CBD

One question I get asked a lot lately is this.

“Is it okay for me to use CBD oil?”

I thought it would be a good idea to address this general question in Mind Matters this week.

First of all, CBD oil and associated preparations are types of alternative medications, medicines that might not be mainstream or readily prescribed by doctors , but are nevertheless used by many people on their own. Alcohol and marijuana are two substances that are often used as “medicines” by those that think they function better with them than without them. Many people self-treat medical as well as psychological symptoms with nonstandard therapies.

Some of these agents, like CBD oil, do not currently have FDA approval for treatment of specific psychiatric illnesses. If you choose to use them, either alone or in combination with standard therapies, you must understand that there are several things to consider. First, they may have unexpected side effects. Secondly, they may interact with other foods or drugs that you already use. And lastly, they may or may not be legal for general public use. I will address some of these issues in the rest of this column.

According to WebMD, cannabidiol is found in the cannabis sativa or marijuana plant. There are eighty similar chemicals in these plants. THC is the major active ingredient, but cannabidiol makes up forty per cent of overall cannabis extracts. Cannabidiol may have antipsychotic properties, but we are not sure why. It might also actively block some of the effects of THC. There is really insufficient evidence for use of cannabidiol in bipolar disorder, dystonia, epilepsy, Parkinson’s Disease, schizophrenia, or social anxiety. Side effects due to cannabidiol use might include dry mouth, decreased blood pressure, light headedness and drowsiness. There is no good data on the use of cannabidiol in pregnancy or breast feeding, nor for many specific drug-drug interactions.

Some of these concerns were addressed in a recent interview on Medscape where Columbia University Chief Resident Angela Coombs, MD, interviewed Diana Martinez, MD, Professor of Psychiatry at Columbia and an addiction expert. Dr. Martinez stated that there is really very little known about how CBD affects humans and why. It may have some legitimate medicinal effects, but the jury is still out on some of these. She stated that if you buy CBD at stores, the advertised doses may not be realistic or true. Some websites of companies that manufacture CBD and have their products tested by legitimate outside companies will more likely list the actual amount of CBD available in their products. It might be very important to know about the presence or absence of contaminants as well. Some states like Colorado may do a better job at this point in testing products for factual labelling and overall safety.

CBD may be effective in treating seizures in some children with specific illnesses such as Dravet Syndrome or Lennox Gastaut Syndrome, obviously a very small group of people. If they do not respond to more traditional medication therapies, high doses of CBD in the neighborhood of 1000 mg might be effective.

The positive symptoms of schizophrenia (such as hallucinations) may be reduced with the use of CBD, but this is in the presence of traditional antipsychotics, not in place of them.

There is not much research to address the use of CBD oil in the treatment of anxiety or social anxiety. Dosing is largely unknown. 300-600 mg seems to be helpful for anxiety.

Dr. Martinez also addressed the drug-drug interactions that might occur when CBD is added to other, more traditional therapies. When the enzyme systems in the liver are affected by substances such as CBD, metabolism of other drugs might be sped up or slowed down, affecting the amount of those medications available in the bloodstream. This might lead to compromised treatment with seizure medications or antipsychotics. She also was not able to clearly answer the question about the legality of CBD at this time. Because of various bills, the DEA, the FDA and other regulators, there is not one specific answer as to the legality of buying, possessing and using these agents. Will it be regulated anytime soon? She was also not able to directly answer that question.

So, if you are thinking about using alternative therapies like cannabidiol, what are some of the things that you might need to consider?

1) It the substance an additive, food, plant, chemical, alcohol preparation or other kind of substance?

2) Is it approved by the US Food and Drug Administration?

3) Is it regulated by the FDA, DEA or other agencies?

4) Is it checked for safety by an independent lab or company for purity, quality, concentration, adulterants, etc?

5) Is it expensive or affordable?

6) Is it legal in your state or nationwide?

7) Does it interact with food, alcohol or other drugs? Are any of these interactions life threatening?

There is no hard and fast advice on the use of CBD oil yet, and much more research is needed.

And a Little Child Shall Lead Them

Funny how the world and its many events can stimulate our brains to recall things. As I write this column it is the seventy-fifth anniversary of D-Day, at that time the largest planned, multi-nation amphibious assault on an enemy defensive line in the history of warfare. I have also been reading about global warming, the flooding in the Midwest, political strife, and other natural and manmade disasters. This has been juxtaposed this past week with the wonderful visit of our two oldest grandchildren to our home, something that my wife and I anticipated with great joy and gratitude. The two opposite circumstances, and their associated emotions, brought to mind a story that I first told in 2005, as I was working as a Red Cross volunteer in Mississippi and Louisiana after Hurricane Katrina had slammed ashore and turned the world upside down for so many people on the Gulf coast. I thought I would share this story with you. It still makes me smile.

 

I had an encounter with a beautiful little girl in Mississippi, just days after the monster category 5 storm had entered her family’s life. It reminded me, harshly and painfully, of what present-day Red Cross workers and thousands of other volunteers are going through right now, trying to do what they can for and with people who continue to suffer in various scenarios in our country and around the world.

 

I met Erica at the First Baptist Church in McComb, Mississippi. We were deploying out of the Red Cross shelter there, and I would often see people in that setting at the church or in the gym where they were making their temporary homes until the aftermath of Katrina’s wrath could be sorted out. She was a frail seven-year-old with beautiful dark skin and large eyes. She had not been eating or drinking in the five days since Hurricane Katrina had demolished her family’s house. She now lived in a small trailer with her parents and younger sister. She had nightmares where her parents and teachers were brutally killed and maimed, and she had lost all interest in playing or singing. We sat crossed-legged on the floor of the education building hallway, busy volunteers bustling around us, a tired Red Cross worker and a little girl who had literally lost everything in her life but her family. I leaned against the wall, happy for a few minutes to sit down and rest. She sat with chin in hands, looking down at the polished floor of the church building. I had tried to engage her in conversation, to no avail. I thought I would try one more thing.

 

“Erica, what’s your favorite food in the whole world?” I asked.

 

She looked up slowly, her interest piqued. She sized me up with those big eyes as only a child can, and I saw a faint glimmer of a smile.

 

“Fortune cookies.”

 

“Fortune cookies?!” I said, truly surprised. I had expected the usual hamburgers, hotdogs or ice cream. “I’ve got your number,” I said instantly, my way to this child’s fragile and damaged psyche suddenly made clear to me. “Give me twenty minutes and I’ll be back.”

 

She looked at me quizzically, but a simple “Okay” came out.

 

I returned to a Chinese restaurant I had just found the day before. I had enjoyed a meal there that nourished my mind, heart, and stomach, and I had struck up a brief conversation with the staff while I was there. Wearing a Red Cross vest was almost always a stimulus for questions from those who lived in the local communities that we served. I sought out and spoke with the hostess, who listened to my story about the little girl whose life had been ravaged by this storm that came out of nowhere and changed everything forever. She stepped toward the back for a half minute, returned and immediately began filling a large shopping bag with handfuls of fortune cookies plus a few dinners for Erica and her family. As I pulled out my wallet to pay her, she pushed it away, tears streaming down her face. “Hurry back to little girl who will not eat,” she said, handing me the bag full of food. “Go. Go now!” I thanked her, many times over, for her family’s generosity and goodness that would mean so much to this little girl and her family.

 

I returned to the church education building hallway, finding Erica sitting exactly where I had left her, surrounded by boxes of peanut butter and tuna that reminded me of a protective wall.

 

The little girl and I sat cross-legged once again on the floor. She looked in the shopping bag that I set down between us, eyes growing big as saucers. There was no mistaking fortune cookies, with their brightly colored wrappers.

 

She looked up at me.

 

“Can you eat just one of these for me, right now?” I asked.

 

The faint smile returned.

 

“Yes.”

 

“Could I eat one with you?”

 

“Yes.”

 

Little hands plunged into the bag. Cellophane wrapping papers crinkled happily. We munched contentedly.

 

“Now, how many of these do you think you can eat?”

 

The little girl from New Orleans gave this some serious thought.

 

“ALL of them,” she said emphatically.

 

“No way! You haven’t eaten anything in five days,” I teased. “You’ll be sick!”

 

More serious thought, eyes narrowing.

 

“Well,” she said slowly, “maybe not TODAY!”

 

The smile broke through.

 

Disasters are overwhelming and ubiquitous. Our personal response, our personal ability to do anything helpful, sometimes seems tiny and insignificant. If we listen, look, and pay close attention, we can make contact with those who need us most and deal with one small crisis at a time. Much like Erica and her bag of fortune cookies, we may not be able to help thousands of people in one day. We can start with one fortune cookie and one little girl with dark skin and beautiful eyes and a smile as big as Louisiana.

 

Erica, wherever you are, you should now be a vibrant young woman. I hope you are doing well. I am so glad that I was able to share your favorite food with you that day, and I hope that your fortunes have made a giant turn for the better.

LAIs

It happens all too often.

 

You have not been taking good care of yourself. You don’t eat, you sleep poorly, and you neglect your medical health. Over a period of months or sometimes years, you begin to isolate yourself from your friends and family. You can’t seem to hold a job. You lose interest in once pleasurable activities. Your thinking becomes odd, your thoughts distorted and fragmented and strange. No one knows about that just yet, because the voices you begin to hear tell you not to mention it, to keep it to yourself. The voices become threatening over time. Sometimes, they tell you to hurt others, or to kill yourself. It becomes harder and harder to tell reality from fantasy. You get depressed, agitated and finally can’t stand it anymore. Someone gets you to a doctor.

 

You or someone you know are diagnosed with a major psychiatric illness such as schizophrenia.

 

The trauma of hearing that kind of diagnosis is bad enough, but then comes the part that most of my patients do not like at all. The part when I talk to them about medications. Now, right off the bat, let me tell you that good treatment of a mental illness is not simply taking meds. It might involve counseling, education, learning new job skills, going to group therapy, talking to your counselor with your family, couples counseling, or getting peer support. That being said, this column will deal with medications, and a specific form of medication, which we will get to shortly. I’m quite sure we will come back to other treatments in this column in the future.

 

So, you have been told you have schizophrenia. Among those many treatment options, your doctor might suggest that you take a medication to treat your psychotic symptoms, one that usually comes in pill form, pills that you must take at least one time per day or maybe more. You discuss how to take them, the possible side effects, how long you might have to take them, and how they should help you recover. You get the prescription filled, begin the course of treatment, and get better! So much better, in fact, that you decide you don’t need these medications any longer, and you stop them. Can you guess what happens then, within a few weeks to a few months? Many patients will relapse, meaning that the same symptoms that got them to come to the doctor in the first place come back, sometimes worse than before.

 

You get so sick during this relapse that you end up in the emergency department and you’re admitted to a psychiatric hospital. You are put back on the same medications you tell the staff you were taking before, since they did work once, and in fairly short order you are discharged home. You see your doctor, you are feeling so much better, things are great, and you are sent home with a new prescription. You may decide, just within the first month home, that you feel so much better, again, that you won’t even get the prescription refilled. Then, those gnawing depressive feelings come back, you can’t sleep at night and you begin to hear voices that tell you that it’s not worth living anymore. Your family starts discussing taking you back to the emergency department, and you know that they are trying to harm you by doing so. You can feel them scheming and plotting against you. The voices agree with you and tell you to “hurt them before they hurt you”.

 

Do you see the pattern here?

 

There is one treatment modality we have which may help you to avoid some of this heartache and misery. If you have a diagnosis such as schizophrenia, and you have trouble taking oral medications or keeping up with your plan of care, including taking medications, then long acting injectables or LAIs, may be right for you.

 

What are LAIs? They are medications that are formulated to be given by injection with a needle into the muscle, from which they are slowly absorbed over weeks or months to treat your psychotic symptoms. They include such medications as Haldol Decanoate, Prolixin Decanoate, Invega Sustenna, Risperdal Consta, Aripiprazole monohydrate, Aristada, and Invega Trinza.

 

Why use them? If you have trouble taking oral medications every day, if you have a substance abuse problem, if you tend to take too many pills at one time, or if you are very sensitive to drug side effects with frequent dosing of pills, then LAIs may be for you. Obvious advantages include not having to remember to take pills every day, not having to come to the drugstore to pick up refills as often, more smooth levels of the medication in your bloodstream leading to fewer side effects, and reduced risk of under or overdosing with your medications.

 

Are there downsides to these medications? Of course. It might take a while to get to the very best dose for you, as you are like no other patient. Dosing guidelines help, but every patient is different. It is not as easy to adjust the ongoing dose of your medication as it might be with pills. You might have some transient pain in the injection site (though a very skillful nurse can inject these medications with little trauma to you!) And of course, there is the always present stigma of having to “go get my shot” every month.

 

Do I think that the advantages outweigh the problems with these medications? If you meet the criteria for receiving this kind of medication therapy, absolutely. If you have the opportunity, speak with your doctor, or make sure your loved one does, to discuss this recovery enhancing opportunity.

 

 

Do You Hear What I Hear?

Did you see the recent Oval Office meeting that included the President, ”Chuck and Nancy”, Mike Pence and a host of live news outlet personnel? Did you watch how the parties in this meeting communicated, or not, with each other?

Listening is an easy thing to do poorly, and a very difficult thing to do well.

One could surmise that the three active talkers wanted to make their points known, over talk and interrupt their counterparts, and make the best impression they could in the reality TV type environment. Stands were made, flags were planted, lines were drawn in the sand. The news media was more than happy to document the sausage being made live.

I don’t think I need to belabor the already made point that this meeting was not very productive.

What does it teach us, or remind us, about listening?

First of all, it must be active. If you really want to listen to someone, and make them feel heard, do these things. Put down everything else for a few minutes. Cell phone in pocket. Newspaper set down on the countertop. Make direct eye contact with the person you want to communicate with and listen to. Did you notice the way the President kept playing to the television cameras? Don’t do that. Look at the person you are talking to.

Listen to the other person’s complete thought before you start talking. Do not interrupt. Sometimes, we are so focused on what we are going to say and how profound it’s going to be that we completely miss the other person’s point!

Seek first to understand, then to be understood. You’ve no doubt heard this before. It works. Get what your companion’s premise is before you try to make them understand yours.

Try to communicate, but not necessarily to persuade. Short of being in a court of law or on a debate team, this is usually the right way to go.

Do not talk over the other person, interrupt the other person, or shout the other person down. I honestly cannot watch some news shows simply because no one on the show has learned to take turns and be polite to others. Sometimes,it really does boil down to what we learned in kindergarten!

Don’t blame.

Take the high road.

Compromise.

Accept responsibility for your own actions and expressed opinions.

That recent Oval Office meeting was a perfect example of how not to communicate effectively.

Learn from it.