Dr. Sharp: [00:00:00] Hello everyone. Welcome to The Testing Psychologist podcast. The podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.
This podcast is brought to you by PAR. Conduct a broad-based assessment of personality and psychopathology with the gold standard Personality Assessment Inventory or PAI. The new PAI Spanish Revised Translation retains semantic equivalents while using clearer and more inclusive language. Learn more at parinc.com\pai.
Hey everyone. Welcome back to The Testing Psychologist podcast. Excited to be here with you and very excited to introduce you to my guest today.
Dr. Craig Heacock is an adolescent, adult, and addiction psychiatrist right here in Fort Collins, Colorado, where he also hosts and Co-Pro produces a [00:01:00] psychiatric storytelling podcast called Back from the Abyss. He has a special interest in the use of ketamine and psychedelics to treat mood disorders and PTSD. Craig is a graduate of the University of New Mexico School of Medicine and did his psychiatry training at Brown University.
Craig is a good friend, a fellow runner, and a fellow podcast host. We have shared many of these interests over the years. I am thrilled to be able to sit down and chat with him about a topic of interest for him and for many of us, but not one that we speak of a lot, and that is substance-induced psychosis. This is a growing problem, particularly among young men. We’ll talk about that during the episode today. A few other things that we jump into are: defining substance-induced psychosis, we’re talking about is it qualitatively different than regular psychosis. We talk about the risk factors for developing substance [00:02:00] induced psychosis, and we talk about prognosis after a substance-induced psychotic break among many other things.
This is a very rich discussion and I think there’s a lot to take away from it for our work with folks. Hope you enjoy the podcast. I will not keep you in suspense any longer. Let’s get to it.
Craig, welcome to the podcast.
Dr. Craig: It’s good to be here, Jeremy.
Dr. Sharp: I’m glad to have you. I feel like this has been a long time coming. We both hosted podcasts here in the same town for years and it’s taken this long to get together and talk about it.
Dr. Craig: No, why is that? Especially because you and I have spoken a number of times. When I was going to start back from the Abyss, I called you and you [00:03:00] gave me some really good advice and when I needed some emotional support two times I called you, Jeremy, is this working? Am I doing this right? I really appreciate that. But it’s strange we haven’t sat down because we have very similar interests and we’re in the same town and we’re podcasters and we’re runners- which is mostly what we are.
Dr. Sharp: Yeah. I think that’s the most important connection, more than anything. Well, I’m glad to be here with you today. Like you mentioned, your podcast, it’s been so cool to see it take off over the years and now it’s just this incredible thing that people are talking about all over the country and world, and here we are. I’m grateful to have a little bit of your time and expertise to talk about something that’s pretty important that I’ve never talked about on the podcast before, which is amazing in and of itself.
My lead question is always, why this particular work is important to you? Of all the things you could spend your time on, why spend time caring about this whole [00:04:00] substance-induced psychosis world?
Dr. Craig: I think there are really two reasons. One is that, in my own personal practice, I’m seeing this explode. For example, up until 8-10 years ago, I didn’t see a lot of substance-induced psychosis. I saw methamphetamine-induced psychosis for sure, regularly. I saw a few cases of cannabis-induced psychosis, and two DMT, but really it’s not a thing I saw much, maybe two crack cocaine, but in the last seven-eight years, it’s exploded. And I’m seeing particularly, young men say age 17, 24, 25, who are having terrible psychotic breaks. And I mean, this is happening multiple times a month, I’m seeing this, and they’re not coming back.
If someone had told me, 20 years ago, 15 years ago, that I would regularly be seeing people [00:05:00] come in heavy cannabis or peer THC users who were having psychotic breaks and then going on into schizophrenia affective disorder, I wouldn’t have believed it. When in residency, we learned that substance-induced psychosis was a hopeful diagnosis because as long as you stop the offending substance, the psychosis was likely to clear. And that was true for the first half of my career, but now it’s largely not happening. And so that got me very interested just in this topic.
And then maybe three months ago, the Nowak Society, which is a psychedelic education and advocacy society in Colorado, they asked me to give a talk in Denver. And they said, talk about whatever you want. And I thought, well, given that psychedelics are really exploding in interest and research and in Colorado, cannabis is legal and psilocybin is on the ballot this fall, so it could be very well-becoming. I thought I want to talk [00:06:00] about this hidden epidemic in psychiatry, which is that, Cannabis, but more specifically, THC is causing an explosion of substance abuse psychosis which is converting to a permanent chronic psychotic condition.
Dr. Sharp: Yeah, that’s terrifying. I’m not going to totally unpack all of that yet because I want to lay some background information for folks because this is something you see more and more, it sounds like over time. I don’t know that we as psychologists or as testing psychologists see this stuff frequently. Psychosis happens, schizophrenia happens, right? We see that, but the substance-induced version is a little more unique. So, let’s like some background. Can you just give me some working definitions? When you say substance-induced psychosis, what are we talking about?
Dr. Craig: Well, let’s first define psychosis, which [00:07:00] again, your audience knows what psychosis is, but I think I just want to put this out there that psychosis, like everything else in psychiatry, psychology exists on a continuum. Psychotic technically means losing touch with reality. But that is a long wide spectrum.
I would think of psychosis like a soundboard. So imagine a soundboard at a concert and there are all these dials. And the biggest dial in the middle is the paranoid dial because that’s usually the index symptom, that’s the main driver often of all the other symptoms, but you’ve got a tactile hallucination dial, you’ve got a visual hallucination dial, ideas of reference mind, reading, thought projection, and many other dials.
And so, psychosis is a condition where these dials are cranked up to some degree, but it presents very differently. [00:08:00] it’s very possible that someone’s sitting in our office with terrible psychotic symptoms but you don’t know. And in there could be uncertain parts of their life, they’re very in touch with reality.
We talk about psychosis like it’s a thing like cancer or anemia but it really is a palette. It’s a soundboard with all these different dials and it can be difficult to assess particularly because of the big dial in the middle, the paranoia dial, it makes it so people do not want to talk about what’s happening.
Dr. Sharp: It seems like a bit of a catch-22. If you’re trying to assess someone and get a sense of their experience and yet they are vigilant or paranoid, that’s another thing to do.
Dr. Craig: Yeah. Let me say, that’s the psychosis end of what is substance-induced psychosis. Let me back up a little bit. The psychosis circuit in the [00:09:00] brain is a dopamine circuit in the midbrain. And it’s the saliency circuit. It’s the circuit of importance. So normally, in the brain when something important happens, you find good food. Where a scary bear lives and gets a little shot of dopamine in the saliency circuit. So that is a very critical circuit. But it turns out that is also where paranoia and other psychotic symptoms come from, from the resiliency circuit.
The core, if you will, the neurotransmitter of psychosis is dopamine. But it turns out that, for example, methamphetamine cranks dopamine and cocaine. So that makes sense why if you overdo dopamine in that in the saliency circuit, you could get psychotic, but it also turns out that a number of other substances feed downstream to that. For example, the cannabinoid 1 receptor, which is where THC binds, it [00:10:00] has very strong downstream effects on the saliency circuit in the midbrain.
Also, the serotonin 2A receptor, which is where DMT and psilocybin, and LSD binds. If you over-activate that receptor enough, you get downstream overactivation effects that the D2 mid-brain circuit. And there’s a CAPA opioid circuit where some more obscure psychedelics act that if you over-activate that you can get downstream D2 effect.
So, substance-induced psychosis is a condition where either directly by stimulating mid-brain dopamine or by downstream effects, you’re getting overstimulation of that circuit. And then all things start to become important. Let’s say you’re having dopamine surging through that mid-brain circuit, and then you look in your rearview mirror and there’s a red car and your brain’s saying, Important, pay attention. This is very important. The dopamine backs off a few more [00:11:00] minutes. You get a surge and you look in your rearview mirror and there’s another red car, and your brain’s saying, Pay attention, Pay attention, Pay attention.
The reason that paranoia is the index or core symptom of psychosis is that the important saliency circuit is what’s telling you that you need to make connections and pay attention. This is important to your very survival.
Again, what happens with psychosis is people start seeing connections and importance and real life or death meaning in things that have no life or death meaning or connections. And that can be caused by primary psychotic disorders like schizophrenia or by substances.
Dr. Sharp: Right. Well, I think you’re setting on my next question really well, which is, is substance-induced psychosis qualitatively different than [00:12:00] “regular psychosis” in some way? Do you make any distinction between those two, either in terms of conceptualization or treatment or even neurobiology? Should we view those differently or is it the same thing that’s happening in the brain and behaviorally?
Dr. Craig: Yeah, I think, for example, different substances have psychotic states, which are fairly characteristics. The substances that go right to dopamine, like crack cocaine and methamphetamine, those people get very agitated and very paranoid. And part of that too is because of sleep deprivation, but there is an extreme level of fear and aggression that you see with the substances that work right on dopamine. Whereas, for example, like with the cannabinoid 1 receptor where THC acts, you tend not to [00:13:00] see that level of agitation and violence. You tend to see very bizarre delusions and extremely strange motivations like cut off this body part or wander into the mountains and live off plants or walk to Denver in a snowstorm. I mean these are actual patients of mine that had psychotic episodes with THC.
So, I think there are some characteristics that certain substances turn up certain dials more than others. And again, if we think of schizophrenia, which of course is a huge tent and probably is a whole bunch of different illnesses that we’re putting under one tent. The classic, if you will, psychotic symptom of schizophrenia is a command or commenting auditory hallucinations outside the head male. And this is very odd, usually emanating from like a [00:14:00] 45-degree angle back from your ears, not right behind you, not perpendicular, but back at an angle. And it’s usually, 1 to 2 male voices who you don’t recognize who is either telling you to do horrible things or commenting, saying terrible things about you. That’s a classic Schizophrenia symptom.
Dr. Sharp: Yeah. Just as a side note, a little digression, where does that 45-degree angle come from?
Dr. Craig: They’ve studied that. They ask people. There are really interesting studies in the phenomenology of auditory hallucinations and that’s how they determine that. With primary psychosis like schizophrenia, voices usually, not always, but most of the time, people say it’s coming from outside the head. And they’ve asked them, is it in front of you? Is it behind you? Is it the side of you? And on average, people say no, it’s back at a 45-degree angle, which you [00:15:00] figure even that’s super creepy. It’s like you can almost see it if you turn your head. I don’t know what that means.
Dr. Sharp: Yeah. Maybe something to bookmark and look up. That’s super interesting that that’s emerged as consistent. So when you’re thinking about it, the assessment part is important for us Of course. I’m curious from the psychiatric perspective, when you have someone in your office, what are some of those, let’s assume they’re not in full-blown psychotic episodes at this point substance-induced or otherwise, what are those little red flags that jump out that prick your ears a little bit and make you want to ask more to dig in?
Dr. Craig: Well, I think now, again, this was not the case 10, 15 years ago, but now when I ask people about THC cannabis, that’s a whole series of questions. It used to be, do you smoke weed? Do you smoke pot? [00:16:00] How much? But now I realize, no, it’s very important what they’re using.
One of my questions, I mean, it’s just everyone I evaluate, but for sure for young men or anybody who’s coming in that’s seeming like something’s not right with them, I’ve learned, you can’t just ask, do you smoke weed? Because most young men in Colorado will say, No, because they’re not smoking weed. They’re vaping THC concentrates or distillates.
Dr. Sharp: And you’re seeing a distinction between those. Like people say, No, I don’t smoke weed when they’re taking dabs?
Dr. Craig: Yes. I come back to these kids, I’m like, Hey, I hear you are actually using, and they say, no, I’m not smoking flour. I’m vaping resin or I’m dabbing distillate.
One of the ways that I’d start the evaluation with any folks that I’m thinking something could be up in the psychosis real, [00:17:00] is I want to know what they’re using because it turns out that the old-style marijuana, if you will, had a lot of CBD and CBN and other accolades in it, which basically seems to balance out the psychosis, manic, and panic-inducing properties of THC.
Dr. Sharp: Could I interrupt you just for a second just for a little bit of context? When you say CBA, CBN, just to put this in context for folks, what does that mean?
Dr. Craig: The cannabis plant, the marijuana plant has THC in it, which is what gets you high, that’s the active ingredient. But there are all sorts of other accolades in there,-many, many many, some of which are still being characterized, but one that’s been pretty well characterized and that a lot of people know about is CBD. And CBD seems to be like the breaks to THCs accelerator.
So, as long as you’re using weed that has enough [00:18:00] CBD in it, and not too much THC, you could probably avoid psychosis, mania, panic, sleep disturbance, et cetera. But there seems to be a tipping point, and it varies I think, depending on your genetic predisposition and trauma history and sleep and everything. But there’s a tipping point for a lot of people, especially young men, we can talk about that where if they’re using too much-unopposed THC, I mean not opposed by CBD or other neutralizing alkaloids, the THC over-stimulates that cannabinoid one receptor that they start getting the downstream flooding of dopamine in this midbrain saliency circuit and they start to get psychotic or manic.
I want to know, I ask people, do you smoke weed flour? Do you use THC concentrates? How many milligrams a day? How many milligrams a week? I never used to ask these questions. It’d just be [00:19:00] like, do you drink? Do you use cocaine? But now, I’m often writing down, okay, he’s using approximately 200 milligrams of THC daily vaped three times a day.
I’m doing these very detailed analyses of what people are using because that’s really tipping me off because inevitably, again, often young men are coming to my office who seem not right. They’re not smoking Indica, which is weaker, although interestingly what is called weak weed in Colorado now is profoundly powerful- many times more powerful way we used to be around when we were in high school and college.
As I’ve talked about on my podcast, going to a weed dispenser in Colorado, it’s like going to a liquor store and all they have is ever-clear vodka and tequila. And you’re like, I just like some beer. No, they only have very powerful strains. But then ironically, a lot of my young patients, especially my young [00:20:00] men, don’t want to mess around with even very potent flour. They want to go right to really ever clear, which is the THC concentrates distillates, which if they have the right genetic predisposition is increasingly likely to flip them into some permanent psychotic or schizoaffective condition.
Dr. Sharp: Yeah. I think it might be important to quantify this a little bit. And the big picture we’re talking about, the percentage of THC is much greater than it used to be like you said, when we were younger, which was, I don’t know, nobody measured back then.
Dr. Craig: No, they were actually. There’s data.
Dr. Sharp: Oh, okay.
Dr. Craig: The weed of the 80s, I was in high school and college in the 80s. the weed of the the80s was like 3% to 6% by way of THC. Now what I hear from my patients, from most of the dispensaries in Colorado, it’s hard to find weed with less than 18% by weight. [00:21:00] Like you have to search for that. The weakest thing they’re selling now is 6 times stronger, than what was available in the 80s. And that’s not what especially my young patients are seeking. They’re not asking for the weaker weed. They want the full-on strongest stuff they can get.
Dr. Sharp: That’s interesting to me. Do you see this as an extension of hyper-masculinity, taking shots versus drinking beer similar process there for guys or is there something else that’s driving that?
Dr. Craig: I actually do. I think in general, young men and men abuse substances way more than young women and women, and I think for sure, men under 25 with their undeveloped frontal lobes, they are more risk-taking, they’re more impulsive, they’re testosterone poisoned, and they [00:22:00] want to go all in, Hey, would you jump off this 40-foot cliff? Yeah. Would you go 50 feet? Would you go 60 feet? Could you go 65? I mean, young men are like, Well if my friends are doing it, I’m in.
I think there is this arms race, not just in the marijuana industry to make more and more potent stuff, but again, with young men. The irony and the sad thing, and what I think is relevant to this podcast, that’s who’s psychiatrically vulnerable. I’m not seeing psychotic breaks that stick in men over 25, or 26. I’m just not.
Dr. Sharp: That’s interesting.
Dr. Craig: Yeah. And I think it’s because of a few things. I think it’s because, by 25- 26 yrs, the frontal lobe is fully developed. Major psychiatric illness typically hits in the late teens or early twenties. So people have escaped that neurodevelopmental window. There’s also evidence that by age 26, or 27, men tend to calm down and stop being so impulsive and risk-taking.[00:23:00] Dr. Sharp: So it’s not a function of baseline susceptibility or something changing physiologically necessarily. You would attribute that to guys just making better choices.
Dr. Craig: Yeah. Although, the latest theory of what’s happening with schizophrenia is that in the mid to late teens, there’s a massive pruning of the brain. The brain’s born with all these potential synaptic connections, and then as you either learn Chinese or don’t, or learn soccer or don’t, or learn piano or don’t, you form different synaptic connections or you don’t. And then by mid to late teens, there’s a huge synaptic pruning. It’d be like, if you invited an arborist to come over to your big old cottonwood and you’d marked it with a whole bunch of flags and said, cut all these branches that are going nowhere. You’re not learning Chinese, you’re not going to be a soccer striker, you’re not going to [00:24:00] learn calc three or whatever.
But what happens with schizophrenia is that this normal process goes amok and the immune system puts little complement proteins all over the brain and says, Cut here, cut here, cut here, cut here, cut here. And the normal synaptic pruning of the brain, it’s like the arborist brought his or her whole crew with 25 chainsaws and they went crazy on the tree and you came out and there’s just like a stump with a few branches. And they said, there you go. There’s your pruning and you think, that’s too much. But that seems to be what’s happening with schizoaffective disorder and schizophrenia. We don’t fully understand why, for example, heavy THC use in adolescence triggers that.
And let me just back up a little bit. We know that schizophrenia is about 50% heritable if you will. So, if [00:25:00] you have one identical twin who develops schizophrenia, that person’s identical twin separated at birth, has a 50% chance of developing it. It clearly has a big genetic component, but 50% of schizophrenia and schizoaffective disorder is environmental. And we’ve long known that can be things like winter birth, prenatal insults like cytomegalovirus, toxic plasma, other viruses, early childhood abuse, and low APGAR scores.
There are a number of things that seem to make the expression of schizophrenia more likely. But now, and this comes from a paper in 2019 American journalist psychiatry, it seemed the number one thing that’s determining whether people are going to flip into schizophrenia schizoaffective disorder if they have that genetic predisposition, is adolescent exposure to THC.
Dr. Sharp: That is the number one influence?
Dr. Craig: This paper estimated in the United States [00:26:00] that 10% of everyone with schizophrenia in the US expressed it because of adolescent THC cannabis use.
Dr. Sharp: That is mind-blowing.
Dr. Craig: Yeah.
Dr. Sharp: I’m guessing that’s changed over.
Dr. Craig: I think that’s changed. Again, we have to be careful with observer bias and expectation bias. There’s always what I see in my office and what you’re seeing in studies, but this paper also talked about how this is really changed and again, hypothesized because it’s not just because of more widespread cannabis use, but it’s what people are using and they’re using it younger.
We’ve known for a long time from some of these big national registries like the Australian men’s study that cannabis use before 15, I think triples your risk of developing schizophrenia quadruples? It’s very high. And again, I think [00:27:00] the male brain, in particular, seems uniquely vulnerable to these insults.
We’ve known for a long time that men have a more neurodevelopmental illness. They have schizophrenia worse. They seem to have autism often worse, and boys just in general, the male brain seems more fragile. We’re seeing that I think in psychiatry, that with adolescent substance use, particularly THC, high levels of THC, unopposed THC, people are flipping into psychosis who wouldn’t have before.
Dr. Sharp: Yeah, terrifying. Having a soon-to-be adolescent boy, I’m thinking about that, how to protect him.
Dr. Craig: Yeah. One of the things I described in my talk in Denver last month was that there are two candidate genes that seem to be the main triggers: that’s the COMT gene, it’s called AKT-1. But what’s notable about those [00:28:00] genes is they both are involved in surprise dopamine metabolism. And again, since dopamine is the final common pathway of psychosis. So people that have particular, what do we call alleles or genetic expressions, and these two genes are at way higher risk of developing schizophrenia or schizoaffective disorder with adolescent THC use.
And we know what those alleles are. I wonder if it might be common here in the coming years, like as part of a pediatric exam, in early teen years you check your COMT gene and your AKT-1 gene and say, Hey, you are multiple folds at risk of developing a long term psychotic illness with adolescent THC use. So you got to be especially careful. I mean, that’s not happening now, but I wouldn’t be surprised if we’re heading toward that.
Dr. Sharp: Let’s take a break to hear from our featured partner.
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All right, let’s get back to the podcast.
I was just going to ask about that. Is this something that’s going to show up on a typical microarray or even like a 23 and Me or something like that? Are these genes that people are actually looking at?
Dr. Craig: Yeah. The COMT gene is actually commonly looked at. Like if you get some of these genetic panels that are now getting more popular in psychiatry where they look at genes that affect the pharmacokinetics and pharmacodynamics of medication, COMT is often checked. I don’t think AKT1 is as commonly checked. But a proxy for those [00:30:00] is there a history of psychotic illness in the family? Is there a history of substance-induced psychosis, schizoaffective disorder, or schizophrenia?
And even now in 2022, I think we need to be spreading the word that if those illnesses around the family adolescent THC use, especially the weed that’s available today is very risky. Other than meth, it’s probably the riskiest thing you could do. And it’s interesting. I’ve been doing this for a few years now.
My patients always think this is so hard to believe. But when I have people who have their first manic episode or first psychotic episode, I always give people a whole list of here’s how you stay healthy.
Number one on that list, I always write no meth, no weed. And people like, what? They’re like, I’m not going to do meth but weed. I’m like, Yeah. If you destabilize back into mania or psychosis, it’s probably not going to be meth because most people in Fort Collins are not doing meth. It’s going to be weed. And I see this all the time. I have so [00:31:00] many people, this has happened many times where people in my practice with a history of mania or psychosis are stable and doing, again, these are usually young men, stable, doing well on medications and then they don’t even have to stop their meds. They dab. They have a day or two of the dab rig with pure THC concentrate and they flip back into psychosis. The next thing I hear they’re in jail, they’re wanting around CSU with a sword. That’s a true story.
It’s complete chaos. And some of these people are on injectable antipsychotics, which in my mind are nearly 100% effective in keeping people out of jail and the hospital. But if they dab THC, if they use pure THC Products, they can overcome the stabilization of their antipsychotic and flip out.
Dr. Sharp: This is a dumb question, but I ask a lot of those on the podcast. Is it just the higher concentration of the THC in [00:32:00] these different, I can’t think of the products, the different products? Is it just simply a matter of the higher THC that’s pushing?
Dr. Craig: Yeah, and I think it is also the lack of CBD and probably other accolades.
Dr. Sharp: I got you.
Dr. Craig: Because there are some small open-label studies that suggest that CBD has antipsychotic properties, it has anti-manic properties, it has anxiolytic properties. It’s interesting that like many things in human history, if we just stick to the plant, it would be okay. But of course we never just want the plant, We want to distill out like, what’s the most hardcore part of the plant?
I think it’s the overactivation of the cannabinoid one receptor with THC. But I think as importantly, or maybe, more importantly, there’s no neurochemical balance with CBD. And again, I think that’s why… I mean, I knew some incredibly heavy stoners in my college. [00:33:00] So many. Nobody got, well, that’s not true, one person I know got psychotic, and I’m talking about that on my podcast in two weeks, but of the many people I knew who basically lived on weed, only one I know of in my whole early life flipped into psychosis, whereas now I see this a lot. So something has changed and I think that’s very clear what’s changed.; the product has changed and the use pattern has changed.
And one other editorializing thing I might say is I’ve argued before and if I were the Czar of Colorado, like the health Czar, I would get rid of medical marijuana. I would make it legal, but let’s just call spade a spade. Like if you want to drink, cool. I mean, some people can drink, and other people can destroy their life, but its legal prohibition didn’t work. Let’s have liquor stores. Let’s educate people about alcohol.
As a psychiatrist, and granted, I admit I come from a [00:34:00] mental health perspective, but I think we could say the same thing about marijuana. Clearly, weed has medical uses. It can help with chemotherapy and nausea. It can help with glaucoma. And it can help with pain for sure, and it can sometimes help with sleep. But in psychiatry, for the most part, THC is a disaster. And I think when we have all these dispensaries over Colorado or with their Green Cross and talking about, Oh, natural medicine use, get your medical card.
Dr. Sharp: It’s misleading.
Dr. Craig: It’s giving people a terrible message. And I think a lot of people in Colorado, nationwide are probably going to be surprised by what I’m saying because they think, Well, wait isn’t marijuana medicine? Isn’t it maybe good for you, good for anxiety? Treat your depression and your PTSD with weed? Well, maybe possibly with the weed from the 80s, not what’s available now.
Dr. Sharp: Yeah. I imagine people are listening, [00:35:00] some people who are really mad right now about medical marijuana. But it’s a good point though. I’m trying to think of another substance where those lines are blurred.
Dr. Craig: I think alcohol, I would argue it’s a really good comparison. Is alcohol good for anxiety? I think the answer is yes if used moderately, and mindfully. So can having a glass or two of wine in the evening help your anxiety and stress? For sure. Having 10 shots of vodka? No. The reason alcohol has been the number one go-to self-medication for all of human history, I think is because it helps a lot with anxiety and stress, except when it doesn’t which is normally when you are using more and more concentrated forms in higher amounts. So, I really think again, mental health-wise, alcohol, and weed are very similar and when used with lower concentrations in mindful ways, in the right [00:36:00] context, they’re probably fine for most people. But that’s not what I’m seeing in my office.
Dr. Sharp: Yeah. Well, that begs the question, which is a difficult question maybe, I don’t know, maybe I thought about this. Should it be legal, or should it be illegal period?
Dr. Craig: Yeah, I think it should be legal. I’m for a few reasons. One is I believe in cognitive liberty. I think people should be able to alter their minds if they’re adults and they’re adequately educated about that; 2, prohibition doesn’t work, and 3, by decriminalizing or medicalizing a substance, we can actually tax it, monitor it, and keep it safer. But I would be vigorously opposed to a new category of liquor store in Colorado that would be medical alcohol. Or as it exists in dispensaries in Colorado, [00:37:00] if you went to a liquor store on the left side was the medical alcohol and the right side was recreational alcohol.
Dr. Sharp: It sounds ridiculous.
Dr. Craig: It’s ridiculous. And I know there are people listening who probably are saying, wait, but marijuana has medical uses. I hear you. But we’re talking here about mental health. It’s really an unmitigated disaster. It sounds absurd, but that’s what we’re doing in Colorado. We’re saying, Hey, you can go in the left door or the right door. And why can’t we just say, Hey, this is a substance that helps some people, but it has major potential risks, and let’s just be honest about it. And for most people, it’s not medicine. At least in the concentration, it’s sold in Colorado, it’s to get really high, which is fine if you want to get really high. No problem with that. But let’s be honest about that. That’s not a treatment for your bipolar disorder. That’s not a treatment for your panic [00:38:00] or your rape when you were 17. That’s not treatment.
Dr. Sharp: Yeah. It’s an important point. I know just historically like the medical route, that was the Trojan horse or whatever to bring in recreational marijuana, but now we’re stuck in this weird place of, we still have medical and it’s the exact same product. It’s just a different door.
Dr. Craig: What a lot of people do is that you can buy so much with your medical card way more than you could ever use for most people. But it’s not taxed. Then you can turn around and sell it to your friends at a good profit. Having a medical card is a way to become a subsidized dealer.
Dr. Sharp: Sure. That’s interesting. I didn’t know. I want to go back to the assessment component and just put in a word. I’m guessing that some folks maybe got a little lost as we were talking about the percentage of THC and alkaloids and CBN and CBA and all that. I want to endorse [00:39:00] or encourage folks if you’re in a state where it’s legal to go and spend some time in a dispensary so you actually know what your clients are talking about so you can ask the right questions and know what’s out there. I think that’s important.
Dr. Craig: Yeah, I think that’s a good idea.
Dr. Sharp: Yeah. So you don’t sound lost and you can ask the right questions.
Dr. Craig: You don’t say, don’t use the word pot. Do you smoke pot? They’re like, what? No, don’t smoke pot.
Dr. Sharp: I’m so uncool. Are there any other assessment components that you’re looking for? I like the deep dive into THC use and knowing that you have to ask all these detailed questions. Are there other things, I mean, are you doing a pretty extensive just substance use history in general? Are you asking for other things, anything you need to be aware of?
Dr. Craig: Yeah. Well, I am huge, and you are too. Your work is crucial for this. [00:40:00] But I’m a huge fan of collateral information and I pretty much won’t see patients without having family input. Maybe if somebody has a little bit of panic or a little bit of anxiety, but especially young people that I’m worried about, I have to talk to their family. And so oftentimes we get, especially, from talking like about 18 or 22, 24-year-old who’s probably ambivalent at best about seeing me.
And we all know that everybody’s going to lie about their substance use. I’m always shocked when people are honest. I had a guy tell me once, hey, I just shot up in the parking lot and I said, that’s so great. You told me. Thank you. Almost wanted to hug him because people are always lying about it. And so I think collateral information because what we’re trying to do is get a longitudinal picture.
That’s one of the things that [00:41:00] were challenged as psychologists and psychiatrists is we see people at a snapshot in time and we’re really trying to understand like, okay, this kid is 19 and having some really bizarre behaviors or seemingly really depressed, but with a very odd flavor. And if we can’t talk to the parents or siblings, we’re not going to get a meaningful history.
Dr. Sharp: I totally agree.
Dr. Craig: One of my colleagues years ago used to say that family collateral is the imaging of psychiatry. I just love that,. I love that image that unless you’ve got family collateral, you’re almost surely missing a lot.
Dr. Sharp: Absolutely. How do you do that? Because this is a thing that we run into as a problem as well. We always try to do collateral interviews. I’m curious how you handle it if kids, young adults don’t want you to talk to their families, or I’m estranged from my family or my parents don’t understand me [00:42:00] and they’ll give you inaccurate information, that kind of thing. Have you found any ways to navigate around those problems?
Dr. Craig: Yeah. Here’s a classic thing that might happen. Let’s say a 19-year-old young man from CSU comes to see me and no family. And as the assessments progressing, I’m thinking something is seriously wrong here. As I try to build some rapport, I say, hey, something I always do is just part of my practice is, I always want to talk to at least one parent, and you can choose which parent. I’m going to do it here. I’m going to do it on speakerphone. I want you to hear everything I ask, and I’m going to tell you right now what I’m going to ask. I’m going to ask, hey, do you have any concerns? What do you think could be helpful? Have you seen any changes over time that would be helpful to me? So I’ll just lay out five or six questions. And I say, we’ll just call on your phone. We’ll do it on speaker phone and you can listen. I said, I’m not going to share anything that we’ve talked [00:43:00] about, but you’ll get to hear my questions and what the parents are saying.
Now, occasionally people will say no, and I’ll say, well, we don’t have to do it today. We can do it next session. Like if you feel like you need to talk to your parents, but this is the way my practice runs and this is the way I operate, and it’s crucial for me to be able to understand you and help you. And again, you don’t have to decide right this moment, but you need to know, I won’t be able to work with you like this. You’ll have to find someone else to work with because I feel like this is so important that I can’t actually really help you if I can’t speak it to at least one person who knows you well.
And in that case, I rarely get turned down. I’ve had a few young people who it took the second or third session. But again, I turned the heat, like I’m not going to keep seeing you. But I think there’s something powerful about doing it in vivo with speakerphone.[00:44:00] Dr. Sharp: Yeah. That’s just the variable that is new to me.
Dr. Craig: They can really say, hey, I’m actually shooting straight here. I’m not going to call and say, your kid is using cocaine or your kid’s going to kill himself, no, I’m just going to check-in. And almost always those calls are incredibly useful.
Dr. Sharp: Yeah. Oh, I’m sure. We typically get really good information from collateral interviews.
Dr. Craig: Yeah. I use speakerphones a lot. People say, Oh, I’m having a hard time with my therapist. I’m like, well, let’s call him, let’s call her, and let’s talk about you. If we get the voicemail, what are we going to say?
Dr. Sharp: Okay. Just go for it.
Dr. Craig: One, it’s good because time-wise it’s good for me because I just have so many patients. I’m so busy. Like, if I saved all my family collateral calls and therapist calls outside a session, I’d never go home. But also I think people really like it when you call their endocrinologist, you call their psychologist in a session like, [00:45:00] Hey, Dr. Sharp, it’s Craig Heacock. I’m sitting here with, Susie, and Susie’s having a really hard time, and blah, lay it out.
Dr. Sharp: Yeah. I’m thinking about the other side. Do you ever get shocked or pushback from the therapist and they’re like, why’d you put me on the spot like that?
Dr. Craig: No. Well, I would say more often than not, I’ll get their voicemail, but I always say like, if you answered, I’d say, Hey Jeremy, I’m on speaker phone right now with Susie, and Susie’s really torn up about X and Y and I just wanted to share two things. I’ve never had anybody complain about that.
Dr. Sharp: Great. I like that. This is an unexpected nugget from this interview I didn’t think we were going to talk about interviewing techniques, but this is good. So I want to ask some questions about the actual nature of THC-induced psychosis. We’re zeroing in on the THC of course, but when this happens, is [00:46:00] it like a, they hit the dab rig, and then it’s like, boom, they’re there into a psychotic episode? Or is this coming on over a number of days or weeks? What’s the flavor here?
Dr. Craig: What I’ve seen with my patients is that the first episode of psychosis or mania, it’s a process. Because if you think about the body, the body has all these homeostatic mechanisms to keep things in check and you really have to abuse the liver, the brain, the heart, and the blood vessels a lot for things to break down. And I think even in the vulnerable adolescent brain, It can take a lot of abuse often before something snaps.
The typical picture with the first episode is, let’s say, heavy THC use over months or a year or two or three. But then again, this goes to the kindling theory of mental illness, which we talk about in [00:47:00] psychiatry is the idea that once you’ve badly sprained your ankle, it’s vulnerable and it will really never be the same. You can go to pt, and you can try to get all the muscles strong and take care of it, but once you have seriously injured your ankle, it’s never going to be quite the same. And so that’s the call the kin link theory.
And we see that in psychiatry with psychosis, with mania, with a serious depressive episode, once you’ve had your first big break, you’re much more vulnerable. And here’s the statistic. So if you’ve had a psychotic episode off meds, not doing drugs, you have like a 50% chance lifetime of having another one. Once you’ve had two psychotic episodes off drugs, I think it’s 75, 80 and after three psychotic episodes, it’s like 95.
I have seen a number of my patients who, as far as I can tell, this is what family collateral, and what they said is they just dabbed one night. They were stable on meds, dabbed [00:48:00] one night, and flipped into psychosis. But I think again, that’s because they already had, if you will, broken the brain a few times or at least once or twice. So they were vulnerable to that.
Dr. Sharp: Right. And then as far as the course of the psychotic episode, well even using the term episode lends itself to an end of finiteness. Is that what you are seeing with these substance-induced episodes or where does it go from?
Dr. Craig: Well, one big factor is whether are we talking about the index, the first episode, or the later episode. With an index episode, the parents they’re like personally, what is this? I’m saying this is psychosis. What’s causing it? And then is the discussion, well, it’s either substance-induced, probably weed again, weed because that’s what people are doing, THC or it’s a primary psychotic illness like [00:49:00] schizophrenia, schizoaffective disorder, and let’s hope it’s the former. But then what’s so hard with many of my patients is they don’t believe that. They think there’s no way weed could do this or dabbing. No way that I could have ended up in jail or a psychological hospital from dabbing because my friends do it, they’re not hospitalized. There’s often this back and forth of people having their index episode using cannabis or THC and they’re in and out of psychosis period of many weeks or even many months as trying to get them to stop.
But once they stop, then is a really scary time because I’m thinking like, okay, is this going to clear? And if it’s just substance abuse, THC psychosis is not going to progress. Usually within a period of weeks, especially on antipsychotics, it’ll clear. But, again, more and more people we’re seeing, it doesn’t clear even on antipsychotics. [00:50:00] They get better but they don’t get all the way better or we try to take them off antipsychotics 6-12 months later and it comes back even without THC.
Dr. Sharp: Right. Let me go back a little bit just to clarify what you said that with these THC-induced episodes, it’s incumbent that they quit using THC to get a clear picture of what’s happening here. And even then with antipsychotic medication, it could take a period of weeks to come out of that. Scary stuff.
Dr. Craig: It is scary, and again, because so many young people are using cannabis. I’ve had CSU students tell me that it’s much easier to get weed than beer. It’s just so widespread and most people, even most people who are dabbing are not going to have a psychotic episode. [00:51:00] It’s such a hard sell when people come in and have been arrested for assault with a weapon. They’ve been in jail and they’re bonded out, and now they’re seeing me for the first time and I’m doing history and talking to the family and I’m realizing this is a cannabis-induced psychosis, THC-induced psychosis, and I’m trying to sell that to them. It’s not an easy sell. Even the parents like, really? Smoking pot could do this. I’m like, Okay, first of all, it’s not pot? Your son or daughter is not pot. This is a whole different deal. And probably it’s some potent Sativa, high THC flour, or more commonly a THC distillate.
Dr. Sharp: Yeah. Are there any tips or tricks around “selling” it to people” and convincing them? Do you have a script or talking points or anything to help?[00:52:00] Dr. Craig: Yeah. One thing I do, and I think this is a thing a lot of therapists do, is to normalize it and say, and I don’t have to lie. I can say, look, I see this a lot. I see this with lots of CSU students or other college students or just young people who don’t have any significant psychiatric history. They start using more and more cannabis. They increase the potency of the strain, and then maybe they start dabbing and then they flip into psychosis.
I say, this is a thing I see a lot. It may feel very unusual to you. This is a common thing and this is very treatable. Oftentimes, I’ll try to sell people like, if you keep using THC, we’re going to have to keep you on antipsychotics, or you’re going to end up in jail or hospital or worse, but if you’re willing to not use THC there’s a good chance, and I’m crossing my fingers that we won’t have to keep you on long-term antipsychotics. [00:53:00] But again, I think, like many things in psychotic, trying to think, it often takes many months longer to get people on board.
I think psychiatry’s the only medical specialty where the sicker you get, the more likely you are to think nothing’s wrong. Or the sicker you get, the more like you are to think that your doctor can’t help you. If you were vomiting blood or you’d lost 50 pounds, or you’re having horrific pelvic pain, you’re probably not going to argue with your doctor. I’m fine. There’s nothing wrong. I don’t have an illness.
With mental illness, as it gets more severe, you lose insight and you even get… I mean, when you’re very depressed, you’re delusional. The world would be better off without me. I’m a piece of shit. I’m a burden to everyone who knows me. That’s delusional. And then when we get into the realm of manic and psychotic illness, it’s absolutely. [00:54:00] I’ve seen people doing extremely bizarre things in the waiting room in front of their family for evaluation. And when they come in my office, I’ll point out, well, what about that really bizarre thing you were doing in the waiting room? What do you mean? It’s nothing? No, I Meanwhile the parents are looking like their eyes are bugging out of their heads.
Dr. Sharp: Right. That’s such a good point. I’ve never really thought about that before, but yes, it is just another layer that makes your job be pretty hard.
Dr. Craig: And it’s a strange reality of psychiatry that we spend a lot of time trying to convince people something’s wrong. It feels so. It’s like you have bipolar 1. Like, well maybe that was just one time. No, like that was a manic episode. Your grandpa was manic, your aunt was institutionalized. [00:55:00] This is a thing. And they’re like, no, I don’t think I have it. That’s the bread and butter of psychiatry trying to convince people.
A joke in psychiatry is if you’re worried that you’re psychotic or getting psychotic, you surely are not. You have OCD or anxiety, but if you are psychotic or getting psychotic, you probably have no idea. You think other people are not fine but you’re fine. It’s really sad. Again, it makes trying to convince people… it’s an easy sell when you tell people don’t do meth, when you say don’t smoke weed, they look at you like you’re an alien. Like, what do you mean? And why are you putting that in the same sentence with meth?
Dr. Sharp: Yeah. It does seem bizarre, but when you lay out the numbers the way that we have, it makes a lot more sense. It’s not the weed used to.
Dr. Craig: It’s not [00:56:00] your mama’s weed.
Dr. Sharp: Yeah, exactly. Well, one of the questions that I wanted to ask you is, is there maybe harm reduction model of smoking weed or a moderation model where if somebody does like, just really want to, I love getting high, I don’t like to drink, is there an option? Not that we’re advocating that people dab but….
Dr. Craig: I think that’s really important.
Dr. Sharp: Yeah. Is there an option that could be better?
Dr. Craig: Yeah, much like my drinkers who will admit, yeah, there’s definitely a problem, but I don’t want to quit. With them, I’m always, Please drink beer, drink wine. Wine and beer because you’re at risk of utter chaos is much lower with those compared to I’m a hard liquor. And so for my people who are at significant risk of decompensating into psychosis or mania with weed but are not willing to stop, I use this comparison. I’d say, look at [00:57:00] fewer alcoholic and you didn’t want to quit drinking, I’d say drink beer. And so, whatever you do, don’t use pure THC. You want to use high CBD, low THC. From the dispensery, you want to go and say, give me the lowest THC high CBD that you can find, whether it’s edibles or flour. And that’s a good start because again, CBD has some real balancing homeostatic properties.
I have some percentage of people who will buy into that. If they’re saying, okay, I do you want to keep using and there’s a part of me that maybe believes Heacock, that maybe my dabbing led me to be in jail, so maybe I’ll try. I’m all about harm reduction because it’s so hard to go from doing a lot of whatever to not doing it at all.
Dr. Sharp: Oh, sure.[00:58:00] Dr. Craig: It is a little bit easier sell to say, could you shift away from pure THC to lower THC- higher CBD products.
Dr. Sharp: Yeah. That’s fair. And I guess in that way we are fortunate and in most states where it’s legal, there’s a choice, right? Maybe you could opt-in just like you can opt into the more risky strains and versions. Well, what else is important to talk about here? Is there anything that I haven’t asked that was in your talk or you feel is worth chatting about before we wrap up here?
Dr. Craig: I don’t think so.
Dr. Sharp: All right.
Dr. Craig: I think I said it all. I brought all my nuggets, and I threw them on the table. That was it.
Dr. Sharp: That’s great.
Dr. Craig: Maybe the last thing, if any of this was interesting to you, as Jeremy [00:59:00] said, I have a podcast Back from the Abyss, which is mostly a psychiatric storytelling podcast, but also there are episodes where I’ll give a talk on some topic where I’ll sit down with an expert like Dr. Jeremy Sharp and talk about EDD. That’s coming out next week on my podcast. Jeremy and I talk about all things EDD, and ADHD, thanks.
Dr. Sharp: Yeah, and I’ll put in another plug for the podcast. It really is pretty amazing. The production level is significantly higher than my own, and it is a storytelling podcast, which is just a different flavor and really rich.
Dr. Craig: Yeah. Thank you.
Dr. Sharp: Yeah. Well, thanks for the time. This has been awesome to cover something we haven’t talked about here before and with someone who is such an expert.
Dr. Craig: Thanks for having me.
Dr. Sharp: All right, y’all. Thank you so much for tuning into this episode. Always grateful to have you here. I hope that you take away some information that you can implement in your practice and in your life. Any resources that we mentioned during the episode will be listed in the show notes, [01:00:00] make sure to check those out.
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