBT) is just as effective as in-person CBT for a range of mental health and somatic disorders, a new review of more than 50 randomized clinical trials (RCTs) showed.
The RCTs included more than 5000 patients receiving CBT for conditions such as mood, anxiety, and body dysmorphic disorders, as well as chronic pain, insomnia, and alcohol use disorder.
“The World Health Organization has designated CBT as essential healthcare, but access remains an important barrier for many people in Canada. Our findings suggest that therapist-guided, remotely delivered CBT can be used to facilitate greater access to evidence-based care,” lead investigator Jason Busse, PhD, McMaster University, Hamilton, Ontario, Canada, said in a press release.
The findings were published online on March 18 in CMAJ.
Access Problematic
In Canada, CBT may be provided within existing government-funded healthcare services and by private providers such as registered psychotherapists, social worker, and psychologists who require out-of-pocket expenses.
Access to evidence-based mental healthcare such as CBT can be challenging in a country as geographically large, and as sparsely populated, as Canada. To increase access, some of the provinces have funded Internet-based CBT, but the efficacy of in-person vs remote CBT remains uncertain.
The investigators searched the medical literature for RCTs that enrolled adult patients randomized to receive either therapist-guided remote or in-person CBT.
The study included 52 RCTs with 5463 participants with a mean age of 43 years, and 3354 (61%) were female.
A total of 17 studies focused on the treatment of anxiety and related disorders, 14 on depression and mood disorders, seven on insomnia, six on chronic pain or fatigue syndromes, five on body image or eating disorders, three on tinnitus, and one on alcohol use disorder.
CBT was provided on an individual and group basis. Treatment duration ranged from 5 to 21 sessions, with the median follow-up of 180 days.
Investigators found little to no difference in effectiveness between in-person and therapist-guided remote CBT on primary outcomes (standardized mean difference [SMD], −0.02; 95% CI, −0.11 to 0.07).
Analysis using end scores also showed little to no difference in efficacy between in-person and remote CBT (SMD, −0.01; 95% CI, −0.11 to 0.08).
Policy Implications
The authors noted that remote CBT can potentially expand access to care as it is more convenient for patients and potentially more cost-effective.
“Our finding that remote CBT is an effective alternative to in-person delivery has potential policy implications,” they wrote.
The researchers recommended Canadian provinces and territories increase funding to boost access to therapist-guided remote CBT, thereby expanding access to evidence-based care.
Study limitations included the fact that most of the eligible RCTs reviewed in the analysis were conducted in high-income countries with middle-aged patients and followed them for a median 180 days, so generalizability of the findings to older patients living in lower-income patients or for longer follow-up periods was uncertain.
The study was partially funded by the Canadian Institutes of Health Research. Disclosures were noted in the original article.
A version of this article appeared on Medscape.com .