Addiction Medicine Made Easy | Fighting back against addiction
Addiction is killing us. Over 100,000 Americans died of drug overdose in the last year, and over 100,000 Americans died from alcohol use in the last year. We need to include addiction medicine as a part of everyone's practice! We take topics in addiction medicine and break them down into digestible nuggets and clinical pearls that you can use at the bedside. We are trying to create an army of health care providers all over the world who want to fight back against addiction - and we hope you will join us.*This podcast was previously the Addiction in Emergency Medicine and Acute Care podcast*
Addiction Medicine Made Easy | Fighting back against addiction
Wait… Weed Does That??? The Cannabis Side Effects Nobody Warned You About
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The story we’ve been told about cannabis—safe, simple, and mostly benign—doesn’t match what we’re seeing at the bedside. Two ER-turned-addiction doctors pull back the curtain on how high-potency products can quietly undercut psychiatric meds, complicate procedural sedation, and nudge recovery off course even when everything else looks better. This isn’t a panic piece; it’s a practical guide to staying safer and getting more from treatment.
We start with psychiatry and a pattern that’s easy to miss: chronic cannabis use can upregulate ABC transporters along the gut, liver, and blood-brain barrier, pushing certain antipsychotics and mood meds out of cells faster and blunting their effect. What looks like “noncompliance” may be pharmacology. We talk through which agents lean on these transporters, which alternatives may perform better, and how to have a stigma-free conversation that protects trust while fixing the plan.
Then we roll into the procedure room. Heavy cannabis use can decrease sensitivity to propofol and other sedatives by altering GABA activity and endocannabinoid tone, often requiring higher doses and tighter monitoring. Add a lesser-known risk—post-propofol hypersalivation in frequent users—and disclosure becomes a safety tool. We share exactly what to tell anesthesia, what clinicians can prepare for, and how to keep airways protected without surprises.
Finally, we examine the “Cali sober” idea through data, not dogma. Large cohort studies link cannabis use to higher rates of alcohol recurrence and new substance use disorders over time, especially with potent concentrates. We cover why potency and pattern matter, how cannabis can dampen the gains of CBT, MI, and contingency management, and what a realistic harm reduction path looks like when abstinence isn’t the first stop. Throughout, we keep language careful—reported use, not admitted; return to use, not relapse—because words shape trust.
If you care for patients, care about someone in recovery, or care about your own health, this conversation offers a clear framework: ask better questions, match meds to biology, and align goals to protect progress. Subscribe, share with a colleague or friend, and leave a quick rating to help others find the show. What did you learn that changes your practice—or your plan—today?
Link to State by State Alternatives to California Sober: https://www.mcsweeneys.net/articles/local-alternatives-to-california-sober
To contact Dr. Grover: ammadeeasy@fastmail.com
New Music, Mission, And Guest Intro
SPEAKER_01Hi, I'm Dr. Casey Groove. I spent years practicing emergency medicine before shifting my focus to addiction medicine. This podcast grew out of caring for patients, hearing their stories, and wanting to do better. Here we talk about recovery, medicine, and compassion. This is Addiction Medicine Made Easy. This episode is on cannabis, and maybe we'll call it the Hidden Dangers of Cannabis, because I have a guest with me today, and as you will hear, he is way smarter than I am, and he taught me a ton about cannabis that I didn't know. My guest is Dr. Andrew Rizzo. He's an emergency medicine and addiction medicine doctor like me, and he works on the East Coast in academic medicine, meaning that he works to train doctors in addition to his job taking care of patients. And he reached out to me that he wanted to do an episode on my podcast about cannabis. And go, Dr. Rizzo, he did his homework and came very well prepared for the episode. This episode has three parts. How cannabis makes psychiatric medications not work as well as they normally do, and scary thought, it makes other medications not work as well either. We also cover how cannabis can cause unexpected medical conditions and how I'm just using cannabis, but I'm still sober is a lot more dangerous than people realize. And a quick science alert before we start. And if you are not a medical provider, don't worry. Dr. Rizzo and I use tons of big words that make sense to the medical providers, and then we summarize all the points we make in terms that will make sense to you. A few quick items before we start. This is the first episode with new music at the beginning and the end. Let me know what you think. And thank you so much to everyone who has left me reviews. I see the number of ratings climbing on both Apple Podcasts and Spotify. If you haven't left a review yet, it's as simple as just tapping on the number of stars that you see on your Podcatcher app and leaving me a rating. So with that, let's get started. All right, good morning, my time. Good afternoon, your time. Let's just start with who you are and what you do.
Cannabis Today Is Not Yesterday’s Weed
SPEAKER_00Well, thanks for inviting me, Dr. Grober. My name is Andrew Rizzo. I've spent the last 15 years as an emergency medicine doctor. I would consider myself a forever emergency medicine guy at heart, but over the last couple years, my world has shifted to this beautiful chaos from working in the public health care system of New York City to some of the deeper, slower work of addiction medicine that I now do mostly in Connecticut. I've dedicated my life to medical education, and selfishly, it does bring me a lot of joy as a physician. I find the exponential power of educating and being a mentor means that I can have a really positive impact on so many patients across the country after training over 50 residents and fellows. And I truly love evidence-based medicine. I think my residents would describe me as an EBM nerd, and I do think being a passionate nerd is something the world needs more of. I've taken the love of emergency medicine from my roots at South Brooklyn Health, and I've transitioned it to my Addiction Medicine Fellowship director role at an ASAM-designated 3-7 facility called High Watch in Kent, Connecticut, where I get to apply evidence-based medicine, MAT harm reduction, to the world's oldest 12-step addiction treatment center. So this really allows me to see both sides of addiction medicine from my early roots to where I've landed.
SPEAKER_01So from one addiction medicine, evidence-based medicine nerd to another, welcome.
SPEAKER_00Thank you for having me. I'm really excited to be here. I've listened to your podcast for years. And I was driving home one evening, and after a really rough shift, I was thinking to myself, what happens when addiction medicine is actually not made easy? Because oftentimes I leave the hospital or I leave my detox facility and I struggle with some really challenging cases and patients and outcomes. And that's when I decided to reach out to you. So I'm not personally in recovery, but I will say that I've watched firsthand over and over again how substance use disorder has destroyed the health of my patients and the downstream damage to family, community, and the strain it puts on our healthcare system. I really hope that this conversation gives a lot of insight to not only your listeners, but maybe to their family, to their friends, and maybe even bring in some new listeners if we talk about some things we haven't talked about in the past.
SPEAKER_01I appreciate you calling out the name of my podcast that yes, addiction is not always easy. Where that comes from is you and I both are our core and our histories in emergency medicine. And the thing I loved about emergency medicine is it was all about getting to the simplest, most efficient way to think through a problem and doing that. My very lovely and lifelong partner and colleague, Dr. Reb Close, who I'm married to, she used to be a succinyl choline person. And I remember being like, Why would you use succinylcholine? And she looked at me and she said, What do you mean? I said, Use rock uronium. There's only one contraindication: allergy to rock uronium. And ever since she switched. So that's my ethos here in this podcast is we can take a very complicated topic, but make it as simple as we can to give you a framework to think through what you're doing the next day at work. So we were going to talk about cannabis today, and my public speaking teacher in high school told me that you should always lead with your take-home points. So I'm assuming the take-home from cannabis is it's a benign drug with no major issues, and it's okay when people use it, right?
SPEAKER_00And I think a lot of issues that we see on a regular basis in addiction medicine and across all areas of healthcare hopefully could be better explained with some take-home points. But really, if we want to hammer down one take home take-home point before I hit these three different vignettes from three different areas of addiction, I think the most important take-home point is communication is everything. And that's communication from the side of the provider, and that's communication from the patient and their family. I think cannabis, although it's becoming normalized in society, there's still a very huge stigma that is carried with it. And oftentimes our patients will not tell us about the amount of cannabis they consume because either A, they don't think it's a big deal, or B, they don't want to be judged from that level of that medical provider and patient relationship. So I think the one thing anyone, if you're gonna stop listening right now, just listen to this one thing is please communicate about your cannabis use to your medical provider, and please, as a medical provider, ask the right questions.
SPEAKER_01So I this is an audio podcast, but I just have to say your face when I said cannabis is a benign drug and everyone should use it, just this kind of the color went out and then the long pause. So, yes, I agree. Cannabis is absolutely not benign. We can argue whether or not it used to be. But my message when I say anything to patients about cannabis, because I don't want to put them on the defense, there is a lot of belief that it is medicinal, is that cannabis is not cannabis and the cannabis has changed. And I try to honor people who maybe used it medicinally 20 years ago, and we can argue whether or not that's true, but just that we have to view it differently in 2026. And I usually lead with that so they don't feel like I'm attacking them. I'm just trying to open the lanes of conversation.
SPEAKER_00I'd like to tell my patients that it's not cannabis as the major issue in regards to the negative response society has been seeing. It is potency is the problem and education is the cure. So I truly believe that the genie's out of the bottle. I without getting into too much of a cultural conversation, I think cannabis is going to be with us in the United States for forever. But we need to educate our patients, their families, and we need to potentially deal with some of the potency concerns that might be leading some of our patients in the wrong direction.
SPEAKER_01So you did your homework in preparing for this, and you prepared us three domains within cannabis that you wanted to go over: some of the mental health complications and issues, some of the medical complications and issues, and then how cannabis affects recovery. Where should we start?
Case 1: Psych Meds Blunted By Cannabis
SPEAKER_00Yeah, great. I would love to start with the psychiatric side of cannabis use disorder because I do think this is a major issue, if not one of the most pressing issues that we've been dealing with in healthcare. Uh, and so I'm gonna use three vignettes. I made up three patients with my age so that there's no crossover. And with that, we can hopefully get into some really interesting educational conversation that will make all of us hopefully better at the end of this. Let's do it. Awesome. I'm gonna start off with a 41-year-old male. He is a history of cannabis use disorder and schizophrenia. He presents to the emergency department for agitated delirium, right? This is something that we see a lot, right? His partner states that he's compliant with his psychiatric meds, but after heavy cannabis use, he will develop these manic episodes, and they typically lead to hospital visits and psychiatric admissions. He takes three milligrams of Risfordone daily. And his partner does mention that after he's stabilized in the hospital, he comes home, he's slightly improved, but really never returns back to baseline. I I bring up this question maybe to you is what's happening with this patient, and how can we as medical providers do something different to help this person?
SPEAKER_01I I just want to share with our audience, if you're not familiar with schizophrenia, in my humble opinion, it's one of the most devastating illnesses that we treat in medicine. Just the inability to really understand reality, particularly with paranoid schizophrenia, constantly seeing things and hearing things that aren't there. And my heart goes out to these people. I had this moment of Zen, and this is a little off topic, but I'll bring us back. I was working in the emergency department, and a lady came in on an involuntary hold, and she had, in her view, seen a drug cartels henchman attack someone. And so she called 911 and was expecting like a military response to come save this person. And law enforcement got there and there was nothing, and it was regrettably her paranoid delusions. And so they brought her to the emergency department and she was like, Why am I here? I needed a SWAT team. And healthcare providers always feel like they're making it up or they're lying. And uh, anyways, I'm getting a little ranty here. But yes, my heart goes out to this person because a lot of my patients with schizophrenia, they tell me, I hear the voices, I want them to stop, and I try a substance. Maybe if I drink enough alcohol, the voices will go away. Or gosh, if I use methamphetamine, maybe maybe they'll stop. So I totally can understand this person's attempt to use cannabis as a way to manage very unpleasant mental health symptoms. But cannabis, as the potency has changed, it's different. And I think you know more about psychopharmacology than I do. So let me give you my understanding. We, for some reason, in our brains have a receptor site where the chemical in cannabis that makes us high, THC, binds. My understanding is it's probably some evolutionary thing where plants wanted to not be eaten by animals. So they created a chemical that made the animal feel sick or weird, and then the animals wouldn't eat it. But we're human. We like altering our sensorium, so we thought it was cool. THC naturally does not bind very well to those receptors in the brain. They're called CB1 and CB2. Because of that, traditional cannabis, which was weak, didn't cause a lot of mental health symptoms. And you and I can probably remember when we were medical students, when the synthetic cannabinoids came out, K2 and spice, they were molecules that bound at the cannabis receptor better than THC, and they cause loads of mental health symptoms. As the potency of THC goes up, the THC just overwhelms the CB1 and CB2 receptors, leading to all sorts of untoward mental health symptoms. And in someone without mental illness, that manifests often as paranoia or psychosis, or so-called cannabis-induced psychosis. But just your look there of you have some incredible fact that you're going to drop on me means I probably missed some of the picture there. So, what did I miss?
SPEAKER_00You know, it's funny is that I was not going to use the word CB1 or CB2 receptor during our conversation, or I didn't plan on it, even though we both know that the CB1 and CB2 receptors are the main receptors for the endocannabinoid system and those exogenous stimulants like THC is something that will stimulate those receptors. However, what the vignette I'm trying to describe is something that I think we see numerous times in the emergency department and in my detox unit. And it really is something a little bit deeper than just the THC molecules. And this has a lot to do with what's called the ABC transporter. So the ABC transporter is a family of molecules. There's about 40 of them, and they're considered P glycoprotein molecules that bind to all of these different cell membranes. And we mostly find them in the liver, GI tract, and along the blood-brain barrier. Now, when we consume cannabis, there is a surge of dopamine and glutamate. These can give us that mania. They bind to the CV1 receptors that could also increase hallucinations, whether visual, auditory, or paranoia, that all just plays a role. But my concern, and this is why I really wanted to talk about it, is really based around the ABC transporter. And the reason this is my concern is because there are so many medications that depend on this transporter. And so what happens is when we use cannabis chronically, these transporters will change, similar to how someone develops tolerance to any drug of abuse over time. And so when we're using or when a patient is using cannabis chronically, these transporters are essentially all being interacted with. When you've been using cannabis chronically, you develop something called upregulation. This upregulation is when there's more receptors being built on this membrane. And then what happens is the bouncer of the cell now pushes everything out way quicker than it used to. So that rispidone, three milligram dose that patient was taking to help control his schizophrenia symptoms, it's not going to work anymore. Because Risperdone is one of many psychiatric medications that depend almost exclusively on the ABC transporter. And then when we admit these patients and they get stabilized in their hospital, often with other medications, and they get sent home on the same Risperdone, they are going to continue see seeing that decompensation in their psychiatric status because of the fact that those upregulated ABC transporters is is going to continue to push the medication out of the cell. Thus, the patient will no longer feel the benefit or see the benefit of their antipsychotic meds.
ABC Transporters And Antipsychotics
SPEAKER_01I love the fact that I had to go to school for eight years to be able to converse with you. Let me see if I can break this down for the non-clinicians that are listening. So essentially, cannabis affects different parts of our brain in different ways. We talked about how the drug in cannabis THC is intoxicating and it can promote mental health symptoms. But you're saying that cannabis itself changes how we process medication, meaning that over time our brain actually doesn't respond to medications as well because we're on cannabis. Did I get that right?
SPEAKER_00Essentially, that is correct. And we call this pseudo-permanence. So what happens is over a long enough time period, our bodies want to go back to default mode, right? And by removing cannabis long term, we are going to decrease that previous upregulation of those receptors, and we'll eventually work our way back to the default mode. But the problem with cannabis or cannabis use disorder is oftentimes our patients don't give it enough time to go back to default mode. So the cycle just continues. And this is where we see people being labeled as either non-compliant with their psych meds, even though they might be taking their psych meds, or they're just labeled as decompensated schizophrenia that people are saying, oh, they need to be institutionalized or they need to be long-term admissions or they need to be pulled from whatever other community or society that they've been involved with. And ultimately, it's really our job, our responsibility as healthcare providers, particularly those in the world of addiction medicine and psychiatric medicine, to look at what meds they're on and see which ones will not utilize the same ABC transporter.
SPEAKER_01Do you think patients need to hear this little factoid more, or healthcare providers need to hear this little factoid more?
SPEAKER_00I think it's a pretty even split between patients and their families and healthcare providers because you know what? Every family who's involved with a patient suffering from addiction, particularly cannabis use disorders, mom and dad are listening to the podcast and they're dealing with their son or daughter who's struggling with cannabis use, but also been diagnosed or labeled as someone with mental health issues on some of these medications. But it's really, I think, their responsibility also to bring these concerns to their psychiatric provider. Because I'll be honest, I think a lot of my peers do not fully understand this concept. And that's really why I wanted to talk about this as one of several teaching points.
SPEAKER_01So you made an interesting point, which is that not all meds go through this transporter. Is there a list of just from a harm reduction standpoint, my patient's not going to give up cannabis, but I need to treat his or her mental illness. I'm going to switch from med A to med B.
SPEAKER_00Yeah. So I have a couple meds off the top of my head that I can think of that would be affected. And I do apologize. Some of them are the trade name, not the generic name, but I will say so Risperdona is one of the main ABC transporter players. We have things like Sericoil or Quitiapine. We have Abilify. And some of the newer psych meds, like Vrailar and Rick Sulti, like these are all medications that really heavily lean on the ABC transporter. And unfortunately, some of the oldest meds are the ones that don't really depend on that transporter. So things like haloperidol, lithium, and even to some extent a lanzepine or zyprexa, which is a very mild utilizer of the ABC transporter, like those are typically the meds that actually a lot of these patients respond best to. And unfortunately, the problem is they also have their own side effect profile. So this is where the importance of the patient, their family, and the provider all sitting around and talking about the particular cases that they're dealing with as the best decision of what medication to potentially switch someone to. Because the worst thing that we could take out of this vignette is saying, hey, I should not be on my respiratory. So this is why, like having this open dialogue with everyone is the best way to keep a patient who suffers from cannabis use disorder and a dual diagnosis of mental health disease safe.
Harm Reduction Med Swaps And Stigma
SPEAKER_01Yeah, I'm gonna bring in some evidence-based medicine here. We talked about a paper when we met last week, and I apologize for the salty language, but it's in the title of the paper, Drug and Alcohol Dependence in 2023. I still partly think this is bullshit, a qualitative analysis of cannabinoid hypermesis syndrome perceptions among people with chronic cannabis use and cyclic vomiting. I covered this paper on my podcast previously, but this is a paper looking at something similar, right? People are getting an adverse reaction to their cannabis in terms of whether it's mental health worsening. In this case, it's this cyclic vomiting problem from cannabis. And what they found is that when healthcare providers went to talk to them about their cannabis use, no one asked, why do you use? Do you understand how this could be a thing? And what can we do to help you with the thing that you're using cannabis for, whether it's pain or anxiety or insomnia? So give me an example of how you might sit down with this patient that you've laid out for us and have that conversation around I I think we probably need to change your meds. I need you to stay on your meds, but I think you also need to reduce your cannabis use.
SPEAKER_00This study that we're that you're talking about is also one of my favorite studies, and I love qualitative research. And as an EBM nerd, I I truly believe qualitative research is actually the future of a lot of really good quality addiction medicine research. So anyone who's listening to this that is in the world of research, please do more qualitative addiction medicine research. I will definitely be reading that. Anyway, yeah, autonomy is what we're bringing up. Like a patient autonomy is so important. And I think in the world of addiction medicine, when we take away that autonomy from a patient, it really can disrupt and or even break our provider and patient relationship. And so what I've changed after reading that paper, actually dealing with some challenging interactions either in the emergency department or in my detox unit is really by saying, hey, look, I think this might be what is going on, whether it's cyclical vomiting from cannabis hyperemesis syndrome, or just you have really bad gastritis with a hiatal hernia and irrital bowel syndrome that hasn't been fully diagnosed. And I will offer you all the resources for you to follow up and try to get better and just feel good about yourself once again. However, I really think going on to some online resources, some groups, whether that's Reddit or Facebook group or anything else, there's a community out there for essentially everyone who's suffering from something addiction related and read about it, read about other people's experiences and say, maybe is that me? Does that sound like me? And by empowering our patients by doing their own research and trying to figure it out themselves, it shows them that we care about them. One, two is it allows them to make their own diagnosis. And then three is when they're ready to come back to us, healthcare providers, whether that means for an endoscopy, a metal colonoscopy, or whether that means for a refill of their capsacin cream, that's a rub on their stomach, they're gonna trust us because they're gonna know that we're not stigmatizing them and that if anything, we're trying to empower them. And so that's a huge point, also. So for the listeners, that's I think our number two point to really take home is empower our patients and obviously avoid any type of stigmatization.
SPEAKER_01So we were gonna go on to the second case on medical issues. Anything else on cannabis and mental health that you wanted to bring up? It's a huge topic, but anything else before we move on?
Case 2: Sedation Fails And Saliva Floods
SPEAKER_00Yeah, a little quick final thing about this vignette is that if mom and dad or grandma-grandpa takes their THC edible before bed to help them sleep, just remember all the other medications that also might be interacting with this. So whether that's their warfarin for their AFib or for their valve replacement, whether that's their antieleptic medications, their birth control, their cardiac meds, or even chemotherapy agents, these all interact. And all you need to do is go online and search cannabis pharmacology interactions with drugs, and you're gonna find a plethora of information that will hopefully empower you to either talk to your doctors or healthcare providers about changing meds or having those conversations about maybe stopping using cannabis if you feel like it's causing a negative outcome to your other meds.
SPEAKER_01You just gave me chest pain. That is insane. Speaking of medical complications from cannabis use, let's bring up the second case.
SPEAKER_00All right. So we have another vignette. This one's more focused on the medical side of addiction in the realm of cannabis, right? So once again, that 41-year-old male he presents to your emergency department. He's got a shoulder dislocation. And looks like he's gonna need some procedural sedation and pain medication to reduce it. He weighs 80 kilos, he has normal vitals, there's no other medical concerns, he's alert, he's oriented, he's cooperative, right? You order some propofol, which is a sedative hypnotic medication. It's made famous due to Michael Jackson-related issues, if some of the listeners remember that, and some IV pain medications. We consented him for the procedure. We have him on monitor, we have a nurse ready to go, right? This seems straightforward. And I know, Dr. Grober, you've spent a lot of time in the emergency department. This sounds like a potential vignette that you've been through before.
SPEAKER_01Yeah, I prided myself as an ED physician on actually being able to reduce shoulders without procedural sedation. But yes, absolutely. You do a couple of good-face attempts, they're too much pain. The next step is procedural sedation, and propofol absolutely was my go-to.
SPEAKER_00Okay, I totally agree with you. Definitely try to use minimal meds for sedation to put that shoulder back in, but every once in a while we do need to use something a little bit stronger. In this vignette, we give a dose of propofol. So for the listeners, the average or the standard dose for procedural sedation for propofol is typically about 0.5 to 1 milligram per kilogram IV push. The medication kicks in pretty quickly, I'd say in about 60 seconds, and it lasts about 10 minutes. Give or take a couple minutes. So it's the perfect medication to get someone really sleepy and have them wake up in a pretty short time period, and we can make sure we can get them safely home. Now, in this vignette, though, I'm gonna give someone a 0.5 milligram per kilo per kilogram IV push dose and the patient's fully awake. I'm gonna give another 0.5 milligram per kilogram dose and the patient's still awake. And next thing I'm giving two milligrams per kilogram of IV push of this very powerful medication that can easily over sedate someone that can lead to things like them stopping breathing or needing to be intubated and put on a ventilator, all things I do not want to do to this patient in my ER.
SPEAKER_01It's funny you bring this up because I had to have an endoscopy two years ago. I was chief of staff at the hospital at the time, and my vice chief of staff, now chief of staff, was an anesthesiologist, and she sits down on the bed, she's hey buddy, I'm gonna do your sedation. She and her question was, how much do you drink? And I told her I do enjoy red wine in the evenings. And I had actually learned a similar question when I would sedate people, as I'd be like, Look, no judgment here. The propofol affects everybody differently. Do you use any sort of illegal substances? What's your alcohol use like? But since we're talking about cannabis, something tells me there's a connection here with cannabis that I didn't know about.
Propofol, GABA, And Endocannabinoids
SPEAKER_00Yeah, so the concern here is that cannabis is affecting how our bodies are absorbing or metabolizing the probofol. And to go back to the vignette before we we hit a bunch of teaching points is once we finally get this person sedated, what we'll notice is that their mouth is just full of excessive saliva. And that requires a lot of suctioning. And that suctioning is something, if not immediately addressed, can lead to things like aspiration or choking on the saliva, right? If you're sedated and you're sleepy and your mouth is being full of saliva, you definitely have to worry about a choking aspiration risk for sure. So now the patient wakes up, right? After you put the shoulder back in, everything actually went okay. And then he admits that he's a heavy daily cannabis user. So to go back to your original question, what happened? Why is cannabis causing all these problems? We should go start with the pharmokinetics of protofol, right? And so the pharmacinetics of propofol are very interesting. It hits many receptors in the brain, but really mostly on the GABA receptors. And it is what is considered a PAM or a positive allosteric modulator, which is very similar to phenobarbital for those who work in addiction medicine. And what that means for those who don't work in addiction medicine or healthcare is that it doesn't bind directly to the GABA receptor. It binds very close to it and it changes how it responds to other types of stimuli. And because this binding occurs, it allows for sedation and a level of amnesia so that the patient doesn't remember what procedures they went through. Now, the problem is when we use cannabis heavily and daily, we actually have noticed that cannabis can bind to the GABA B subunit. So this is one of five different subunits that are found on the GABA receptor. And that GABA B subunit is found in the hippocampus and other parts of the brain. And when that binds to it, it actually downregulates or decreases its response to things like propofol. This is a major concern because now we need to give a much higher concentration of propofol to get the same benefits as someone who is cannabis naive. And when the procedure is done and the pain and everything has resolved, we often worry about how sedated a patient might be. And that is a also a major concern because if I've given you 300% more propofol than the average person your weight, I am now have to worry about you being over-sedated. I have to worry about potentially you losing your airway or choking on your saliva. And I now have to increase my concern in regards to your recovery process in my otherwise busy ER.
SPEAKER_01Let me see if I can translate. I feel like I need an extra year of school to talk to you about this one. So we talked about in the first vignette that cannabis changes how our brain absorbs and retains some medication. But you're also saying that cannabis interacts with parts of our brain that makes medications work differently. So it's basically a second way in which cannabis affects how medications work in our body. Is that right?
SPEAKER_00That is correct. And there's going to be there's a third way and there's a fourth way too. So we could keep going down this pathway. And I will tell you that there's something called it's anandomide, right? And I think you've talked about this on previous podcasts. A E A. Anandomide is our endogenous endocannabinoid molecule. That when we talk about a runner's high and we talk about feeling good after you work out or something, those endogenous cannabinoids that are being released are typically from anandomide. And what's interesting is that probofol will also bind to some of our other molecules within our endogenous cannabinoid system. And that alone can also cause this double hit where our bodies are not getting the same sedation as we normally would if we didn't use cannabis on a regular basis. So our patients that are using cannabis on a regular basis, now they're dealing with not only this issue with the GABA receptor, but also an issue with the fact that their endocannabinoid system has been uh dysregulated over time. And because of that, now there's two reasons why propofol is not going to be as effective.
SPEAKER_01Let me ask a question here again. Oversimplified ER doc question. So the way I often describe things like post-acute withdrawal syndrome to my patients, which is where a person stopped a substance, they've gotten through the acute withdrawal phase, and all their brain chemicals are just trying to figure themselves out. Insomnia, anxiety, unstable mood. It's like throwing a rock into a pond, right? So the rock lands in the pond and it pierces the surface of the water, and that might be the single receptor pathway that the drug acts on, but there's ripples. Right? So, in other words, those ripples involve affecting the other receptor systems. So you might use alcohol, which affects two specific receptors, but it also affects your serotonin and your mood and your dopamine and your pleasure. Now, another analogy, if you've ever been to an air show like with the Blue Angels, is like all five of them streak across the sky and they release a chemical so you can see their path. Is the way I'm thinking of it in my mind, is it more that cannabis is it's like a big stone that really ripples out and affects everything else? Or is it more like an at a strike system where it attacks like five different receptors all at once? Is that a decent analogy or not so good?
SPEAKER_00It's a decent analogy, and I actually really like the the stone hitting the pond analogy because I think it's a call for more research in addiction medicine because we started off addiction medicine, it's a relatively new field, right? It's a relatively new field in the grand scheme of healthcare, and we started off just focusing just on where the rock hits the pond, right? That's been a major focus from the very beginning. But really, to truly take care of patients and the complexity of addiction is we need to focus on those ripples. We need to look at how far these ripples go. And by focusing on these ripples, we can give the best care possible to our patients. So this is why I love addiction medicine, and this has allowed me to transition so seamlessly from emergency medicine to addiction medicine is that the search, the constant search for new information and to better understand and do a better job, allows me to chase those ripples from where the rock hit the pond. And I totally agree with you. Like the amount of receptors and the amount of dysregulation that we see, not just with cannabis, but almost every drug, is way larger than what we initially thought. So it's not a simple one drug, one receptor, one problem, right? I wish it was.
Managing Hypersalivation And Procedure Safety
SPEAKER_01You know what I'm almost putting it together in my mind as we've had this conversation about cannabis is that the molecules in cannabis are complicated enough in how they interact with our brain that it's actually both. It's like taking five rocks and throwing them into a pond at the same time. And cannabis works in different ways, and there are so many ripples that interact. Does that seem like what we're talking about in terms of the uniquely complicated relationship that cannabis has to our brains?
SPEAKER_00Definitely. And I think that also goes with how we have to have conversations with patients who are withdrawing from not using cannabis, right? And I say, because people use cannabis for all types of symptoms, when we withdraw, we take the cannabis away from a patient, or we have them stop using it, or they stop using it, you're just going to reverse all of that. So everybody's pond is different and all those rocks are scattered in all different directions. And one patient's going to have a different withdrawal symptomology versus another patient. And I think that's why it's our job to really address all of the little areas along the pond and how we can help manage a patient and their family through those challenging times. I totally agree with you.
SPEAKER_01One question about language you used, a big passion of mine is stigma. And I think all of us in addiction medicine really want to reduce stigma. You mentioned after the sedation, he admitted to using cannabis. An admission almost sounds like he's at fault. Would a different word like he reported using cannabis be less stigmatizing?
SPEAKER_00Yeah, I think the way we talk to patients in the world of addiction is really important. And whether we're talking about urine drug screens and the words around that, or whether we're using the word a return to use versus relapse, these are really important. And I do think that sometimes our jargon or the way we talk to patients will affect them negatively, and it's usually accidental. I think it's almost always accidental. No one, nobody wants to purposely give a negative experience to a patient or their family just based on something that we say. However, uh Yeah, I also think patients often hide for their cannabis use because they don't want to be labeled as a quote unquote drug user or suffer from substance use disorder, because I often think patients really just want to get good care and they're worried that there are people out there in healthcare that won't give them good care when they do admit to using, right? And I'm using the word admit because oftentimes a patient does feel like it's a secret that they have to let out.
SPEAKER_01Yeah, one of my colleagues in emergency medicine, Dr. Rod Rojas, I was reading his charts after seeing a patient that he had seen and then came back later and saw me. He used the term politely declined instead of refused. And I was like, you know what, Rod? Well done. So I started doing that. Just in the interest of time, because we've got one more vignette to get to, anything else on some of the medical complications from this case vignette?
SPEAKER_00Yeah, we didn't really even talk about the hypersalivation concerns. So there is a there's a clinical presentation called chat. And although I do love a good medical acronym, I'm not a huge fan of this one. And it stands for cannabis-induced hypersalivation after propofol. I know we could do better, but it is what it is. Yeah, we'll take it. You're right, you're right. We'll take it. And this is essentially a paradoxical autonomic surge where your cholinergic outflow to your salivary glands go unchecked after getting propofol. And this is essentially the opposite of dry mouth. So we know that with cannabis use disorder, a lot of patients will complain about a dry mouth. And this is essentially the opposite. I don't want to call it wet mouth because that just sounds strange, but we could call it the opposite of dry mouth for now and figure out what to do with it. But this is just overall just a really important thing to talk about because if anyone's going to go for a procedure, whether that is a knee replacement, a shoulder reduction, or an endoscopy, by telling the anesthesiologist, by telling your medical providers that you've been using cannabis on a regular basis, can help prevent this hypersalivation issue from occurring and ultimately keep you safer, right? And that's our job is to keep our patients safe. I would agree.
SPEAKER_01I'll be darned. Off to run this by some of my anesthesia colleagues. I just texted my group of addiction docs, three of us are emergency physicians. I did not know this was a thing.
Case 3: “Cali Sober” And Cross-Relapse
SPEAKER_00Actually, all the evidence, actually, most of the evidence has come out from the Pacific Northwest, so or from Colorado over to the West Coast. And that's because when legalization in the Pacific Northwest and Colorado and California occurred, the GI actually, the GI doctors or gastroenterologists and anesthesiologists are the ones that were noticing this. And so case reports were coming out as far back as five, 10 years. But really, it's something we still just don't talk a lot about in addiction medicine. But it's just something that's so important. But yeah, anesthesiologists are definitely picking up on this, and there's a lot of evidence that's coming from our anesthesia colleagues. Um yeah, we can move on to the final case, and this is actually one of the most challenging cases, and this is like the addiction recovery perspective vignette, right? Once again, that 41-year-old male presents to your office, Dr. Grover, and he was originally dealing with opioid use disorder, alcohol use disorder, and he said, Look, I want to be absent. I want to get off of everything. So after several months of using MAT, MOUD, different different levels of therapy and education, you're able to get this 41-year-old off of opioids and alcohol, and he's feeling great. He comes back to your office and he says, Hey, Dr. Grover, I am doing amazing, but I also started this new lifestyle. It's called Cali Sober. Right? So, how do we in the world of addiction medicine respond to this? Should we celebrate it as saying, hey, congratulations, that's harm reduction. I am so proud of you. Keep doing this as long as you feel like it's allowing you to live your best life and be productive and be happy, or do we really push for some abstinence, or is there something in between?
SPEAKER_01I told you about this funny list of all the different states of sober. I'll send this to you and I'll put it in my show notes. But California's sober, no alcoholic drugs except marijuana. New York sober, no alcoholic drugs except cocaine. Kentucky sober, no alcoholic drugs except a cool, tall mint julep on a sweltering July afternoon. Oregon sober, no alcohol that's not uh an IPA. Texas sober, no alcohol except beer cans to shoot. Maine sober, no addictive drugs except lobster rolls. It goes on for all 50 states. Ironically, we here in California do not call it California sober. Yeah, this is a tough one. I was just trying to look up my friends at the Addiction Medicine Journal Club. They did an episode on this, which really shows that when people bring in uh cannabis, there is an increased risk of relapse, return to previous use, and a decreased ability to stay in treatments. I think how I look at it with my patients is I have the I can get you sober and keep you sober group, I have the harm reduction group, and I have the I can just be kind to you because you're not ready for treatment at all, but when you are ready, I'm here group. I think this falls somewhere between group one and group two. For my patients that I really want to keep sober, I'm gonna say let's not do that. But for somebody who was using fentanyl and was homeless and in and out of jail, and they're willing to work with me to at least monitor it and see it's not escalating, I would reluctantly, from a harm reduction standpoint, be willing to work with them. What's your take?
SPEAKER_00I think as the expert, you nailed that and agree with everything you said. Um, but we can go through some of the evidence that's behind this. So, what we're really talking about is something called cross relapse, right? So this is when a A patient comes in to a either office, a detox facility or hospital setting, and their drug of choice is not cannabis. But what they do is they start using cannabis, and then there are some concerns that this will actually bring them back to or return to use to whatever their primary drug was, which often is the one that's been a little bit more destructive to their life from the start. And this evidence really does come from multiple large-scale longitudinal studies. So the first one I found that I thought was really interesting is out of Columbia University. This was a study published in drug and alcohol dependence in 2016. It looked at 27,000 adults. And it found that individuals with a history of AUD who use cannabis were five times more likely to experience a recurrence of their alcohol use disorder compared to those who abstained from cannabis. And they looked at this over, I think, a three-year period. So it was a good chunk of time where they were able to follow a lot of these adults. And it does give us a lot of insight to say that we should support and respect our patients who are able to get off of way more dangerous drugs like IV fentanyl, methamphetamines, and things like that. But we do have to take a look at it with a very cautious eye. And this is maybe a patient that you want to come back to the office more frequently for follow-ups, just to make sure that they stay on the right track, or just maybe give them as much educational information as possible to hopefully redirect them when they're ready to maybe redirect and cut out their cannabis use. There was also a really interesting study. It was out of JAMA Psychiatry in 2016, also. And this looked at 34,000 participants. And basically it said that baseline cannabis use was a significant predictor to develop a new substance use disorder within three years. So not just returning to use from an old like alcohol use disorder, but this is someone who's never had any other SUD that now has picked up a new use disorder after using cannabis for several years. So this is where we have to deal with focusing on the long-term health of our patients. And if cannabis use is going to lead them down to a new substance use disorder that might be even more detrimental to their life and their family, that is also a major concern. And then really, like it's about listening to our patients, really. At the end of the day, it's listening to our patients and making sure that they can find purpose and happiness in their life, right? Their goal of recovery is happiness and purpose. And although I work at an absence-based facility and I've seen so much success with 12-step absence-based care, I do have to recognize the patients that I'm taking care of that might not do as well in that same model. And that is why I look to find those and then direct them to so that they can find their own purpose and happiness, whether that's through M O U D or any other type of MAT, and make sure that their quality of life is at a level that gives them additional purpose.
Potency, Therapy Efficacy, And Follow-Up
SPEAKER_01I think the other part is, like we had said earlier, is that cannabis is not cannabis, right? If somebody's using one of these high potency preparations, waxes or dabs and they're getting 80% THC, that's going to cause a lot more problems than somebody who's consuming a THC edible at five milligrams at bedtime. And for most of my patients, if they're really insistent on using some sort of cannabis product, my usual ask to them is can it please be an edible? Because you can actually quantify the amount of use more. Because you and I both know it's very hard to figure out like I puffed for one second or I took a deep breath rather than a small breath. You just can't know how much THC you're getting. I do quantitative urine drug screens in the office looking at THC levels, but in talking to the lab, it's a combination of how much they've used over the last three weeks along with their use in the last few days. So somebody will have a big spike and they're like, oh, it's because I had an edible like before I came into clinic or whatever it would be. So I think it do you have any sense of the data of which cannabis use patterns are the most destructive?
SPEAKER_00I think that if your patient's backpack is making noise because their dab rig is clanking together, that is way more concerning than being on a like a high CBD to low THC ratio gummy that they take at night because of some poorly treated and managed PTSD. So like I definitely agree with you. Once again, potency is the problem, education is the cure. That will change a lot of these conversations for sure. I will tell you though, right? We we deal with so many patients that need and really depend on therapy, including CBT, motivational interviewing, contingency management. And in 2021, there was a study that came out of the American Journal of Psychiatry that actually showed people who use cannabis during these cognitive therapy type of treatments often were less successful in completing programs and often didn't take in as much in regards to getting long-term answers and treatment for the underlying issues to their substance use disorder. And this is really based around things like cognitive dampening and emotional muting, right? So cannabis can often cause this cognitive dampening. And when this happens, it prevents CBT and MET and CM from really allowing patients to get the full benefit from it. And although we don't have a ton of great studies on long-term cannabis use disorder abstinence or recovery, we do know that CBT and contingency management and motivational interviewing has been shown to be quite effective in across the board of the world of addiction medicine. And if we're not getting a full positive response because they're actively using cannabis during these sessions, I think that's another reason to be concerned as a addiction medicine provider.
SPEAKER_01Is that when you're getting therapy under the influence of a cannabis product or that cannabis products any use makes the therapy less effective?
SPEAKER_00Interesting. I don't, off the top of my head, I cannot recall in the method section if they're talking about patients who are actively using cannabis. I'm pretty sure the response to that study was the patients that are admittingly using cannabis on a regular basis, but I don't think they designate whether or not they're actively using during those sessions. But you can argue that with THC being so lipophilic and the fact that it stays in your system for so long, you might not be acutely quote unquote feeling high, but at the same time, it might not give you the same effect as if you were completely absent from cannabis for several days before your CBT or your MI therapy session.
SPEAKER_01I I just was wondering because I'm sure if you have three beers before therapy is not going to work as well either.
SPEAKER_00Yeah, totally agree with you on that.
SPEAKER_01Okay. So as we as we're wrapping up here, did we miss anything on this third vignette about cannabis affecting recovery?
Final Takeaways, Gratitude, And Closing
SPEAKER_00No, I honestly just had a really great time with you today, Dr. Grober, and I do have a tremendous amount of respect for what you do with this podcast because it takes a lot of time, dedication, perseverance, not only in the field, but also on your free time by putting in all this effort to educate patients, their family, and many people in the healthcare system that are dealing with addiction on a regular basis. I had a lot of fun, and hopefully you did too. And maybe that means we're gonna get to chat again about some new challenging cases in the world of addiction medicine. But I do want to thank my patients, my medical staff, my residents, my fellows, my family, my wife, and my four cats who constantly motivate me to be the best version of myself. Uh and I would love to end off on one of my favorite quotes, and it is by a poet, or he's a writer too, who actually suffered from significant alcohol use disorder, Charles Bukowski. And it is you begin saving the world by saving one man at a time. All else is grandiose romanticism or politics. And I thought, to me, when I hear that quote, I think this is exactly where emergency medicine and addiction medicine truly intersect. It's finding that one patient every day and really working with them on a one-on-one basis to create a curated level of care that brings them happiness, joy, success in the recovery process because we both know how damaging drugs and alcohol can be to our patients and to society.
SPEAKER_01They call it recovery because you get your life back. Thank you so much for listening to Addiction Medicine Made Easy. If you found this helpful, please leave a review. It really helps others find the show. And a huge thank you to Central Coast Overdose Prevention for supporting this podcast. And always remember tweeting addiction saves.