Medical Cannabis, THC and mental health explored – Part 3

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

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

You can click here to read ‘Medical Cannabis, THC and mental health explored – Part 1’ and ‘Medical Cannabis, THC and mental health explored – Part 2’ if you missed either. In part 3 below, you’ll find the final part of audience questions to the panel and their answers.

Hannah Deacon
So we have a question here talking about a clinician who seems to be prescribing sativa strains for daytime and Indica strains for night-time because there may be a thought that they are more sedating but it is very difficult because actually those terms are not really true.

It’s about terpenes and myrcene for example, which is sedating, but that isn’t always the case so I think it is again about the clinician in my opinion. Clinicians are still learning a lot about those strains and there’s not a whole lot of information for doctors sometimes about what terpenes are in there. 

So why is that happening? Or is it again because we just look at this learning still and you’re trying to find what’s right for people?

Dr Niraj Singh
You’re absolutely right Hannah, it’s still work in progress. We’re still learning all the time.

It’s much more about the terpenes and understanding them better. As we get more evidence about the effects of specific terpenes we know that they are significant. 

I think of the analogy between CBD and THC and how it’s like the accelerator and the brakes. Then the terpenes are like the steering wheel of the car. So that shows the significance that they have. 

And flavonoids as well – we say we don’t know about that but flavonoids are important. When it comes to the cannabis plant we’re barely scratching the surface.

Hannah Deacon
I think you’re absolutely right. There’s been a big focus on CBD and THC – rightly – because that’s what we’ve known, but terpenes play a big role in the medical effects on people and that’s really really important. 

It’s about moving away from that terminology and as you say, looking at terpenes and flavonoids and trying to understand how that might make people feel. 

Dr Niraj Singh
Exactly and I think that will happen eventually. We will be seeing the patient and saying well actually these are the symptoms they have, they have difficulty with pain, you know anxiety, problems with sleeping, and doctors will be saying what I want is something with this much more terpene or X and Y and this this will happen as we get to learn more.

And the same with the cannabinoids themselves. So obviously we have THC and CBD, but we’re learning about other ones like CBN, and CBG and all these acronyms but as these get start to get isolated more, the benefits of those kind of concentrates of particular cannabinoids, and positive effects of those get known.

Hannah Deacon
Thank you. And so we have another question for Pious here. How did the Community Mental Health Trust respond to the knowledge that he was starting a cannabis medication scheme? Were they supportive?

Pious
No. Initially, they actually threatened to go to social services because they were saying that they thought I was placing myself at risk and I didn’t know what I was doing. And then I ended up meeting with two doctors, the whole shebang. 

We then very quickly decided that I did know what I was doing, I was able to make my own decisions. They weren’t happy, but I think at the same time they weren’t able to offer me any help. I think we ended up writing to my GP, and my GP wrote a very strongly worded letter. 

At the end of the day, it’s a legally available medication. I’m seeing a psychiatrist who has my best interests in their heart. Yes, I live with a mental health issue. But I don’t think that necessarily makes me an expert in my own mental health issues. 

And I think that’s why I trust a psychiatrist, who has my best interests at heart, and is going to prescribe things that they feel is safe for me rather than me just choosing whatever.

To me it’s really important actually, that that is an element of control. The doctors taking charge of that – they weren’t happy but also, they couldn’t really do anything.

Hannah Deacon
What’s the difference between black market cannabis and prescribed medicinal cannabis?

Dr Niraj Singh
It’s so variable what you get on the streets – patients themselves will say that to you. And that’s one of the reasons which leads them to get medically prescribed cannabis, they just don’t know what they’re getting.

 They do get symptomatic relief sometimes, but sometimes they don’t at all, and it’s so inconsistent. 

Medically prescribed cannabis has to go through the good manufacturing practice – the GMP – so it has to be processed in a particular way. What one gets on the streets could be adulterated with heavy metals, pesticides, microbes, all sorts of different things. 

And the main thing being that actually you don’t know quite what’s in there, really. 

So from that point of view, although the plant may be originally, you know, the same from the cannabis plant, the processes of production are obviously vastly varied.

Hannah Deacon
I think you’re right. And I think it’s really important for it to be clear that when doctors talk about prescribing medical cannabis, it’s about as you say, the safety, it’s about ensuring that we know where it’s coming from all those sorts of things.

We’re not saying it’s a different plant. We’re just saying that it can be a very different experience, when you buy black market to when you buy a private prescription. And we need to know that we’re going to be as safe as possible, especially people with chronic illness and children, for example. So thank you for that answer. 

Are you involved in any research Dr Singh, and if so, can anyone be referred to you?

Dr Niraj Singh
Indirectly through Project 2021 yes. But this is something of real importance and something that’s always on my mind is actually –  we need to really build the evidence base. We really need to do that and as clinics we do need to do that. As clinicians we need to do that, particularly as we get to see more patients and we’re seeing these outcomes. So it’s something that’s always on my mind. 

I was conscious of speaking to a colleague across the pond who said that when they started off many years ago, that one of the things that they regret not having done, is start to really crunch the numbers and do much more of that kind of research aspect. 

The will is there, sometimes the time isn’t and that’s one of the issues. But hopefully, you know, we can get a group of like minded people who are willing to really pick the mantle and do more research. We know we’re not going to get double blind, placebo controlled studies in this area. Naturalistic open label studies, case reports, real world evidence –  that’s what we need to build on.

Hannah Deacon 
Here’s a question from a patient who’s been self medicating for 20 years and he’s a Cancard holder but still can’t afford to have a prescription. 

Do you have any particular advice for people who need cannabis but can’t afford it?

Dr Niraj Singh
I mean, first and foremost is to understand what is the reason that they’re taking it for? And what extra support do they need? Because for me, it’s very much around the prescription, but actually, the lower the amount that somebody can take, the better. 

So what are the other additional things that that person has, that they can benefit from? Be it through the health system or other sorts of other areas?

Do make inquiries. I think the nice thing is that not even not so long ago, we were having a very restricted range of products in this country. And as time goes on, we’ll get a wider array of products coming through even more. And hopefully, that will then bring costs down even further. 

That’s what I would really like to see. I think the country has a real opportunity – it’s been one of the biggest exporters in the world. 

There’s a real opportunity here, and not a lot of work that is going into actually trying to change that. It’s a bit like turning an old tanker around, but ultimately the benefits are really there for the country, for the pace of the economy, and hope for pricing as well.

Hannah Deacon
What makes a consultant doctor more qualified in describing medical cannabis compared to a GP? Should GPs be allowed to prescribe?

The family doctor at the end of the day is more close to the patient but GPs are only allowed to prescribe under direction. So the consultant has to initiate the prescription and then a GP could continue the prescription like you do with any other NHS prescription.

But it’s about getting that funding on the NHS, and also about legislation. 

Dr Niraj Singh
I think they should be able to actually. Lots of GPs have particular interests and different areas. So some may specialise in areas around otology, or even mental health. So they might have specific interests now. But you’re absolutely right Hannah – they can continue prescriptions, but only with appropriate training. At the end of the day it’s primary care – the first line – where people go to. 

That’s where a majority of people who struggle with depression and anxiety go to first, so why not? Why shouldn’t they have the opportunity to prescribe? 

They absolutely should – I’m keen for that. And again, it’s back to education, expanding the numbers of clinicians who are able to prescribe.  

I think, in this territory, none of us are experts, we’re all learning along the way. I’ve mentioned before that I learned as much from many of my patients, they teach me all the time. I know about mental health problems, but a lot of my patients are experts by experience, so they know what’s helped them, and they can teach me, and they can let me know. 

And, you know I’ve amassed so much knowledge, just from spending time in consultations, listening to their words of wisdom. There needs to be a much more open mind in this arena, really thinking much more about what kind of clinicians can be there – maybe not just doctors.

Hannah Deacon
Pious, do you think if your GP could have prescribed that that would have made your situation easier for you?

Pious
Yeah, I think he was quite upset that he actually couldn’t.

I think it’s very important that GPs can do that because they have an extensive knowledge of your entire health from childhood until adulthood, and I think actually, GPs are the best suited people to be doing that. 

GPs see you more on a regular basis. They know your health inside and out. And I think really It’s important to monitor that because the way I see cannabis is that it’s treating a system rather than a specific symptom. It just happens to help those symptoms.

Hannah Deacon
What do you think of the potential of micro dosing with THC for mental health conditions?

Dr Niraj Singh
Yes, some of my patients actually do, and it’s very much subjective. And again, it comes back to that idea of subjective therapeutic dosage. 

Some individuals do just need very, very, very tiny amounts of medical cannabis. And, you know, if that works for them, and they’re able to function, and they have a good quality of life. Absolutely. I’m very supportive of that.

Hannah Deacon
Thank you. Right. I’m going to do one more. And then I’m afraid we’re going to have to say goodbye. But thank you so much. We’ve had over 50 questions. So I’m sorry, we haven’t got through all of them. 

At the moment, things like vaporizers are relatively unheard of, what are your thoughts on the development of cannabis related technology that could make medicinal cannabis more mainstream?

Dr Niraj Singh  
It’s an interesting one, actually. So I think in North America, they’re much more ahead of the curve, aren’t they in terms of delivery modes. And I think we will be seeing much more – in this country, obviously, oil and flowers at the moment, but I think there will be a time where we’ll be seeing more edibles, creams, nasal sprays, etc. 

And I think we are looking towards some sort of vape cartridges as well. 

I think there’s huge scope. People do express a preference for certain delivery modalities. And I think technology will expand. I’m a total tech dinosaur, so I haven’t really gone into that area,  but certainly I think we are going to see it expanding over the next few years.  

Hannah Deacon
Thank you so much to Dr. Singh for joining us. Thank you to Pious, thank you to wonderful Gillian who’s behind the screen. They’re doing the moderating and we’ve had over 50 questions this evening. So I think we better do another one of these because it’s obviously very popular! Thank you to LYPHE Group, our sponsor this evening.

Thank you to Lyphe for putting forward Dr. Singh to come and speak this evening. Thank you so much you’ve been really interesting to listen to.

End of Part 3 – You can click through to read ‘Medical Cannabis, THC and mental health explored – Part 1‘ and ‘Medical Cannabis, THC and mental health explored – Part 2’ if you haven’t yet.