Background: As access to legal marijuana rapidly expands, providers need to better understand the relationship between cannabis and mental disorders, including eating disorders. This presentation examines the history, politics and epidemiology of cannabis. The neurobiological, physical and behavioral effects of cannabis use will be discussed. Research on the effects of cannabinoids in eating disorders and other mental illnesses is lacking. Clients may report that cannabis relieves some of their eating disorder symptoms. The presenters will share practical and effective clinical techniques to engage clients in a non-judgmental way, so that symptom-substitution is avoided, as they move towards eating disorder recovery.
Objectives: 1. Following this presentation, participants will be able to identify three short-term and three long-term effects of cannabis use in the eating disorder population.
2. Following this presentation, participants will be able to define medical marijuana, recreational marijuana, cannabinoids and endocannabinoids.
3. Following this presentation, participants will be able to explain at least two treatment techniques to address cannabis use and/or mis-use among clients with eating disorders.
By: Molly McShane, MD, MPH, FAPA and Kelly Souza, MA, PsyD
- Part 1: Overview of Cannabis
- History of cannabis use in the US and worldwide
- What is medical marijuana?
- US policy update: medical marijuana legal in 30 states and Washington, DC
- Who can “prescribe” medical marijuana?
- Varieties, formulations, routes of administration
- Cannabis contains more than 100 cannabinoids
- Tetrahydrocannabinol=THC, main psychoactive cannabinoid, for chemo-related nausea, AIDS wasting
- Cannabidiol=CBD, not psychoactive, for pain and seizures
- Neurobiology: Endogenous cannabinoids & cannabinoid receptors
- Neurobiology: how cannabinoids activate the brain’s reward system
- Epidemiology, increasing use and addiction risk, decreasing harm perception
- Effects of use in adolescence—brain developing into mid-20s
- Study findings: frequent use, starting at young age, associated with reduction of IQ and development of schizophrenia
- Short-term effects: tachycardia, hypertension, tachypnea, conjunctival injection, memory and judgement impairment, motor coordination impairment, reduced anxiety
- Long-term effects: amotivational syndrome, impaired cognition, chronic respiratory and cardiovascular problems, increased anxiety, depression and psychosis
- Research findings on mental health effects lacking
- Roadblock for research: marijuana is Schedule I controlled drug
- Cannabis for PTSD—studies in progress
- Cannabis for eating disorders? Minimal supporting evidence
- Appetite effects: endocannabinoid system is dysregulated in anorexia and bulimia nervosa, so may not experience “munchies”
- Risk of use in EDs: symptom substitution
- Part 2: Managing ED clients who use cannabis
- How much is too much?
- Cannabis Use Disorder DSM-5 criteria
- Risk stratification: occasional vs. chronic user
- Addressing: “It helps my anxiety”, “It makes it easier to eat my meals”, “I only use it for sleep.”
- Harm reduction approach: 1) agree on measurable outcomes for assessing improvement of the mental health problem cannabis is treating, 2) use lowest “dose” for least amount of time, 3) monitor for adverse effects, 4) meet regularly to evaluate progress
- Treatment approaches: Motivational Enhancement Therapy, CBT, Contingency management
- Explore positive and negative consequences
- Teach client to identify cravings, avoid triggers, increase coping skills
- Medications for relapse prevention: N-acetylcysteine (NAC) and gabapentin
- 12-Steps, Narcotics Anonymous, Smart Recovery
- Engaging family and social supports
- Conclusions
- Questions?
While research on the benefits of cannabis in mental illnesses is lacking, much is known about the potential harms. Epidemiological data shows that cannabis use is increasing, potency of the substance is significantly increasing and perception of its harmful effects is decreasing, especially among adolescents. This has led to rising rates of cannabis dependance. Short and long-term effects of cannabis use range from tachycardia, to impaired motor function, to impaired cognition and amotivational syndrome. Chronic cannabis use increases the risk of anxiety, depression and psychosis.
Clients may report that cannabis relieves their anxiety, insomnia, ruminating thoughts and increases appetite. The effective provider will help the client understand that cannabis use may replace eating disorder behaviors, but it does not treat the underlying illness. Instead, cannabis can cause further avoidance and numbing. Approximately 50% of people with eating disorders struggle with substance abuse, so providers should regularly discuss drug use with their clients. Clients who meet criteria for moderate or severe cannabis use disorder may benefit from specialized addiction treatment and/or supportive groups, such as narcotics anonymous. Given the ubiquity of access to cannabis, providers must engage in earnest discussions about cannabis with their clients in order to support them on the path to full recovery.
Molly McShane, MD, MPH serves as Medical Director of Monte Nido and Affiliates. She is double-board certified in Psychiatry and Addiction Medicine. As a leader in the field of eating disorders, Dr. McShane presents regularly around the country. She graduated from Duke University and the University of Miami, and has trained in psychoanalytic psychotherapy. Dr. McShane is the recipient of the prestigious Laughlin and Ginsberg Fellowships, is a Fellow of the American Psychiatric Association, is a member of Alpha Omega Alpha, and Assistant Professor at Florida International University. She is on the Board of Directors of the Eating Disorders Coalition.
Hello, my name is Kelly Souza. I am a licensed clinical psychologist with an extensive background working with many different populations. I’ve worked in residential foster care programs with children ages 5-17, adolescents on probation, a psychiatric hospital serving clients with severe chronic mental illness, substance abuse at all levels of care, and eating disorders. I’m recovered from an eating disorder and eating disorder treatment has always been the population I’ve been most passionate about not only due to my personal experience, but because when clients choose life and choose recovery, what unfolds is such a beautiful process.
