Guest: Dr. Kevin Gray – Psychiatrist
Host: Dr. Linda Austin – Psychiatrist
Dr. Linda Austin: I am Dr. Linda Austin and I am interviewing Dr. Kevin Gray, who is a psychiatrist at the Medical University of South Carolina. Dr. Gray your area of interest and expertise is a fascinating one, which is marijuana use and the treatment of marijuana abuse and this is an abuse in teenagers. Let’s talk about the treatment of marijuana dependence and abuse. I know that you own take on this is that you start with the pediatrician. Of course, many pediatricians they may or they may not be comfortable with new treatments. How does one go about treating marijuana abuse and dependence?
Dr. Kevin M. Gray: Well, I will begin by saying that this is a topic we need a lot more information on. Thankfully in the last decade, there has been a lot of good behavioral treatment research in terms of treating adolescent, who are dependent on marijuana and again primarily behavioral treatments seem to be the best evidence base we have and a variety had been tried many of which are similarly modestly effected meaning that some people are able to quit, but not all are ready to quit similar to cigarettes.
Dr. Linda Austin: Does the teenager need to be motivated to want to quit? What if they are dragged in by their parents?
Dr. Kevin Gray: That’s a key element of treatment and it’s a really, really difficult thing to do and I will tell you clinically I have had very few kids, who present of their own volition saying, ?I need to stop using marijuana.? Almost always it is someone else, be it a family member, be it a friend, or be it a police officer, who has given them good reason that they need to quit.
Dr. Linda Austin: So, let’s imagine that you were talking to that youngster. Let’s imagine, it’s a boy 16 years old, who has been using marijuana every day. Where would you start with? What would you say to him?
Dr. Kevin Gray: Well the first step in evidence based treatment that we know at this point is actually called motivation enhancement therapy. What you really have to do is - I talk about it like a scale and you sort of say - well you have on the one side of the scale weighing down all the good things about marijuana for you and then we talk about what sort of this counterbalancing? What’s on the on the other side of the scale that may be setting you back, may be troublesome with marijuana, and we try to evaluate both of those signs and of course I have a bias in that, I want to show the patient, the adolescent that those bad things are outweighing the good things.
Dr. Linda Austin: So, what are some of those bad things that you would point out to the youngster?
Dr. Kevin Gray: Sure. We often make the mistake of saying, ?Well this is going to hurt you in the long run.? You are going to be in a lot of trouble when you are older and you are still smoking this marijuana. Really, have to get it to here and now with teenagers and so the things that I really find hard to begin with or saying, oh gosh legal consequences. Talk about how immediately if there are caught, how significant and harsh the legal consequences can be it just for possession, both legal and with schooling. They may be expelled from school if they are caught within at school talking about those potential drawbacks that could happen here and now and today. In addition to that, then we talk about cost, saving money, talk about relationships with positive fears and talk about any relationships that may have dissolved because they are spending most of time smoking marijuana.
Dr. Linda Austin: Do you find that these youngsters have much insight or awareness of how marijuana affects them?
Dr. Kevin Gray: It’s interesting because to some extent they are very knowledgeable about high and the specific about what they like about it and their knowledge is specific to the good things and what’s interesting to me is that I will have numerous patients, who have told me that marijuana makes me concentrate better and actually if I smoke marijuana before I go to school, I do a better job in school. In that case, often times they have had actually get their report card and track their report cards over time and show as they have been using more marijuana clearly their grades have been dropping and that kind of confrontation sometime is very key and sort of saying, ?I know you like the high and I know you like the way it makes you feel, but the evidence is not supporting that it makes you concentrate better in fact its quite the opposite.?
Dr. Linda Austin: So, what happens then in the treatment? Let’s say the teenagers say well I don’t know may be you know, may be I will think about it. What do you do then?
Dr. Kevin Gray: Well, thinking about it is a good progress and what I do with that thinking about it, I take it and run as I - you get to that point and if you can just get them to come back to the office to the next time or come back to the school where you are providing and wherever you are providing treatment if you can get them to come back and at least half part of the engage with you, you have made big progress and from there you start working on refusal skills. So, how do you go to a party and be around friends, who are smoking and you are okay with saying, ?You know actually guys I really don’t want to use this time.? How do you handle withdrawal symptoms, how do you handle cravings without using.
Dr. Linda Austin: How do you handle cravings?
Dr. Kevin Gray: Well, it’s much likely we teach cigarette smokers and for anybody, who smoke a lot of cigarettes they have experienced cravings distraction, chewing gum, doing something with their hands, staying dizzy, and also just avoiding those situations where you are most attempted. People crave a lot more when they are around people, who are using or they are around pretty familiar with the smell of marijuana. So, evocative when people smell it, wow, they really want to smoke marijuana.
Dr. Linda Austin: So, you have to avoid it. Now, cigarette smokers will tell you that a year after they have had their last cigarette. They still want to light up, not all, but many will say that. Do you hear that also with marijuana smokers?
Dr. Kevin Gray: Yes we do and not with all of them and I would say not with all cigarette smokers either, but we do with some. Some people are very prime to like marijuana and it stays with them.
Dr. Linda Austin: Are there medications that can be used to treat marijuana addiction?
Dr. Kevin Gray: In theory, there is a lot of potential in that area. In terms of what we know so far is very little. There have been some studies of some medications none of which have actually shown any effects. Particularly, studies have focused on treating withdrawal syndrome and there have been studies with. I believe Bupropion which is also known as Wellbutrin there has been one with naltrexone, which is also called ReVia. There has been one with Serzone, which is the brand name for nefazodone and actually there has also been another one with divalproex sodium or Depakote. None of them seem to have a significant affect on the withdrawal syndrome or say, but there is an interesting new class of medication that is on the horizon that affects the endocannabinoid system.
Dr. Linda Austin: In what of these medications, I guess I should first ask what is the endocannabinoid system?
Dr. Kevin Gray: Well, and this is a really, really fascinating area and something that for me and makes research into marijuana so fascinating is that we have this whole system of what we call endocannabinoid. So, we actually have the active chemical in marijuana, we have small amounts of similar chemical in our system and that system seem to modulate a lot of different things that we do it modulates metabolism, it modulates good feelings, depression, anxiety, and it touches on a lot of things, but we are quite sure about this specifics of it, but there are medications that are being developed to target blocking some of these endocannabinoid receptors and these medications are primarily being developed to help with weight loss and potentially also with smoking sensation.
Dr. Linda Austin: So, let me see if I can translate that into a simple visual image. If you think of these endocannabinoid as chemicals that may be a like little keys and they fit into locks that are on the cell membrane surface in the brain and then the marijuana actually are also like a little keys it happen. Coincidentally to fit into the same locks and signal to turn on certain things in the cell will have to do with a lot of the same feelings that you get when you smoke marijuana is that right like whether you are anxious or whether you are serene, you are appetite those kinds of things is that very necessary.
Dr. Kevin Grey: Absolutely, in the class of cannabinoid receptor blockers, what they would do if we continue with the lock and key, analogy is what these receptor blockers do is sort of like I don’t hear a recent prank of kids that put super glue into the locks of the school, you know, they could access that’s locks and keys. So, basically with this does is insert that super glue into those receptors and so, if you smoke marijuana gets in your system; it doesn’t hit those receptors therefore you don’t get the affects. That is in theory. There has been one study that shown, that taking of these blockers and then smoking marijuana, it does block the affects, but that’s all we know at this point.
Dr. Linda Austin: Very fascinating, we will look forward to seeing recruits of your research efforts in years to come.
Dr. Kevin Gray: Thank you so much.
Dr. Linda Austin: Thank you very much Dr. Gray.
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