Medical Cannabis, THC and mental health explored – Part 2

Consultant Psychiatrist Dr Niraj Singh recently spoke at the Medical Cannabis Clinicians Society discussing the usage and efficacy of not only CBD, but also the powerful component of THC, when treating mental disorders and illnesses.

In the webinar Dr Niraj Singh appears with Hannah Deacon, executive director at MCCS, and Pious, a patient advocate from the Plea Community.

You can click here to read ‘Medical Cannabis, THC and mental health explored – Part 1’ if you missed it. In part 2 below, you’ll find a range of audience questions to the panel and their answers.

Pious
I’m 31 years old –  for a good 30 years my entire life was the four walls around me, because my anxiety was so severe. I recently attended an event, went on the train for the very first time – and that’s a really big thing for me. 

For some people that might be a small deal, but for me it was a huge thing. And now to come on a panel to talk to people and see people like yourself, that’s a major step. Even just going into the supermarket and then being amazed by all these different coloured toothbrushes – it kind of made me realise actually how much of my life I have wasted and I wasn’t really living, I was just existing.  

Medical cannabis has given me that gift to be able to actually live. I often describe my life as going to live in Kansas and likening myself as Dorothy and then walking into a world of technicolour. So for me, medical cannabis really has changed my life for the better.

Hannah Deacon
Thank you for sharing that. And how has it been with your family and friends – have they been very supportive and seen the difference in you?

Pious
My mum was very supportive, I think like any mother just wants their child to be happy. So my mum was kind of very receptive towards that – she did want to speak to my GP and I know she wanted to speak to the clinic as well.

My sister was a bit less supportive. My sister has a background within mental health. She’s a psychiatric nurse, and I think she was just concerned and impacted by stigma and held certain beliefs about it, but ever since, just going to be more receptive and looked into it more. My brother, again, has been, I’ve been very lucky. But actually my family’s been quite supportive but I’m aware that’s not always the case for patients sampling.

Hannah Deacon
That’s wonderful. That’s great. Let’s move on to some questions. We’ve got lots and lots to get through.  

Q: And so first Dr Singh – how did you become aware of medical cannabis and the potentials of treating it? 

I think you’ve covered that a bit when you were talking but could you expand a bit on you know, how you know, what sort of motivated you? Was there a particular patient? Or was it just something that you felt that you were missing from your toolkit, so to speak, when you were treating some patients?

Dr Niraj Singh
I was really just searching around for alternative ways to support patients so I’m very much around  what other supplements or what other additional things can help individuals –  even now in my practice day to day I will recommend various supplements. 

Now this is kind of veering off track from what I’ve been trained to do as a doctor, and I think that that’s something that hopefully will be rectified in the future. 

Undergraduates in medical school and even nursing as well – need to be exploring more widely. We know health can benefit from lots of different things and one most important thing is obviously whatever is there in our natural environment. 

In my view it is put there for a reason and it does match up with what’s there in our endocannabinoid system. When one does become unwell, we need to supplement that. 

So that was the real driver originally, just thinking about what I could do differently for my patients. 

Medical cannabis offers a really viable opportunity for people really to regulate the symptoms of their conditions and improve. It’s important that it’s also known, but actually, that needs to be part of the sort of holistic strategy as well. 

It’s important that the treatment is there, but that’s just one arm of things – one arm of health really. 

We need to be thinking much more about the effects of diet, the effects of exercise, you know, good sleep pattern, recreational hobbies, work etc and the all around effects. 

I hope that in the future much more emphasis on that happens in medical training.

Hannah Deacon
Yes, I think it’s having that holistic view as a doctor of the person isn’t it. And that’s something that is lacking sadly for a lot of patients  –  a doctor that doesn’t just see you as if you’ve got epilepsy, a brain, or if you’ve got pain and pain. 

Actually, everything that you do with your body impacts your health, and your mental health. So as you say, diet, exercise, supplements, everything like that has an impact. 

Doctors are not taught that really. They’re taught about prescribing drugs to prevent symptoms, and it’s about thinking a bit further out of that box and looking at the way other things impact health.

Dr Niraj Singh
That’s right Hannah. It’s very much about symptom focus and treating the symptom. One of the great things about medical cannabis is that it can treat a myriad of things at the same time. So, it’s not uncommon for patients to come back to me and say ‘I’ve had this pain in my legs, and that’s gone as well and actually, I didn’t realise how much that was really hampering things and causing me more anxiety.’

The mind and body aren’t separate, although the system we have at the moment almost suggests that. So we’ve got specialties in lots and lots of different areas. But actually, the mind and body are one that’s connected, right? That can’t be argued.

Mental health impacts on physical health, physical health problems also impacts on one’s mental health. So it’s very useful to have something that actually is not just simply focused on the system, but actually getting much more to the foundation of the problems. 

And that’s where the endocannabinoid system is isn’t it, it’s much more of a foundation, which affects all the other surfaces and symptoms. 

Hannah Deacon
Q: What are the most common myths you’ve come across surrounding medical cannabis and mental health or in particular THC and mental health?

Dr Niraj Singh
One of the main myths is addictiveness and that people will become dependent and addicted. Now high dose THC street drugs and things have caused a lot of problems in the past for many, many people, that’s very true – and there is evidence to suggest that it can cause increased psychosis, etc. and things. 

But actually, when you look at the evidence, dependency is far lower when you contrast it, say to alcohol, cocaine, smoking. Even on the recreational side, I think it was still at 9%, compared to alcohol, cocaine being in the 20%, and tobacco being in the 60%. 

The unfortunate thing is that we often get programmed in a way to think that actually this is how a certain thing is and that’s what needs to shift. There needs to be some more balance in the narrative as well – and certainly at medical school and nursing schools. 

We need to keep informing colleagues that this is a medicine and can be extremely beneficial and life changing for individuals with quite serious chronic mental health and physical health problems.

 

Hannah Deacon
Q: How do you deal with stigma amongst colleagues when they learn that you prescribe medical cannabis? And how’s that been for you?

Dr Niraj Singh
Yeah, that’s been an interesting one actually. I always have a spectrum of responses from colleagues when I start to mention this from the downright “what on earth you’re talking about, are you okay?”, to more of a curiosity, and a bit more interest in wanting to see more. It’s been a tough one.

Hannah Deacon
Does that worry you? I mean, that must be very difficult to have people who are openly against what you’re doing. That must be very difficult as a doctor.

Dr Niraj Singh
I suppose really, for me, the reason I got into this was for patients – to help people. Like I said at the beginning when I first started prescribing, it was nerve wracking because I wasn’t really kind of sure how this is going to go. 

You have to have an element of trust in this process as well. And so that was already a barrier. And colleagues already have a series of barriers which they’ve been conditioned with, and we need to really start to tackle those.

And that comes with building the evidence base, sharing case studies, and also the patient voice, which is extremely powerful. We need really, really strong advocates who can communicate the benefits that this medicine has. 

I have had some challenges to the point of things being taken to higher levels because of concerns, but ultimately for me,

I believe in it and, for me it’s about the patients getting the benefit from this. And so that really is the lead driver.

Hannah Deacon
Thank you for that. Because actually, it’s very important that we would like you to prescribe, otherwise, there wouldn’t be anyone able to access this medicine so thank you, because I know it can’t be easy sometimes.  

Has there been any changes to the regulations regarding online prescribing? So you do sort of a zoom call or whatever with your patients? Is that still something that you can do?

Dr Niraj Singh
I think remote online appointments are here to stay. It does benefit a lot of people with mental health problems because it’s not an easy thing to travel, to get from
A to B. 

Having the opportunity to do virtual consultations is a real boon for patients, but also for ourselves, to get to see patients who are hundreds of miles away and be able to support them now.

There is an argument that says, well, actually, you don’t really get all the information necessarily, you know, through body language, etc. During a virtual consultation, I think that that argument does have some merits, but actually, overall, if you look at it, and things, I think, the benefits outweigh any potential disadvantages.

Hannah Deacon
I definitely agree with that because obviously, for people with epilepsy, they were having to travel from Scotland down to London, for example, to get a prescription. Unless you need a physical exam, I think an online conversation is so much better for people with anxiety, or very chronic illness who don’t want to travel to London on a train. 

Hopefully, it will be here to say because I think it’s worked really well and patients seem to be really receptive to it, as well as doctors. And I’m sure you can see a lot more people as well, if you can do it online, rather than face to face.

Dr Niraj Singh
Absolutely – there will be some who do feel uncomfortable coming on a screen and we make reasonable adjustments for those individuals and see them face to face when needs be.

Hannah Deacon
Q: If you have a private prescription and you’re doing well with it, what if you have a mental health issue? How do you think you need to go about starting to convince your NHS consultants that you’re stable, and you can be on that product and start counselling? That it is safe to take small amounts of methylphenidate while using cannabis if not taken at the same time?

Dr Niraj Singh
I think communication is really important. And I know sometimes it’s difficult for patients to have that conversation with the NHS doctor. But I think that it’s very important that the medical cannabis prescriber as best possible does have that communication bridge with any prescribing doctor as well. 

We need to be on the same page as best possible and I think that’s part of educating as well and trying to impart knowledge and sharing that. 

I have spoken to NHS consultants and discussed treatment options. And by-and-large, they’re actually quite receptive but there’s always some barrier. It’s almost like they kind of understand and are really keen to explore, but actually that they themselves are not willing to take the next step themselves. 

As far as I’m aware, there’s no evidence to suggest that there’s any absolute contraindications between certain psychiatric medicines and medical cannabis prescriptions.  And actually, some people prefer to have a bit of additional medicine alongside as well. 

Some patients are very keen to reduce the use of conventional psychotropics, which I’m supportive of. Again, that needs to happen hand in hand and communication with their other prescribing consultants as well. 

Hannah Deacon
In my experience, a lot of people and families I know take a lot of pharmaceuticals together. And it doesn’t seem to be a question.

But if you take medical cannabis people question whether they can take it with a pharmaceutical. But actually, there’s not a lot of understanding of the interactions of all those pharmaceuticals. 

It’s about trying it, looking at what happens and any side effects that may come. And we were always told to give cannabis two hours apart from pharmaceuticals, but again, some people don’t do that. Do you have an opinion on that Pious? How do you do that? If it’s relevant to you, or how people in play that you might know off that state take pharmaceuticals and take cannabis.

Pious
Originally I ended up speaking to my own GP. Because I tried speaking initially to Dr. Google “does cannabis interact with XY and Z?” Then I ended up going to my GP and then into my pharmacist, and found that my pharmacist was quite helpful.

They couldn’t give me the information there and then, but they took my number they looked into and they got back to me. 

I’m not really on any medications. I stopped everything after medical cannabis because to me that they weren’t working. So why am I going to continue to take something that for me personally, doesn’t work? 

But I do think it’s important to kind of speak to your doctor, speak to your prescribers involved in your care and don’t just suddenly stop taking the medication.

Hannah Deacon
Q: Does one need to have exhausted all other treatments for medical cannabis to be prescribed?

Dr Niraj Singh

The patient must have had two licenced treatments before medical cannabis is considered.  Now licenced treatments doesn’t necessarily mean that that individual has to have taken an oral medication necessary.  So it could be for example, cognitive behavioural therapy or any specific psychotherapies that that person has gone through. 

So as to be two licenced unless there’s any sort of mitigating reasons why we would need to consider medical cannabis, if that person hasn’t had already had two licenced treatments.

Sometimes patients have hesitancy around side effects of conventional medicines, because maybe a relative or friend or something has had that. We always have to consider things on a case by case basis.

End of Part 2 – You can click here to read ‘Medical Cannabis, THC and mental health explored – Part 1‘ if you haven’t yet. We’ll be uploading part 3 from this webinar next week week, so make sure you check back for more.