Use of Cannabis for Physical and Emotional Pain (Webinar)

Use of Cannabis for Physical and Emotional Pain (Webinar)


CARRIE CUTTLER: Hi. I’m Dr. Cuttler. I am an assistant professor in
the Department of Psychology. I run the Health and Cognition
Lab where we primarily look at the effects of cannabis,
both chronic and acute effects of cannabis, on cognition
and mental health– and a little bit of
physical health, as well. Thanks for being here, today. I’m going to talk about the
use of cannabis for physical and emotional pain. So just to give you a little
bit of a brief overview of my talk, today. I’ll start by giving a very
brief history of cannabis. I will mention the top
three reasons that people– medical cannabis
users use cannabis. I will briefly describe
previous research on cannabis use and its effects
on headache and migraines pain, as well as on anxiety
and depression. I’ll then discuss a
study that we conducted looking at the acute and
long-term effects of cannabis on headache, migraine,
anxiety, and depression. I will then discuss a second
study we conducted in my lab examining the links
between depression, anxiety, coping motives, which
is just using cannabis to cope, and problematic cannabis use. And then, I will
discuss a third study where we examined cannabis
use as a moderator of the relationships between
physical and emotional pain. Finally, I’ll end by
giving a brief summary. And I will propose a band-aid
model of cannabis use. So the oldest known record
of cannabis use comes from a Chinese emperor named
Shen Nung this handsome devil over here– in 2727 BC. He investigated cannabis for
its medicinal properties, using himself as a test subject,
like good scientists did back in the days. In the second century,
a Chinese surgeon used a mixture of
cannabis resin and wine as an anesthetic
to perform surgery. In addition to using it
for medicinal purpose, the Chinese were also
some of the first to report using cannabis
for medicinal reasons. Ancient Indian religious
texts describe cannabis as a source of happiness that
diminishes fear and anxiety. In these texts, the
god Shiva is described is going to chill out
under a cannabis plant after he got in a
fight with his family. He apparently got a
little bit hungry, and decided to eat
some of this plant, and it became his favorite food. Cannabis was not introduced to
Western medicine until 1839. And at that time, it was
promoted for its analgesic, so pain relieving, sedative,
anti-inflammatory, anti-spasmodic, and
anti-convulsive properties. And apparently, it
was the treatment of choice for Queen
Victoria’s menstrual pain. And it was widely used as
medicine in the United States in the 19th and
early 20th centuries. While cannabis was used
widely as a medicine in the US in the 19th and
early 20th century, the concept of smoking cannabis
for its psychoactive properties was apparently brought to the
US by Mexican refugees in 1910. Its use for
recreational purposes then became popular among
black jazz musicians and other minority groups. And then Harry Anslinger, who
was the head of the Federal Bureau of Narcotics, then led
a campaign to outlaw this drug, alleging that its use
led to violent crimes. I’m not always comfortable
with saying this quote, but I will quote him. He is quoted as saying,
“reefer makes blackies think they’re as good as white men. There are 100,000 total
marijuana smokers in the US, and most are Negroes, Hispanics,
Filipinos, and entertainers. Their satanic music,
jazz, and swing result from marijuana use. This marijuana
causes white women to seek sexual relations
with Negroes, entertainers, and any others.” So clearly the
demonization of cannabis was steeped in
racism and ignorance. And in fact, the term marijuana
was used intentionally by Harry Anslinger in
order to associate the drug with Mexicans in a
contempt to stigmatize it. In the late ’30s– and
this is why we usually use the term cannabis,
now, instead of marijuana because it’s history of that
term is steeped in racism. So in the ’30s,
newspapers were filled with stories of “killer
weed” and reefer madness was in full swing. In 1937, US Congress passed
the Marijuana Tax Act, which banned its use in
medicine and outlawed it as a dangerous narcotic. And as a result, research
was effectively terminated for the next 20 to 25 years. And this is why we know
so little about the drug. Cannabis is presently still
considered a Schedule I drug in the United States. Schedule 1 drugs are considered
to be the most dangerous drugs with no recognized medical
benefits and a high risk of abuse and dependence. Clearly, it has no business
being scheduled that way. Nevertheless, presently
33 states and the District of Columbia have
legalized cannabis for medicinal
purposes and 10 states and DC have legalized it
for recreational purposes. I’m Canadian. Canada federally legalized
cannabis in the fall of 2018. It’s one of the first
countries to legalize cannabis federally– second. And just as a fun
fact, $1.5 billion worth of recreational cannabis
was sold in Washington state in 2017. That translates to about $4
million of cannabis products sold every day in
our state alone. We recently conducted
a large scale survey of over 1,400 medical
cannabis patients. We asked them why
they use cannabis. And the top three reasons that
they reported using cannabis was for pain, anxiety,
and depression. More specifically, 60%
reported using cannabis for pain, 36% for
headaches specifically. 58% reported using
cannabis to manage anxiety, and 50% reported using
it for depression, even though most states do
not recognize emotional pain as a legitimate reason
for medicinal cannabis. So I’m now going to just turn
to a brief discussion of results of previous research on the
acute effects of cannabis on headache and migraines pain. Now, somewhat
surprisingly, there’s been very little
research examining the efficacy of cannabis in
the treatment of headache or migraine. And most of the studies
that have been conducted have been retrospective
in nature. So rather than examining pain
before and after cannabis administration, these
studies have just asked medical cannabis
patients to think back to when they used cannabis to
treat headaches or migraines and report how
effective they found it. There’ve been three
retrospective studies and all three indicate
that cannabis may have potential therapeutic efficacy. So in that large scale survey
of medical cannabis patients I just mentioned
on the last slide, we found that they reported
that after using cannabis to treat headaches, their
headache severity decreased by an average of 3.6
points on a 10-point scale. Similarly, another
retrospective survey of over 100 medical
cannabis patients who were diagnosed with
migraine and were recommended for medical cannabis treatment
in Colorado, approximately 40% of that sample reported
a positive effect, with a decrease in
migraine frequency from over 10 migraines per
month to fewer than 5 per month. So more than a 50% reduction. Another study found that
2/3 of cannabis users indicated a slight to
substantial decrease in their use of other migraine
medication after initiating medical cannabis use. These studies indicate that
many people use cannabis to treat head pain
and they do report positive therapeutic effects. Nevertheless, there’s only
been one clinical trial. And the results of that
trial reveal that nabilone– nabilone is a
synthetic cannabinoid. So– and it’s orally consumed. I think Marinol is another
common word for it. But this study found that
nabilone was more effective than ibuprofen, Advil, in
reducing pain intensity. It also reduced intake
of other analgesics and generally increased
quality of life. There have been a large number
of correlational studies linking anxiety to cannabis use. And they fairly reliably show
that anxiety is positively– really not positively
in a good way, but positively related
to cannabis dependence and problematic use. This includes social
anxiety, generalized anxiety, agoraphobia, and
panic attacks have all been linked to cannabis use. So quite a large number
of longitudinal studies have shown that cannabis
use and cannabis dependence are related to an increased
risk for subsequently developing anxiety symptoms and
anxiety disorders. So suggesting that
using cannabis is leading to increases in
these disorders over time. Of course, other studies have
failed to find these effects, or have found that controlling
for confounding variables abolishes the
effects of cannabis in predicting
subsequent anxiety. And still others studies
have revealed evidence that anxiety diagnoses predict
subsequent cannabis use or cannabis use disorder. So there’s evidence
for both directions of potential causality. So this latter piece
of evidence suggests that maybe the anxiety
is coming first and that people are using
the cannabis in order to self medicate. So we have evidence
for both sides. There were two
recent meta analysis and they actually
converged on the conclusion that cannabis use
is actually not related to a significant
increase in subsequent anxiety. So a link that’s
a bit confusing. There have been
several studies focused on investigating the
acute effects of cannabis intoxication on anxiety. And the results
show that cannabis can have anxiolytic
or anxiogenic effect. In other words, it can
decrease or increase anxiety. Research suggests that low
doses of THC decrease anxiety, while high doses may
actually increase anxiety. So THC, tetrahydrocannabinol,
is the primary psychoactive ingredient in cannabis. It’s the ingredient that
produces, typically, the euphoric and
intoxicating effects. Research on CBD– so CBD
is the second most common phytocannabinoid, cannabidiol. And it is believed
to offset some of the negative
detrimental effects of THC. And consistent with
that research on CBD suggests that low doses
may reduce anxiety. There’s one animal
study suggesting that really high doses
are not effective. So low doses are
effective, but high doses don’t have an effect–
doesn’t increase it, just not very effective. And there’s also some
evidence that CBD can actually reverse the anxiogenic
effects of THC, that CBD can actually
counteract the anxiety that can result from too much THC. So again, CBD does
typically work to balance out potentially
detrimental effects of THC. Experience might also moderate
some of these effects. So more experienced
users may be more likely to report
anxiolytic effects, that they may feel less anxiety. While less experienced,
novice users may be more prone to
experience sort of anxiety when they’re intoxicated. Pre-existing levels
of anxiety have been found to be associated
with these effects. So people who have higher
levels of anxiety, naturally, are more likely to have
an anxiety response to cannabis than people who
have lower levels of anxiety. And I’m not aware of
empirical evidence, but it certainly appears
to me that people would be more likely
to experience anxiety from intoxication after
oral administration than after smoking or
inhaling or vaping. And that’s just because the
effects of oral cannabis take a long time to take effect. It can take an hour or more. Problem is some people
get kind of impatient. And think, oh, it’s not working. So I’m going to
eat a bunch more. And then, whoa, the effects
really kick in a little bit too much and it’s too late
to do anything about that. Whereas when it’s
inhaled, the effects are almost instantaneous. And so people can self
titrate once they’ve reached sort of their desired
level of intoxication. So they’re less
likely to overdose. There’s no CB1
receptors in the brain. You can’t actually
die from cannabis. There’s no documented cases
of death from cannabis. It physiologically
can not happen. An overdose of cannabis is
typically an anxiety or panic attack or acute psychosis. Turning to depression,
results of research indicate that
depressive symptoms are related to more
frequent cannabis use, cannabis dependence,
and problematic cannabis use. There have been a large number
of longitudinal studies showing that cannabis use at
a baseline time period predicts subsequent, so
later, depression and later suicidality. So that would
suggest that cannabis is causing or contributing to
the depression and suicidality. But at the same
time, this effect could also be because people
who’ve experienced adversity early on in life may exhibit
a propensity to use cannabis, as well as an increased risk
of developing depression. And consistent with that,
several research studies have found that
controlling for confounds abolishes these effects. Other studies have found that
depression at a baseline period predicts subsequent
cannabis use or cannabis use disorder, suggesting that,
again, they’re self-medicating. And some research has actually
found that cannabis users have lower levels of depression. So a real mixed bag of
research, but usually we can trust the results of meta
analyses a little bit better. And when two men
analyses converge, well, that’s a little
bit more compelling. And there have been
two meta analyses that converged on the
finding that cannabis use on baseline time period is
associated with an increased risk of subsequently
developing depression, as well as suicidal ideation, suggesting
cannabis use may exacerbate or contribute to
these conditions. Now, a bit more than a decade
ago, rimonabant, which is a CB1 antagonist– so think complete
opposite effects of THC. And they tested this as
an anti-obesity drug. The idea, here, is that
CB1 agonists, like THC, increase appetite, right? People smoke weed,
they get the munchies. And so the idea was maybe if
they antagonize this system, using a CB1 antagonist, maybe
that would decrease appetite. And it did. The problem was
a bunch of people became depressed and
suicidal and they had stopped their clinical trials. So this suggests that
blocking this system can produce depression
and, therefore, the idea would be that
activating this system may actually have some
anti-depressant effects. There’s just not much
evidence for this. So one double blind,
placebo-controlled trial that was conducted in the ’70s
found that low doses of THC failed to demonstrate
anti-depressant effects in a sample of eight patients
hospitalized for depression. We do have some problems here. Eight patients. It’s not a power you’re going
to get from this sample size. We’re talking very
severe depression, if they’re hospitalized for it. And the marijuana
in the ’70s, if that was what they called a
low dose in the ’70s, there would be a trace amount
of THC in that weed, nowadays. So, yeah, some issues. Nevertheless, consistent with
this, several medical cannabis clinical trials
examining the effects of synthetic cannabinoids
on other primary conditions. So these are clinical
trials for things like cancer and
multiple sclerosis, looking at the effects of
these synthetic cannabinoids. And they measured in some
of these studies depression as like a secondary outcome. Of course, a lot of people
who are suffering from cancer and other conditions have
some appreciable levels of depression, as well. So they measured depression
as a secondary outcome. And these studies found
that synthetic cannabinoids, like nabilone and [? viximol, ?]
had no significant effects on depressive symptoms
that were secondary to other medical condition. Really just not very much
research on the topic. So since cannabis
is so commonly used to manage symptoms of
physical and emotional pain, but since very little
research has really been conducted to
examine its efficacy, I decided to conduct
a study in order to examine whether
acute cannabis intoxication
significantly reduces symptoms of physical pain. And here, I focus on
headache and migraine pain and/or emotional pain. And here, I’m focusing on
depression and anxiety. Second, I wanted to examine
whether the reported efficacy of cannabis would vary
as a function of THC and CBD concentrations. So we do have a
little bit of evidence there that CBD and
THC might actually matter for things like anxiety. So we wanted to look at whether
different levels of THC or CBD would produce better
or worse effects. We want to examine the dose
of cannabis that would produce the largest change in symptoms. And then, we also wanted
to look at whether there’s any long-term consequences
associated with using cannabis to treat physical
and emotional pain. And we did this in two ways. The first was we examined
whether there is any evidence that tolerance to
the medical effects would develop across time. So maybe people report really
large decreases in anxiety early on, but as they
become a little bit more tolerant to the effects
of the drug over time, maybe it becomes a
less effective drug for reducing these conditions. And secondly, I
wanted to examine whether repeatedly
using cannabis to manage physical
and emotional pain would increase or decrease
their severity in the long term. So just looking
at their baseline, before they used
cannabis, symptoms and see what’s happening
to those over time as they keep using
cannabis to self-medicate. So we accomplish this by
using an advanced statistical technique called
multilevel modeling to analyze global back
data from strainprint. This is a medical cannabis app
that allows medical cannabis patients basically to
track their symptom reduction as a consequence
of using cannabis in their own environment. They don’t know that scientists
are using these back data, so we can pretty much
trust that they’re being straightforward
because their goal in using this app is to
try to find the strain that is producing the
largest reductions in their personal symptoms. So to use this app, they
first indicate the condition or symptom that they
are experiencing and about to use cannabis
to self medicate for. They then rate the
severity of that symptom on a scale ranging from 0,
meaning none at all, to 10, meaning extreme. Next, they indicate the THC and
CBD content of their cannabis. And actually a lot
of these data are pulled from
Canadian-licensed producers who have good reliable
data on THC and CBD. They indicate the
method of administration they’re going to use. So again, are they going
to use oral administration? Are they going to smoke,
vape, that type of thing. They input their dose
after they’ve used. So their dose is quantified as
number of puffs or inhalation method. And then, they re-rate their
condition or symptom severity about 20 minutes after
they’ve initiated the app. So after they’ve used cannabis. And because we know that
cannabis has memory impairing effects, there’s a
push notification that prompts them to come
back and re-rate their symptom severity about 20
minutes after use. Now, we limited this down to
only the sessions involving inhaled cannabis and
symptoms that were re-rated within 4 hours of use. So it pushes them and prompts
them to re-rate their symptoms 20 minutes after use, but
they can re-rate it five days after use. So we cut that
down to four hours. And the reason we did this, and
looked at inhaled cannabis four hours after use, is because–
up to four hours after use, is because we know that the
effects of inhaled cannabis are going to be
fairly immediate. And we know they’re not going to
be sustained beyond four hours. And so we just wanted
to really capture that period of
acute intoxication. In total, we analyzed over
33,000 tracked cannabis sessions. A little better than eight. We had over 1,500
medical cannabis patients use the app, collectively,
more than 15,000 times to track changes and headaches
severity after using cannabis. We had over 800 use the
app more than 10,000 times to track changes in
migraine severity. 770 used it more 5,000 times
to track changes in anxiety. And over 500 used
it over 3,000 times to track changes in depression. And here are the
primary results. So the crimson bars are
their symptom severity rating before using cannabis. And the gray bars are their
symptom severity rating after using cannabis. What you can see is
fairly consistently symptoms are reduced
by about 50%. So we see a 48.5% reduction
in headache ratings after cannabis use. A 53.7% reduction in migraine
ratings after cannabis use. A 50% reduction in
depression ratings. And a 58% reduction in anxiety
ratings following cannabis use. With respect to whether
THC, CBD, and/or their interaction would
significantly predict change in severity ratings, we
found no significant effects of THC, CBD, or THC
by CBD interactions– we certainly had enough
power to find these things, if they existed– on the magnitude of change
in headache, migraine, or anxiety severity ratings. What this suggests
is that any cannabis would do to reduce the
symptoms by about 50%. Levels of THC and CBD
really didn’t seem to have any reliable effects. However, we did detect
a significant THC by CBD interaction on change
in depression severity ratings. So this figure, here,
is showing you– I don’t know if you
can follow my mouse, but this figure
here is showing you that cannabis that is low
in THC and high in CBD produced the largest change
in depression, and high THC, high CBD less so. We also found very
little evidence, again despite ample power,
too much power, really. We found little evidence
of any dose effects. All doses were related
to significant reductions in headache, migraine,
depression, and anxiety. The only real difference, here,
was right here with anxiety. Two puffs was better than one. After that, no significant
gain from smoking up to 10 or more puffs,
did not really seem to produce
any larger benefit. And what that suggests is
that low doses, micro dosing, appear to be
sufficient to reduce physical and emotional pain. A couple hits seems
to be sufficient. So turning to some of
the longer term effects, first, we explored
whether tolerance to the effects of cannabis on
reducing physical and emotional pain would develop over time. And the results
revealed no change in the magnitude of reductions
in headache, anxiety, or depression across time or
across cannabis use session. So we saw equal 50%
reductions, basically, the first time they used
cannabis and tracked it with the app to the 1,000th time they
used cannabis and tracked it with the app. We saw very similar reductions. Suggesting that people were
not developing tolerance to the therapeutic
effects of cannabis, completely contrary
to our expectations. And this is science. I don’t have directional
hypotheses for a reason because it always
blows up in my face. Contrary to our expectations,
we found a significant increase in the perceived
efficacy of cannabis in reducing migraine severity
across time and cannabis use sessions. So this suggests that
as people continue to use cannabis to
treat their migraines, it becomes more effective. This is great, if it’s
true, because many headache and migraine sufferers
do develop tolerance to the effect of their
medications over time. In fact, there’s this, like,
headache rebound effect that can happen, where they’ll
start having more headaches because of the medication
they’ve been taking. Now, at the same
time, as much as I would like that to
be true, I wonder if this is an artifact, kind
of a statistical artifact, arising from the fact that
maybe people who find cannabis to be more effective
in reducing migraine, are more likely to use it more
and for longer periods of time. And so that is another
way of interpreting that finding because
this is not something we’ve manipulated directly. Finally, we examine
whether baseline symptoms would change as a
function of using cannabis to treat physical and
emotional pain across time. And the results revealed no
effects of time or cannabis use sessions on baseline symptoms of
headache, migraine, or anxiety. What this suggests is that using
cannabis repeatedly across time to treat these conditions does
not improve them or exacerbate them in the long term. Instead these symptoms
appear to just be maintained at a fairly
steady rate across time. Whoops. Whoops. In contrast, we found that
baseline symptoms of depression significantly increased
across cannabis use treatment sessions. This suggests that
regular use of cannabis to self-medicate for depression
may exacerbate depression in the long term. This is consistent with
the results of those meta analyses that shows that
cannabis use did not really predict anxiety, future
anxiety, but the cannabis use did predict future depression. And it also makes sense at
a neurobiological level. So we know that activating the
endocannabinoid system, sort of our internal system
that THC binds to, we know activating this
has anti-depressant effects through animal
models and what not. Habitual use of cannabis
could cause that system to become desensitized,
which might then make people more vulnerable to depression. So clearly medical
cannabis patients use cannabis to treat
physical and emotional pain. And it does seem to work
in the short term, but not the long term. And using cannabis
to manage depression may actually exacerbate
it over time. We wanted to know
whether there were other potential consequences
of using cannabis to cope. So previous research
indicates that chronic recreational
cannabis users most commonly report using cannabis
to cope with problems and negative affect, stress,
problems, negative affect. And so for this next
study, we set out to examine whether there’s links
between depression, anxiety, and problematic
cannabis use, as well as to determine whether
these links might be mediated by coping motives. So we wanted to examine
whether symptoms of depression and
anxiety are related to using cannabis to cope. And whether using
cannabis for that purpose is, in turn, associated with
problematic cannabis use. And by problematic
cannabis use, I just mean that people are
reporting that their cannabis use is creating
problems in their life. So maybe they’re getting
in fights with their family because their family doesn’t
want them to use cannabis, but they still do. Maybe they’re going to work high
and getting reprimanded for it. Maybe they’ve run into
legal difficulties. So they have a DUI or
something like that. We recruited about
420 cannabis users in the psychology subject pool. I think it was like 423, but
420 seemed a better number. And we had them complete an
online survey that contained measures of cannabis use. Specifically, we were measuring
their motives for cannabis use, so why are they using
cannabis, specifically interested in coping
motives, using it to cope. We measured the problematic
cannabis use, again, problems associated with use. We measured the frequency,
quantity, age of onset of use. And we also measured
depression and anxiety. We used a Hayes
PROCESS macro for SPSS to test a series of
mediation models. So some fancy stats. We want to examine whether
coding motives would mediate the relationship between
anxiety and cannabis problems, as well as between depression
and cannabis problems. And the results show that
depression and anxiety were indeed related to
more cannabis problems. So increases in depression
and increases in anxiety were associated with reporting
more problems stemming from cannabis use. Further, both anxiety
and depression were related significantly
to coping motives. So people with
depression and anxiety are more likely to
use cannabis to cope with their negative affect. All of this is
just obvious, yes? But not really documented. Finally, the mediation model
revealed that coping motives mediated the relationship
between anxiety and cannabis problems, as well as the
relationship between depression and cannabis problems. So these results indicate that
increased levels of anxiety and depression are associated
with using cannabis to cope with negative affect. And using cannabis
for that purpose is related to increased
problems with cannabis. So now, we have
evidence that use of cannabis for
anxiety and depression may maintain anxiety and
exacerbate depression. And here, we’re seeing
that using cannabis to cope with negative
affect may actually increase problematic use. The last study I’ll
discuss was conducted to examine whether cannabis use
is related to pain, depression, and anxiety in patients
with opioid use disorder. Secondly, we sought to examine
whether frequency of cannabis use would moderate the
relationship between pain intensity and depression and
anxiety in these patients. So what effects
cannabis use would have on these specific
relationships. And I predicted
the exact opposite of what we found once again. For this study, 150
adults receiving medication-assisted treatment
for opioid addiction completed a survey measuring
pain intensity, depression, anxiety, cannabis use,
and self-efficacy, which refers to one’s confidence
in his or her ability to manage his or her symptoms. The sample demonstrated very
high rates of cannabis use. Almost all of them
had used cannabis at some point in their life. Over half of them had
used in the past month. And nearly a third were,
what I would refer to as a near daily user. A daily or near daily user,
using 20 or more times in the past month. The sample also
reported very high rates of physical and emotional pain. So 60% were experiencing
major depression. 63% were experiencing anxiety,
clinically significant levels of anxiety. And 58% percent had a
chronic pain diagnosis. Somewhat consistent with some
of the very first results I told you from our sample
of 1,400 medical cannabis patients, 60% were reporting
using it for pain and about 50% were reporting using
cannabis to manage anxiety. So this is just basically
a correlation table showing correlations between
all of these variables. Surprisingly, we did not find– science is always surprising. We did not find
significant relationships between cannabis use, pain,
depression, and anxiety in this specific sample. Could be a range issue, just
that there were so high levels of all of these things. I’m not sure. Cannabis use was only associated
with reduced emotional self-efficacy. This indicates that
cannabis use is associated with diminished
confidence in the ability to manage negative
emotional states. Cannabis users are less
confident in their ability to handle these
emotional states. We see expected associations
between physical pain and emotional pain, here. Of course, great correlation
between depression and anxiety, as you would expect. We also see that depression
and anxiety are also both related to reduced
emotional self-efficacy. Again, they feel less
confidence in their ability to manage their negative
emotional states. Pain intensity was
not related to that. This is a depiction of the
results of moderation analyses, where frequency of
cannabis use was examined as a moderator of the
relationship between physical and emotional pain. And the results
showed that cannabis– the frequency of cannabis use
was a significant moderator of these relationships. I thought it would be the
exact opposite of this, which is why I said and
to do this analysis, I thought, well,
you know, people say cannabis might
help people who have opioid addiction to
taper off the opioid drugs and whatnot. And so I thought maybe
it would be helpful. But no, we didn’t find that. So just– I’m going to draw
your attention to the blue lines first. The blue lines are
representing people who don’t use cannabis at all. So a the very small minority
of people who don’t use cannabis at all. And what you see here
is a fairly flat line, indicating really not much of
a relationship between physical and emotional pain. So very low relationship
between physical pain intensity and anxiety and physical pain
intensity and depression. And then, here, as we move
up– so orange are using a bit. Pink are using more. And green are our
daily, near daily users. And you can see these slopes
gets steeper and steeper, with the green line
represents the steepest slope, representing the strongest
relationship between physical and emotional pain, suggesting
cannabis users demonstrate a bigger link between
these two things. Now, if you recall,
though, cannabis use was associated
lower self-efficacy. So we conducted additional
moderation analysis, this time entering in
self-efficacy scores into these moderation
models as covariance. And when cannabis
users’ diminished levels of self-efficacy were
statistically controlled, frequency of cannabis use was no
longer a significant moderator of the relationship between
physical and emotional pain. These results suggest
that relying on cannabis to manage symptoms may
undermine users confidence in their own ability to manage
their symptoms on their own, independent of cannabis. So in this way, cannabis
can become like a crutch. People start to rely on
it as an external way of handling their emotional
pain instead of relying on [? them self. ?] So in summary, medical cannabis
patients commonly use cannabis to treat pain,
depression, and anxiety, and recreational users
also commonly use cannabis to cope with negative affect. The first study I showed just
indicated that acute cannabis intoxication reduces symptoms of
headache, migraine, depression, and anxiety by about 50%. But these symptoms are
maintained in the long term. And depression may
actually be exacerbated by long term regular use of
cannabis to self-medicate. The second study indicated
that another problem with using cannabis to
cope with negative affect is it may increase detrimental
consequences associated with use. And finally, in
the third study, I provided evidence that
more frequent cannabis use may potentiate the
relationship between physical and emotional pain, leading
to further entanglement of these symptoms. However, this
effect may be driven by diminished self-efficacy
in cannabis users. Again, people might come
to rely on cannabis, and no longer trust their own
intrinsic ability to manage their pain on their own. Collectively, the
results I’ve discussed indicate that
cannabis is serving as a band-aid, in
that it’s temporarily masking the symptoms,
but it’s not addressing the root core issue
underlying these problems. So people experiencing
physical or emotional pain may turn to cannabis
and find it’s effective and it does reduce their
symptoms in the short term, and that becomes
negatively reinforcing. Their pain goes away, they
want to keep doing this. Problem is this doesn’t
decrease their symptoms in the long term. It only maintains
or exacerbates them or entangles their
symptoms in the long term. So when the high wears
off, the symptoms return. They need to use more
cannabis, eventually increasing their risk for
becoming dependent on cannabis. As such, people experiencing
anxiety and depression should seek out cognitive
behavioral therapy to learn how to effectively
reduce their symptoms in the long term. They need to be– should be
working toward a solution that are getting at the
root core issue underlying these problems. I think anti-depressants,
anti-anxiety medications are similar band-aid. Advil, Tylenol, any of that
stuff, is a similar band-aid. Potentially some of
those other things have worst side effects,
especially anti-depressants, anti-anxiety medications,
and things like this. So there’s not a
long-term solution to a problem like
headaches or migraines. And band-aids really do seem
to be sort of our method. But for depression
and anxiety, we know there’s longer
term solutions. Again, cognitive
behavioral therapy can teach people how to change
these dysfunctional thought processes and prevent them
from relapse in the future. So a better
longer-term solution. And I just, finally, wanted to
thank all of my collaborators. Obviously, this research
is never done alone. And I have a lot of
collaborators that I work with. I wanted to just quickly
thank strainprint because they are the
ones that provided the data for the first study. And I’d also like to thank WSU’s
Dedicated Marijuana Account. I’ve received a couple
of grants from them. And this is money that comes
from the excised tax dollars from the sales of recreational
cannabis in our state. And I’d like to thank you. SPEAKER: And so we
do have questions. CARRIE CUTTLER: Great. SPEAKER: Some may have been
answered throughout your theme, but the first one was
the slide with the dots and the lines, they
are asking, were are you implying dependency? Which I believe you
ended up answering. CARRIE CUTTLER: This one? No, not necessarily
implying a dependency. I don’t know. We didn’t really measure
cannabis dependence in that study at all. Again, my initial instinct
was that maybe cannabis use is going to help them to reduce
physical and emotional pain. I thought we would find
a beneficial effect in this group. And we did not. What we found was, again,
that cannabis users were just showing more entanglement in
physical and emotional pain symptoms. But again, it all boiled
down to self-efficacy. It was really just that
the cannabis was serving as a crutch and
they were no longer confident in their own ability
to overcome these symptoms. So it was much more the fact
that they were using cannabis as a crutch that was producing
this effect than the cannabis, per se. SPEAKER: Which is
what Morgan had asked. So cannabis, essentially,
substitutes coping mechanisms? CARRIE CUTTLER: Yeah, exactly. And that is where it– you
can get into a problem. And so, yes, a lot of people
use cannabis to cope, generally. Cope with stress,
anxiety, negative affect, problems in life. It’s their coping mechanism. And unfortunately,
we repeatedly see in my research
and other research that using it for that
purpose is associated with more dependency. And that’s because your
problems don’t go away. The cannabis doesn’t seem
to either in this state. So then they do
become at greater risk of becoming dependent on it
when that becomes their only coping strategy. And so people should be learning
better coping strategies. SPEAKER: OK. Is there a potential confound
in the opioid-using population and the opioid use itself? In other words, was
there a measurement of their current opioid use in
relation to their cannabis use? CARRIE CUTTLER: So
they [? were all ?] on medicated-assisted therapy
to stop using opioids. And they would all
be using opioids at pretty similar levels. So no, I don’t think that
cannabis and opioid use is confounded in that study. SPEAKER: How is cannabis any
worse than opiates– he said, opiates– for pain
as a band-aid? How is cannabis any worse
than SSRIs for depression as a band-aid? CARRIE CUTTLER: [? I’m ?]
[? not ?] [? going to ?] say it [? wasn’t. ?] I
didn’t say it was. In fact, I said it might be
associated with fewer side effects. The side effect becomes, again,
becoming dependent on this. But, you know, we know
at least benzodiazepines are way more addictive
than cannabis and produce way more tolerance
and dependence than cannabis. We’re not saying it is worse. And I have been called
out by reviewers when I try to use this band-aid
term, calling something a band-aid. And people automatically think
what I mean, band-aids are bad. I’m not saying
band-aids are bad. I have a six– seven-year-old. He just turned seven. Band-aids are amazing. Like, I’ve placebo-wrapped
a sprained ankle and he could run. It was a miracle. So and– I’m not
saying it’s a placebo. But I’m just saying
that band-aids make people feel better. I’m just saying it’s temporary. It’s masking. It’s not– it’s not a treatment. You’re not treating the
root core underlying issue, so much as you are just a
temporary sort of reprieve or masking of the symptoms. And yeah, people can
work on their SSRIs and it has like a
longer term effect. But you don’t
necessarily want to be going to work high all the time
and maintaining that high all the time. So– SPEAKER: Could there
be a biological basis for the entanglement? CARRIE CUTTLER: No. And again, I think the intent–
not that I can think of. And again, the
entanglement is more to do with using cannabis
to cope and the issues with self-efficacy. Again, once we controlled
for self-efficacy all of those effects went away. We no longer saw that cannabis
moderated that relationship. We didn’t see more
entanglement in cannabis users than non users,
when we controlled for their emotional
self-efficacy. And again, that just suggests
that people are relying on it. It’s becoming a crutch. And then, that is
potentially the reason why those symptoms are
getting all entangled is because that’s their crutch. They don’t have another
coping mechanism, potentially. SPEAKER: Is there a
possibility that low efficacy can lead to higher
cannabis, while not necessarily being caused by it? CARRIE CUTTLER: Yeah,
yeah, absolutely. And it is all correlational. That’s a very good point. Yes, absolutely. It could be that because
people don’t feel confident in their own– I honestly never
thought of that. So good for you. And I’m usually really good
on correlational studies and thinking that through. But yeah, absolutely. It’s possible that people
who have less confidence in their own intrinsic ability
to deal with these things then turn to an external
source like cannabis. Absolutely. Absolutely. SPEAKER: My husband recently
quit smoking marijuana, three weeks ago. He’s been placed on Zoloft to
manage his depression symptoms. If you consider this
medication a band-aid, how or where can I get
him in to CBT treatment. He doesn’t want to use pills as
a way to cope in the long term. I was under the impression he
had a chemical imbalance, which meant he needed to use
this medication forever. Do you have any advice
for this situation? CARRIE CUTTLER: So
cognitive behavioral therapy can be administered by a
registered licensed clinical psychologist. I don’t know where you are. If you’re in Pullman,
Laurie Smith-Nelson is one person. But basically, you just
want to do a Google search for a registered licensed
clinical psychologist. And they are trained
in administration of CBT treatment. Typically, psychiatrists
and medical doctors are giving these
prescriptions for medications. But psychologists are
trained to give therapy. And some research, anyway,
on the efficacy of CBT vs. anti-depressants and
anti-anxiety medications shows that both are equally
effective in the short term, but the long-term
effects of CBT– there’s better long-term
effects of CBT than medications. That when you stop
taking the medication, the symptoms are
more likely to return than when you stop the therapy. And CBT is not Freudian
psychoanalysis. You’re not doing this
for 20 or 30 years. We’re talking you know 8,
10, 12 sessions type thing in order to teach a
person how to identify their dysfunctional negative
thoughts and correct them. OK? SPEAKER: Perfect. And would you say a person
using cannabis or CBD for headaches slash migraines
could develop dependency? And then, also,
anyone using cannabis can develop dependency? So we’ve already answered– CARRIE CUTTLER: It sure could. I mean, it doesn’t have
massively high, like, addiction rates or
dependency rates. It’s actually fairly
low, like 9% of people seem to become kind of
addicted to cannabis or dependent on cannabis. So it’s not, like, massively
high rates or anything. But, yeah, people who
use it more regularly– and, again, like I was saying,
people who use it to cope, specifically, seem to be
more likely to go that route. But lots of people also use [it
without developing dependence]. SPEAKER: So there’s
some thank yous. Let’s see. Cannabis can have protracted
withdrawal symptoms. There is a common
misconception that it does not cause physical withdrawal
symptoms, which is false. CARRIE CUTTLER: So yeah,
the withdrawal symptoms most commonly reported
are irritability. And again, this is
because cannabis has these effects on moods
that are generally positive. And so when you take
it away, then you’re going to have the
negative effect on moods. Irritability is one. Sleep problems is a huge
one because cannabis– another reason cannabis
is very commonly used for sleep problems. And loads of people report
that it helps them sleep. So then, when people
stop using cannabis, they can have sleep problems. There can be issues with
appetite as a withdrawal symptom, as well. People report reduced appetite. But it’s not like
alcohol, right. It’s not like heroin. You’re not going
to go into this, like, I have a severe flu. You’re not going to
have the shakes, right. None of that type thing. We’re talking some irritability,
some problems with sleeping, maybe a little
bit less appetite. I have a paper out recently on
acute effects and withdrawal effects, if anybody
is interested. And again, generally
withdrawal symptoms are mild compared
to other drugs, and, yeah, you
can’t die from it. Mild compared to other drugs. And they last as
long as two weeks? A week or so. SPEAKER: What do you think
the future of legalization will be for the
federal government? CARRIE CUTTLER: We
are going that way. It will eventually
be federally legal. Depending on what happens
with the government, I think it will eventually
become federally legal. And I think that
Canada is currently a really nice experiment just
happening up north that we can sort of watch and observe. And then, decide from there. I think that right
now what we have is a mini experiment
with 10 states plus DC serving as the
experimental group. And other states, serving
as the control group. And we’re finding
all sorts of things that we didn’t really
expect to find. We’re finding youths rates don’t
seem to be actually increasing. That was the biggest concern, is
that all these adolescents are going to start smoking
pot all the time. That’s not happening. In fact, a regulated
market can help control that a little bit better. We’re finding higher
clearance rates, that police are actually solving
more crimes in Washington state than before cannabis was
legalized because their time is not all tied up with these minor
cannabis offenses and whatnot. So yeah, time will tell. I think, eventually, yeah, it
will become federally legal. And also, once they
realize the tax money that’s involved in
this, I don’t see how they’re not going to be. I mean, four million dollars
a day in Washington state? That’s insane. And the tax dollars
coming off that are huge. SPEAKER: All right. Well, thank you very much. I appreciate your time
and your questions. Thank you.

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