An International Collaboration between the Divisions of Child and Adolescent Psychiatry in Lithuania and Canada on Cannabis
By Prof Chris Wilkes, Division head of Child Psychiatry, Dept. Psychiatry, University of CALGARY, Canada; Dr Sigita Lesinskiene, Vilnius University, Lithuania
The Lithuanian Society of Child and Adolescent Psychiatry and allied professionals from the clinics of Psychiatry in both universities in Lithuania (Vilnius University and Lithuanian University of Health Sciences) organized a conference on June 3rd, 2021 entitled “Consequences of psychoactive substance use and the treatment needs for children and adolescents”. This topic is salient and timely in Lithuania; as the government is planning the legalization of the use of small doses of cannabis. Consequently, in order to protect healthy development and plan services in child and adolescent Psychiatry it is imperative to learn from other countries such as Canada, that have gone through the legalization of Cannabis recently.
Dr Sigita Lesinskiene, a Past Vice President of IACAPAP has extensive experience in international collaboration on advocacy and education and invited Prof. Chris Wilkes, also a former Vice President of IACAPAP, from the University of Calgary to give an update on Canada’s experience with Cannabis 3yrs post legalization. In 2018, at the IACAPAP Congress in Prague, Prof. Chris Wilkes gave a lecture on the challenges facing Canada with the new 2018 legalization of Cannabis use. In light of the COVID pandemic restrictions Dr Lesinskiene and Prof Wilkes thought this would be an ideal opportunity to organize a virtual update on the Canadian experience.
Dr Lesinskiene was aware that the Lithuanian Society of CAP needed to discuss this sensitive issue of legalization of Cannabis, so they wrote letters to the Ministry of Health and other governmental bodies advocating for more coordinated service integration to support youth with these dependence issues because of the associated co-morbidities. Dr Lesinskiene and colleagues emphasized that opportunities for continuous treatment for youth with addictions in Lithuania are significantly lower than for adults. In Lithuania minors intoxicated with alcohol and psychoactive substances are often treated in intensive care units at children’s hospitals. After the stabilization of a life-threatening condition, they are discharged to homes or care. However, relapse is common and when mental and behavioral deterioration occurs, they are often placed for 2-3 weeks at inpatient treatment units at the child and adolescent psychiatric hospitals. Nevertheless, treatment is often short, and outpatient care is fragmented and insufficient. Thus, the goal of the conference with an international speaker was to share experiences that can facilitate, strengthen interventions and avoid creating systems that obstruct the timely delivery of addiction services for minors.
Prof Wilkes during his presentation emphasized that the legalization of cannabis in Canada has polarized the medical profession because social and political policy is now dictating the medical usage of Cannabis for a variety of conditions, including psychiatric disorders. Currently there is no level 1 evidence, double blind control trials, that cannabis is indicated for the primary treatment of any psychiatric disorder. To the contrary, we have evidence that early use is associated with later addiction and the development of psychosis in vulnerable youth as well as worsening of anxiety and depression in some youth. A UNICEF study in 2013 revealed that the prevalence of use over a year for Canadian teens was around 28%, the highest of 29 countries. A study by the WHO in 2016 revealed a prevalence rate over the last 30days was 13% for 15 year olds but overall 20% prevalence for 16- 24 years of age.
The Ontario CAMH 2012 study of teens in grade 7 to grade 12 was around 20%. It is estimated that 37% of high school students in grade 12 in Ontario are using Cannabis. A Deloitte survey in 2016 estimated that an additional 17% of the population will try Cannabis if it is legalized. The availability of cannabis in our society at present is a direct result of the aggressive marketing by some companies and complicit involvement by some well-meaning but misinformed medical doctors about the selective role of medical cannabis. In fact, the deloitte survey reveals that this is going to be big business representing a $22.6 Billion market potential in Canada. This should not overshadow the importance of avoiding its use among vulnerable groups such as children, adolescents, pregnant women, and those with severe and persistent psychiatric illness.
Prof Wilkes emphasized that there is no doubt that cannabis has been used for thousands of years around the world for the treatment of pain and the induction of euphoria as a welcome relief from the painful demands of life. However, the medical role of cannabis is quite specific and includes pain relief, especially in certain cases of arthritis, multiple sclerosis and as an adjunct to treating chemotherapy induced nausea. Additionally, the decreased opioid death rate in some states that have legalized cannabis speaks to the role of harm reduction strategies for opioid addiction using legalized cannabis. Now the legalization of cannabis has promoted welcomed research evaluation of cannabis use in medicine, especially of the differential roles of Tetrahydrocannabinol (THC) and Cannabindiol (CBD) in conditions such as intractable epilepsy and anxiety, but we are still waiting for that data.
Although the decriminalization and increased availability of medical cannabis is good for some Canadians, this is not a benign substance, and it needs to be strictly regulated. The brain does not have alcohol receptors, but it does have cannabinoid receptors which are intimately involved in the brain and immune system. Cannabis plays an important role in our stress regulation and reward systems. Early use risks impairing our neuro-development, neural plasticity and therefore our ability to learn. Legalization of cannabis without careful regulation risks increasing its availability for the most vulnerable populations in our communities, homes, schools, work, and other public places. The social, medical, and legal systems need to work carefully together for the benefit of all Canadians.
Prof Chris Wilkes emphasized that overall in Canada there has only been a 2% increase in Cannabis use since legalization. Canada like other countries has been impacted by the COVID pandemic and the increasing use of Alcohol, Opioids, Crystal meth and other psychedelics when people are in lock down. However, services in Calgary have evolved over time to a more trauma informed and neuro-developmentally sensitive approach to addictions. Heavily influenced by the adverse child events literature and the work of the Harvard Child Development centre that promotes an eco-bio-developmental perspective. This work clearly show that trauma gets under your skin, an ACE score of 4 or more can double the risk of cardiac disease and Lung cancer and is associated with a 700% increased risk of becoming alcoholic. All this knowledge has led to cross ministerial collaboration with Child Welfare Systems, Justice, Education, health and Non-Government organizations to ensure a spectrum of services available for children and youth with addictions. Services are now looking at these patients differently, with the question of what has happened to you and how can we help, rather than the traditional approach of what is wrong with you and using a more punitive approach. However most public addiction services only involve a short term residential placement with outpatient follow up and are associated with frequent relapses; whereas some private organizations in Calgary have a 2 year treatment program with better results. Clearly when it comes to the legalization or decriminalization of drugs in our society, we still have a lot more work to do and child and adolescent mental health professional have an important role to play in these discussions.