FACEBOOK LIVE: Case Study: A High That Does Not Last, with Dr. Adam Livingston, PharmD

Hello, everyone. I'm Adam Livingston PharmD. I'm a clinical pharmacist working here at NutriChem compounding pharmacy and clinic. Today I just wanted to comment and sort of talk about a case that we put up in our NutriChem case study series. It was a blog post, kind of showing a case study that we had here at neutral camp, and it was entitled a high that does not last or self-medicating with cannabis and alcohol hide that does not last. I don't know, If you're just tuning into this video, you might want to go read the case study on our NutriChem blog first, and then come back to the video just to get my comments on this case. I thought this case was really relevant right now. 

Because I don't know if people have seen sort of the Health Canada Statistics as everyone's going through the COVID 19 pandemic and the lockdown. If you've seen some of the Health Canada and addictions Canada statistics can be a little bit alarming and we're seeing this in the pharmacy as well, that statistically and just from our experience at NutriCHem, we are seeing more and more people sort of self-medicating with alcohol and cannabis and the statistics from Health Canada are reflecting this. It's a stressful time for everybody. A lot of people are anxious a lot of uncertainty. So we've noticed that a lot of people are sort of dealing with anxiety and mild depression, sort of what we call a kind of a sloppy way of kind of using alcohol or cannabis to sort of get that short term relief. But really, what a lot of people don't realize is long term, using substances or abusing substances like that, to help control stress and anxiety and mood can actually backfire. 

So this was the case that we put up it was Alex a 22 year old male as an engineering student. Obviously, this is all been made up for confidentiality purposes, but this is based on a real case. And it's actually based on a number of cases that I've seen in the clinic working with D prescribing and medical cannabis. A pretty classic case of someone dealing with stress and anxiety and depression and basically starting self-medicating with cannabis and alcohol. And Alex was,  like I said, a 22 year old engineering student who came into the clinic basically getting worse and worse anxiety with everything that's going on with COVID these uncertain times. And then also just being a busy guy with a lot of life stress anyway, coming in basically saying you know, I've been trying to work on my anxiety and depression using a lot of cannabis and more and more and more cannabis, very high THC indicas things like that which have that sort of acute mood stabilizing or anxiety reducing effect. But the more and more and more you use them you know, higher and higher doses of THC are actually associated with anxiety. So that was one of the first things I wanted to drive home here. 

There's a few things so self-medicating with cannabis and alcohol. We're talking about cannabis. So cannabis for a lot of people can be helpful for their anxiety, but high doses of THC for many actually can make anxiety worse, especially if you start to keep using them chronically. So that's something a lot of people are surprised about because I do work a lot with medical cannabis and I am a proponent of cannabis for people for things like pain, anxiety and sleep. However, when we look at anxiety specifically and mood disorders, cannabis, especially high dose THC can actually be a really bad idea. For patients dealing with anxiety it gets your heart rate up and can actually make it can actually induce anxiety, if you're using really high doses of THC, especially continuously. So a lot of people kind of find that, you know, I started using cannabis and at first I actually liked the feeling. I like the euphoria. I found that I calmed it down. However over time, their anxiety just gets worse and worse and worse and they're not equating it to the fact that, okay, you're using cannabis, the cannabis can actually make the anxiety worse. So they actually think that their anxiety is just sort of getting worse because of circumstance or their mental health specifically, but actually, it's the cannabis that's driving the anxiety to get worse. And then they're thinking, oh, I'm going to use more cannabis to treat this anxiety and it becomes this cycle of you know, really high dose THC, making their anxiety worse and worse and worse. 

So if you look at the case, one of the first things I would suggest is okay, you have to stop THC. And then when we talk about cannabis and it being helpful for anxiety, we're really talking more about CBD. So a lot of these patients that come in, they have a history of anxiety, they've tried to use cannabis to treat their anxiety. It maybe worked in the beginning, but then long term, their anxiety is actually getting worse. We need to stop the THC and this is where you want to use the other component of cannabis called CBD. And that's the anti-inflammatory and in my opinion, a better anti-anxiety component. of cannabis. So whenever we're talking about using cannabis for anxiety, we're usually talking about using CBD specifically, and possibly only a very low dose of THC. High dose THC can quite frankly induce anxiety so we avoid it and patients are coming in using lots of THC and saying, I don't get it, I'm smoking all this weed, I should have no stress and it's actually getting worse. It's like high doses of THC cause anxiety and you're going to feel more wound up and more stressed out, for sure. 

So that was the first thing I wanted to touch on, you know, being the medical cannabis guy. One of the sort of experts in the area. There's a lot of misinformation about cannabis and one of the first things is you know, people come in with anxiety and they use cannabis, I'm probably going to ask, you know, how much THC are you using. And two, do you have digestive issues because that's the other thing that the gut brain connection is emerging is such a powerful factor in people's mental health. That you know, if someone comes in with that anxiety and they're using cannabis, stop the THC and we've got to do some digestive work right away. And that's where I would probably refer to a naturopathic doctor who really, in my opinion, own the microbiome and the diet as a medicine. So in this case, you know, immediately stopped the THC. 

Let's get you started on some CBD which sort of counterbalances that THC effect, and we need to start working on your digestion. And then just some simple things for sleep like adding in some magnesium can be really helpful at bedtime. Another thing I'd like to touch on that I thought was important and why I put this case up wasn't just the cannabis and the gut brain connection to help with anxiety and mood. It's also alcohol. So a lot of people will you know, I think most people are aware that consuming too much alcohol is not good for you. And most people are probably aware that consuming too much cannabis is probably also not good for you. But with alcohol, what's interesting is you know, it's very similar sort of using the THC in that you can kind of blunt your stress acutely with a couple of drinks, you can have a couple of drinks calm down and say, “oh, this is nice and my anxieties been lessened or maybe my moods a little bit improved.” When I use a little bit of alcohol or a little bit of cannabis, long term, high doses are taking in lots of alcohol, you're sort of trying to use the alcohol as a bandaid. Instead of sort of dealing with your issues over time, it can actually make things like depression worse. And again, like cannabis, especially high dose THC, and big doses of alcohol are actually associated with depression and worsen anxiety. So it's, you know, a lot of people are sort of trying to use these chemical band aids right now to help with their stress, help with their anxiety with everything everyone's going through with COVID and the financial stress of what COVID has done and the public health stress and they're seeking out and you know, we've seen 20% increase sales from recreational cannabis stores. Some statistics have like 30% more alcohol consumption. So people are reaching for these sort of quick and dirty fixes to help with their immediate stress, their immediate anxiety, their declining mood I'm getting, I can feel like I'm getting depressed with everything that's going on in the world. 

Please don't just reach for the bottle or reach for the joint. A little bit of that is fine. But I'm telling you, I've seen a lot of cases where long term, you're actually causing more harm than good. And it's actually going to make your anxiety or depression worse. So that's why I wanted to showcase this study. And even before COVID or regardless of COVID. A lot of young men especially men sort of age 20, even up to 40. This is a classic case where they come in, they've tried everything for their anxiety or their depression. They've tried some pharmaceuticals, maybe they haven't worked very well. They've tried a few lifestyle things. Maybe they haven't worked too well. They've been using a lot of cannabis, a lot of alcohol to sort of numb their issue. And be sort of a temporary band aid. But when that temporary effect comes off, the bigger problem is actually getting worse and worse and worse. So I just wanted to you know, as someone that's a proponent of medical cannabis, I'm a proponent of appropriate use of medical cannabis and recreational cannabis really, and I think people are overusing THC, and it's just going to make their anxiety and some of their problems worse. And I don't think that you're going to find your solution in the bottle of alcohol either. In moderation, it's fine. But, you know, both of these are classified in pharmacology, you know, alcohol and cannabis are technically depressants in that day, like, as you use them more and more, you will get more and more of a depressive effect on mood and you can get worsening anxiety. So a lot of people find that counterintuitive. Because they have those acute effects of reducing anxiety or maybe improving mood a little bit with a euphoria. They think oh, okay, I can just sort of chemically bang myself with these but you're actually making it much, much worse. So I would really try to go towards more of the lifestyle fixes and some of the you can go look at the case study and some of the suggestions. 

I also did not even put in everything that I would normally recommend for lifestyle options for dealing with anxiety and depression. Exercise blows in my opinion blows all the [inaudible] drugs and all the antidepressants right out of the water. You know, the number needed to treat of an exercise regimen to get a positive result is about two. So one or two people if you start exercising, you will get a noticeably better and a noticeable increase in mood or reduction in anxiety. And that is frankly much better just to being a pharmacist and looking at a lot of studies on drugs and their number needed to treat exercise diet getting proper sleep, far more effective than just you know smoking a joint or drinking some booze or going right to antidepressants. Those sort of quick chemical tricks are just that they are sort of tricks and they might give you a short term benefit, long term, more problems and a lot of cases. And I'm not saying some people don't do well on antidepressants, but to be frank, it's often sort of a minority. I'm not against them, if you've tried many options, and that's what you're going to use, that's fine. But I think there's a lot of other options especially for mild to moderate depression, where any depressants have not shown to be much better than placebo. In severe depression, antidepressants can be more of a first line option in our opinion. But there's so many things you can do for anxiety and depression, before having to turn to sort of heavier duty pharmaceuticals or just you know, drinking too much alcohol or smoking too much cannabis. There's so many things you can do. And in our follow up blog that I'll put up, I'm going to give a lot of suggestions that people can do. For stress management, reducing anxiety and improving mood, that are non-chemical essentially, or you can sort of use, you know, you can use your own hard work to sort of reset your chemistry instead of having to use an external chemical to sort of try to shift your mood or reduce your anxiety. So that'll be in the follow up blog. 

If you go ahead and read the case study. We did do a follow up with this patient later, and I'll write this in the follow up. But Alex actually ended up having a massive reduction in anxiety and did avoid an episode of depression. He still to this day, this was several months ago, but now we've been following up more long term. He still avoids THC because he now realizes that you know, THC was actually the root of a lot of his anxiety. He uses CBD, a lot more CBD and he doesn't really drink much alcohol anymore except for you know, one or two drinks with friends occasionally, which is a healthy sort of low risk way to consume alcohol. He also has done a ton of work on his digestion. So that's the other thing is we always take a holistic approach, right. You come in, okay, let's get you off the THC. We'll deal with your cannabis issues, we'll put you on CBD, maybe get you set up on some supplements, and then I'm going to put you in, I'm going to get you to a naturopathic doctor to get a full assessment of your digestion was going to look at your hormones, your thyroid, there's so many things that can affect anxiety and depression that we-it's not enough for me just to say okay, get off the THC and start CBD. Like there's so many underlying causes, we need to do a full panel. Look at all your hormones all your different like organic acids for example, urinary organic acids can be helpful. All your different hormone panels can be really helpful for being like, “wow” look at how high you know, this marker is that's indicating that there's this other root cause with your anxiety. So we want to attack it with this sort of holistic approach of okay, we'll deal with the cannabis. Okay, let's get rid of the alcohol. Alright, let's look at the gut brain connection. What about hormones like sex hormones, also thyroid hormones. So this is the beauty of neutral cameras that we work as a team. And when someone comes in dealing with anxiety, anxiety is so for example, is so multifaceted, that we have a whole team in place where we can attack your anxiety from 10 different directions. And in general, we get very good results in the case study that I put up of Alex, the engineering student that was overusing and over self-medicating with cannabis and alcohol. In that case, he was actually very successful working with us. And we have a number of cases like this. Where you know, patients come in and they're sort of surprised by the treatment protocols that we put in place, but within one or two months, they see a drastic difference. And to be honest, they're also sort of have gotten rid of some of their addictions two things like alcohol and cannabis and other abuse substances. Because they just don't feel they need them and they also realize once they're not using them, “oh my god that was actually making my anxiety and depression worse,” despite it being kind of a trick of making me feel better, quickly, long term that was the thing that was causing it on top of, for example, digestive issues. 

So there's a lot more to anxiety and depression than just “oh, I have anxiety,” it doesn't strike like an infectious disease necessarily often there's many factors leading to you feeling so wound up and anxious all the time.

So that was basically my rundown of the case. I will hopefully be posting either a video or a follow up blog, following up on this patient and also maybe put in some other comments. I'd also love to put up almost like a guide for people in the next little while on things you can do sort of non-pharmacological or even non-supplement, non-external chemical of what you can do to shift your biochemistry in a better direction for moving and reducing anxiety and dealing with stress. Everybody's stressed out right now there's an epic, there was already an epidemic of anxiety before COVID. And it's absolutely gotten for like just working in our clinic. We're dealing with a ton of anxiety with patients right now. And it’s understandably, right, it's really uncertain time for everybody very stressful from a health perspective and a financial and economic perspective for everyone. But there's many things you can do that don't require you kind of getting stuck in the chemical rigmarole of using sort of illicit substances or harmful substances, or even in my opinion, harmful pharmaceuticals, you can avoid those and there's a lot of things you can do. In a lot of cases, that can be very, very helpful.

So I think that'll be the next thing I put up and we'll talk about exercise and particular types of exercise that can be helpful for anxiety and depression. Meditation, some breathing exercises that I use myself that can be very good yoga, mindfulness, I'd like to actually, instead of just saying those as buzz words, I'd like to actually put up a guide for everyone in this next little while, and things that we will use in our clinic with patients, as well as things I use myself that I've found quite effective. Because you know, I was young once I abused alcohol and substances when I was young to deal with stress. And I can totally attest to the fact that it's sort of a short term benefit and a long term deficit. In terms of what you can do to your mental health. If you abuse cannabis or abuse alcohol, I would really try to advise you to avoid that, because it's a bit of a trick and you can get led down this pathway. That's a real slippery slope. And I've seen it in myself and I've seen it with patients in our clinic. 

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So that was it. I will hopefully be in touch soon. If you have any questions or anything, feel free to comment on the video or contact the clinic to book a consultation for medical cannabis questions, deprescribing and more. I’m here for you!

Thank you.