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.

Pain

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“Yeah, Doc, I drink. I drink a lot. Some nights I drink a case of beer and a half pint. Can’t sleep if I don’t drink. Relaxes me. Pure and simple. Numbs me up like novocaine.”

A toothless grin.

“It’s the feeling of floating away. I don’t know, I just keep coming back to it. Stuff goes in, feel a little flushed, a little rush, then I go somewhere else, you know? I just kinda float off on a cloud for a while. Things back here hurt. I don’t have a job. I can’t buy my kids stuff. I can’t provide. I’m nothing, Doc. I’m nothing to nobody.”

One tear, sliding silently down the weathered cheek like a raindrop after a crashing, lightning-filled storm.

“It just feels good somehow. I know that’s weird. My mom freaked the first time she found out I do it. Oh, I don’t know, whatever I can find. My Dad’s box cutter, a kitchen knife. Razor blades are the best. I watch myself do it, you know? I sort of float over myself, watch myself cut. The lines are neat, sharp, clear. But it’s the blood that helps me. Watching the blood trickle down makes me feel something. It makes me feel human. It just- I don’t know- it just makes me feel something. Anything.”

A recent conversation with a friend made me revisit a concept that I return to over and over again in my professional life.

“We all just want to be significant. We all just want to know we matter.”

Simple concept, that. Self-worth. Self esteem. Mattering to your friends, your family, your spouse, your children, your employer. Should be a given, shouldn’t it? We’re all created, we all have a place here, and we all matter. At least we should.

What keeps some people from feeling that they really matter? What drives them to drink, to inject themselves with toxic substances and to incise themselves in neat, orderly rows of red ooze?

Pain. The common denominator is pain.

No, I’m not talking about the pain I felt when my doctor jabbed my knee with a needle last night to give me relief from unneeded fluid buildup. I’m not talking about the pain you feel when you hit your thumb with a hammer or burn yourself on a hot stove. I’m not even talking about the pain after surgery for the cancer that you now know will eventually kill you.

I’m talking about that deep, aching, throbbing, existential pain that makes you question why you are even here. Why you are alive at all. Can’t relate? I am so glad you can’t.

That kind of pain burns a hole in your soul like change hanging heavily unspent in a pocket. It demands to be felt. It will not go away. It eats at you, day after day after day, making you question your values, your worth to your children and your ability to contribute anything of value to the world at large. It wears you down like a slow-moving glacier, cold and heavy and relentless, sliding over the once-green bumpy mountainside of your life and reducing it to one, long, perfectly smooth expanse of nothing. It leaves no distinguishing marks. You become nothing. You are nothing.

And so you fight desperately to spend that pocket change, to trade it for something shiny and new, something that will make you feel good for a minute, an hour, a day. You try with all your might to melt that glacier, knowing full well that it is too large, too heavy, too wide and deep to extract from the hillside of your life below. You push up and out, but feebly. You take the last breath from the last air in the last pocket, and you resign yourself to the fact that no one will even know that you were here. You are nothing.

So you drink. You can quit anytime you want to. You’ve done it a thousand times. But you don’t.

So you push the plunger one more time, biting the rubber and holding it tight, feeling the inescapable, orgasmic flush of absolute pleasure that will kill you. You don’t care if it does, because for this one moment, this one beautiful moment in time, all is right in the world and God Himself is sitting here with you, stroking your sweaty forehead and easing you out of the world you’ve come to hate.

So you cut. You make the lines fine, evenly spaced, surgically precise. You wait for the first drop of blood, the first small rivulet that stands up for one second, supported by its own surface tension, that same surface tension that has kept your life intact for one more day. You watch the blood trickle down, a small red river of pain, tiny, tiny pain that flows out of you and is controlled by you and is something that you can deal with. Something that you can see, and feel, and hide from others for just one more day.

Maybe tomorrow will be better.

Maybe tomorrow the pain will go away.

Speedballing

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There is hardly a population that is seen in the emergency department that thinks it’s more special than our friends the substance abusers. After all, part of abusing substances is the feeling, the absolute conviction, that one is special and unique.

Now, before I write this morning’s post and alienate half my readership, let me give you this one whopping, multi-part disclaimer. A boatload of my patients in the clinic and the EDs abuse substances. I have family members who are or have been abusers of alcohol. My grandfather died of complications of alcohol dependence, henceforth known as Alcohol Use Disorder, Severe. He was younger than I am now at the time of his death. Some of my best friends and colleagues have been substance abusers.

I’m not writing today’s post to put people down or demean them or call them names or put them in a box (oh, yes, dear readers, substances abuser do just fine, thank you, putting themselves in their own boxes). I’m writing to show that they are indeed a special group in the ED, a difficult group for both ED doc and psychiatrist to deal with.

Oh, and one more thing. I do use the term substance abuser (as opposed to the more PC and sterile people who abuse substances) liberally here. Why? This group of patients, with their recidivistic bent and self-inflicted injuries and relentless march toward death if they’re not treated are viewed by many practitioners as alcoholics, addicts, junkies, poppers, pill heads, pot heads, crackheads, and worse. Oh, hell, they call themselves these names. Don’t be naive and don’t look so surprised.

There are a few glittering gold threads that run through the repeated admissions of substance abusers (SAs). I shall tell you about them here.

First, they are absolutely, unfailingly, supremely entitled. An addict wants what he wants when he wants it. Which is usually right now. Like 80 mg of morphine. Or another shot of Ativan. Or a couple of Lortabs. Or a totem pole (Xanax). They rarely care that the heart attacks and the broken bones lay littered across the ED and came in ahead of them. They are already starting withdrawal, they’re sweating and feel sick and have muscle aches. They hurt. They don’t give a damn about your lupus flare or your gall bladder. They came in with a good story, goddammit, and they expect you to swallow it hook, line and sinker and give them their drugs.

Secondly, they are liars. Now, again, before you throw the rope over the tree branch and come for me, think on this. I did not say that they were bad people. Some addicts and alcoholics that I’ve known would give you the shirt off their back if they thought you needed it. They are smart. They have advanced college degrees. Thye make lots of money. But, they are liars all. Why? Because first of all they lie to themselves. They can’t see life as it is. They can’t stomach what they are and what they’ve become. They must lie to you to be able to continue lying to themselves. The old saw about “When is an addict lying? Anytime he moves his lips” is true, my friends. It may make you angry, but there it is. Deal with it.

Third, they are searching for something. SAs have big gaping holes in their lives, their hearts and their psyches. Vast swaths of emptiness that will not be filled up. So they try to fill them up with Jim Beam and Wild Turkey and grass and horse and crystal. For a while, that intense ten minutes of rush or that three hours of blackout time, it works gloriously. They transport themselves to another world. They feel normal. They feel good. They have found nirvana. They fit in. They have found “it”. Problem is, when the high goes away, so does the answer, like the smoke from the crack pipe. Drifting upward and gone. Back to that profound, aching, lonely, absolutely black hole of nothingness that begs to be filled. Search for more drug. Do it. Feel good. Repeat. Good God, what a cycle of destruction. You know, you shouldn’t, but you do. Over and over again. Until you end up homeless, on the streets, in jail, or dead.

Finally, they are in great pain. Not just the physical pain, though that may have been what started them down the path to destruction. Psychic pain. A pain so deep that they will do anything, anything, to make it go away. A loneliness that street friends and protitutes can’t fix. A pain that cash cannot buy them out of. A pain that narcotics can chase away for while, but not for long. Oh, they will tell you that they need the alcohol to help them sleep or the liquid morphine to ease the back pain enough to walk, or the pot to keep them mellow and out of jail. They will try to win you over, spouses and friends and family members and doctors alike, to their side because you know what they need and you want to help them.

The problem, my dear readers, is that we do know. We know very well what the addict and the alcoholic and the pill popper and the crackhead need.

It’s just easier for us, in our own pain and uncertainly and self-doubt, to slip them another twenty dollars, write them another prescription, and detox them one more time.

For you see, my friends, you and I are not that different from the addict, are we?

We are entitled to our own delusions. (Everything is fine.)

We are consummate liars. (To ourselves first and foremost.)

We are searching for something. (Peace, just for once, would be nice.)

We are in pain. (Oh, please, let me ignore it and hope that it goes away. Oh, please.)

Substance abusers.

We live with them, we love them, we try to treat them.

We want to help them.

We have the very best intentions.

And we are all, addict and family and provider, in so much goddamn pain.