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Case Report

Medical Condition:Skin disorders

Description

Systemic mastocytosis and medical marijuana
Medical Condition
Skin disorders
Symptoms
Pruritus, flushing, nausea, vomiting, diarrhea, abdominal pain, vascular instability
Skin Disorders
Eczema
Abstract
A 21-year-old college student with systemic mastocytosis uses inhaled medical marijuana to relieve symptoms and gain homeostasis.
Patient information
Gender
Male
Age
18-24
Brief history and target symptomatology
Beginning in his teen years, this young man has had urticaria pigmentosa, allergy to multiple foods and food preservatives resulting in frequent flareups of abdominal pain, nausea, vomiting or diarrhea. Sunny, cold or hot weather could cause generalized arthralgia.
Previous and current conventional therapies
The patient still takes Gastrocrom (Cromolyn, a mast cell stabilizer) but believes that medical marijuana is the most important factor in his well-being. He carries with him at all times injectable epinephrine in case of anaphylactic reaction.
Clinical response to Cannabis
The patient's most frequent symptom is sudden bouts of gastrointestinal distress (pain, nausea, diarrhea). For the past 2 1/2 years, since he started using medical marijuana, he has had few flareups, when carefully avoiding known food allergens and other precipitants.
Additional Comments
This patient most likely suffers from the indolent subtype of systemic mastocytosis. The pathologic manifestations of this disease are the abnormal accumulation of mast cells in the skin, G.I. tract, bone marrow, and lymph nodes and the frequent association with hematologic disorders. A genetic (proto-oncogene c-KIT) mutation is usually detectable in the mast cells and their precursors. Symptoms are due to the release from mast cells of leukotrienes which are responsible for contraction of smooth muscles, stimulation of vascular permeability, and attraction and activation of leukocytes; these are three to four orders of magnitude more potent than histamine. Counseling, prevention of exposure to mast cell secretory stimuli and symptomatic treatment are the mainstays of current patient management.
Reference: Hartmann. K, Bruns,S and Henz,B: Mastocytosis: Review of Clinical and Experimental Aspects. Journal of Investigative Dermatology Symposium Proceedings (2001) 6, 143–147
Cannabis
Usual method of Cannabis administration
Vaporized
Frequency of Usage: Time Per Day
5
Frequency of Usage: Days per Week
7

Case Report

Medical Condition:Arthritis

Description

Dupuytren's Contracture resolves with topical cannabis salve
Medical Condition
Arthritis
Symptoms
Painful finger contracture deformity with palmar fascia and flexor tendon deformity
Pain Scale: Before Cannabis Use
6
Pain Scale: After Cannabis Use
1
Abstract
46 year old male carpenter with slowly progressing Dupuytren's contacture of his right 3rd finger was advised to try using a home made concentrated cannabis salve with an occlusive barrier (nitrile glove) at bedtime in order to reduce daytime pain. Patient returned one year later for his medical cannabis recommendation withnear complete resolution of the contracture.
Patient information
Gender
Male
Age
45-54
Brief history and target symptomatology
Several year progression of palmar fascia and flexor tendon contracture of the right third finger was making it more and more difficult for this patient to swing a hammer on the job. He was looking for a non-psychoative alternative for daytime pain relief. Exam found a classic thickened and deformed palmar fascia with firm bead deformities of the flexor tendon.
Previous and current conventional therapies
Massage, splinting.
Clinical response to Cannabis
Within several weeks of bedtime cannabis salve and a glove the contracture had nearly entirely resolved.
Additional Comments
Dupuytre's contractures may in part be due to upregulation of myofibroblasts. The endocannabinoid system has been described as a mediator of mesenchymal stromal cell immunosuppressive properties. http://www.ncbi.nlm.nih.gov/pubmed/24312195
Cannabis
Usual method of Cannabis administration
Topical
Cannabis strain (if known)
High THC/Low CBD strain
Frequency of Usage: Time Per Day
1
Frequency of Usage: Days per Week
7

Case Report

Medical Condition:Psychiatric disorders

Description

Harm Reduction: Alcohol Use Disorder, Cannabis-induced Psychotic Disorder and a tale of two Hemp Oils, in a Patient diagnosed with a Cluster A & B Personality Disorders in Long Term Behavior Therapy.
Medical Condition
Psychiatric disorders
Symptoms
Cravings and a strong desire to use alcohol, failure to maintain work, continuing to use alcohol despite having interpersonal problems worsen, other activities used for leisure stopped, alcohol use continued despite awareness of prior history of suicidal behavior and legal problems (incarceration secondary to DWI and assault of a police officer), tolerance, cannabis use, abandonment fears, unstable interpersonal relationships, emotional instability, impulsivity, suspiciousness, obsessive compulsivity, problems with attention and concentration, a history of sexual abuse and sexual acting out, pain secondary to breast cancer and a thought disorder.
Psychiatric Disorders
Personality disorder
Abstract
This case highlights the use of harm reduction approaches, motivational interviewing techniques and cannabidiol, in a person, diagnosed with cluster A and B traits - other specified personality disorder 301.89 (F60.89), personal history (past history) of sexual abuse in childhood V15.41 (Z62.810), obsessive-compulsive disorder 300.3 (F42), major depressive disorder 296.22 (F32.1) alcohol related disorder 303.90 (F10.20), Substance induced psychotic disorder with onset during intoxication (F12.259) and attention-deficit disorder predominantly hyperactive/impulsive presentation 314.01 (F90.8) who suffered severe psychosocial stressors and relapsed after over ten years of sobriety on alcohol and cannabis.
Patient information
Gender
Female
Age
35-44
Brief history and target symptomatology
The patient was in behavior therapy once a week for five years. The patient was in A.A. stable and progressing in treatment until a series of external events and her reaction to them destabilized her and she relapsed on alcohol and then cannabis. At the start of treatment she presented with subtle circumstantial speech. In session shaping was used to modify this behavior. Diagnostically, the patient looked like an old school borderline, not psychotic but seemly on the borderline of a thought disorder. The first destabilizing event was being diagnosed with breast cancer during engagement to a man she developed misgivings about. The patient underwent a radical mastectomy and reconstruction surgery got married and within a short time divorced. The divorce in turn triggered psychosocial stressors in relation to financial and emotional instability. During this time the patient was experiencing pain secondary to cancer and was placed on pain medication. The patient was on multiple psychotropic medications: Escitalopram Oxalate, Adderall and Zolpidem. The combination of the stressors, pain and psychotropic medications strengthened a prior maladaptive coping response, the detached protector, unconsciously used as a psychological defense to blunt emotional pain. In addition, the patient relationship hopped into a stormy relationship with a man during her separation prior to divorce. The situation became more unstable as the patient began having relationship problems in her new relationship and subsequent job problems then job loss. This triggered a dramatic period of turmoil in the patient from 2/25/13 to 7/15/13 during which time she was also in an outpatient substance abuse program to reduce the use of pain medication and psychotropic medication, at this time the patient stopped her sobriety of over 10 years, and eventually admitted herself for psychiatric hospitalization. The target symptoms of clinical interest was harm reduction: trying to stop drinking behavior and the use of cannabis in a person who is willful to stop despite some insight that alcohol use is suicidal behavior, as per history of psychiatric, medical and legal problems all alcohol related. Despite all of these symptoms the patient did come to every psychotherapy session, except when she was in an outpatient drug rehabilitation program to reduce pain and psychotropic medications, missing the last two scheduled appointments.
Previous and current conventional therapies
Behavior therapy -Motivational Interviewing techniques, Schema focused therapy, Cognitive Behavioral Therapy, Acceptance and Commitment Therapy, Dialectical Behavior Therapy, Behavior Modification), Pain management, Psychopharmacology.
Clinical response to Cannabis
Working with the patient psychotherapeutically she stopped alcohol use. Stopping alcohol use as per harm reduction was very significant as per suicidal and other self defeating behaviors. She was willful however, about stopping cannabis use. The challenge with the patient’s cannabis use is that she diagnostically had cluster A and B personality disordered presentation and had circumstantial speech, the effects of the cannabis, started to evoke more of a thought disordered presentation but still not psychotic one. Cannabidiol was recommended to the patient as a harm reduction intervention to reduce the chance of a psychosis developing. The patient was willing to try cannabidiol in the form of “drops” placed under the tongue. As per her willfulness I did not get specific with the patient as per dose and timing of dose with cannabidiol. I simply told the patient “this is good for you it will help you and you can’t kill yourself with it, the only thing I ask is that you use the cannabidiol every time you use cannabis and use your own wise mind to find a balance that works for you”. Within two weeks of pairing the cannabidiol with smoked cannabis she reported, a reduction in agitation, paranoia, and stopped acting out sexually in bars. In week three the patient reported a reduction in anxiety, and started to report a tremendous surge in reflective functioning, awareness of awareness. This change in reflective functioning was very beneficial to the patient, for example schema activation, became easier to spot and the patient was able to utilize these connections to reduce her use of pain medications (working with her pain management doctor), and make less self defeating decisions feeling more present in the moment then being in ones head (fused with thought), and felt more confident handling interpersonal situations. In week four of cannabidiol paired with cannabis the patient contemplates looking for work and is working on her resume. She continues to benefit from increased reflective functioning and is improving with emotional regulation, interpersonal communication and awareness of her own thought process (schema activation). Week five the is patient in awe of her insights into her thought process, reporting a reduction in impulsivity secondary to reflective functioning, her ability to attend to the external environment improved, she felt calmer and more organized in her thinking. Week six the patient reports that she is able to observe her own splitting or all or nothing thinking more clearly and how fast she turns, shifting from one psychological mode to another (vulnerable child, angry child, and undisciplined child). Week 7 a change is noted in session. The gains made in prior sessions appear to wan and the patient presented with an increase in thought disorder. Assessment revealed a tale of two very different hemp oils and speaks to the confusion surrounding this term. The patient read on the oral drop label of the cannabidiol the term hemp oil and secondary to her obsessive nature went on line and discovered the Simpson treatment and followed his method for hemp oil from cannabis. This hemp oil has far more potency, as per 9-tetrahyrocannabinol, in the liquid form. She reported that she could no longer afford cannabidiol and stopped its use. The patient was willful to stop using the Simpson treatment, despite attempts to educate and confront her willfulness. Week 8 the patient is using only the Simpson treatment. Despite her appearing high the patient still had the benefits of years of our treatment accessible to her and the increased reflective functioning, she reported and we worked on her profound insight, her underlying thought disorder. The patient disclosed that she was living in shame of stigma of being diagnosed with a thought disorder and a fear of medications that a prior psychiatrist had wanted to put her on. She revealed that “I used to say to myself this was my prior LSD use but now I can see its not and I’m aware and I’m sharing about it”. Week 9 the patient reveals that the disclosure of her psychotic process was very helpful although difficult to do and feels less shame. While these insights were extremely helpful to the patient’s overall future mental health her current functioning was more impaired secondary to the Simpson treatment. The patient was willful about stopping her use of the Simpson treatment despite increased relationship and work challenges. She reported that it’s as if “your brain ran at half speed and then you feel that you have your brains back”. Week 10 turns out to be our last session. Two more sessions were scheduled but the patient failed to show up. During our last session, the patient was less organized in her thinking, showing signs of persecutory delusions, and is less willful about stopping the Simpson treatment and more willing to restart cannabidiol as a mono therapy, seeing a psychiatrist or going in patient. I never see the patient again. Three weeks later I get a call from a psychiatric nurse at a facility hour’s away upstate. The nurse asked for clinical information about the patient as per our treatment, at the end of our conversation the nurse said, “the patient said it was very important, to tell you that “you have been a great help to her, she believes that between the psychotherapy and the CBD (cannabidiol), what ever that is, she now realizes that she does have a thought disorder and is willing to be assessed by our psychiatrists and that she would take an anti psychotic if recommended”. The psychiatric nurse was very intrigued by the patient’s presentation and the use of cannabidiol. “Up here (a rural part of the state) we don’t hear as much about new treatments what is this stuff, CBD, anyway?”
Additional Comments
What makes this case unique is the growth the person continued to experience even in the face of a developing psychosis. The relapse occurred within the on going context of behavior therapy and even as cognitive abilities became more disorganized other parts of her thinking showed more clarity and insight into her own cognitive functions when cannabidiol was introduced. Harm reduction had several goals that were accomplished. The first was continuing to treat the patient despite her willfulness to work with a psychiatrist, go inpatient, etc. Based on continuity of treatment, the patient became willing to stop using alcohol, which was suicidal behavior as per her history. Treating a willful patient who will not stop using cannabis and who diagnostically is in a population at risk for psychosis was the aim of the cannabidiol intervention. What worked was to tap into her willingness via motivational interviewing techniques that helped her to see that cannabis, despite the risk of psychosis based on diagnosis, was actually less harmful than alcohol as per her own history of assaulting a police officer, multiple DWI’s, sexual acting out and other self defeating behaviors. The next intervention as per cultivating her willingness was her agreeing to add cannabidiol when she was using cannabis. Clinically the goal of adding the cannabidiol was to reduce the probability of a psychosis. I was surprised to find that not only was a psychosis temporally avoided, but in addition the patient reported improvements in cognitive functioning, as per her attention and concentration, and increased reflective functioning which resulted in increased abilities to identify automatic thoughts and schema activation and use this knowledge in a goal directed manner. The patients self report of adding the cannabidiol to her cannabis use was dramatic in her positive descriptions of self states, seeing her role in interpersonal interactions more clearly, her thinking was more organized and she reported a reduction in anxiety. These positive experiences in the context of a strong therapeutic relationship combined with the cannabidiol increased insight and willingness to finally accept, while working through shame and feelings of defectiveness, that she did have a psychotic disorder and she admitted herself for psychiatric hospitalization and hopefully a change in her stance toward a different diagnosis and different psychotropic medication, just as was recommended to her so long ago. This case highlights the fact that the cannabis did not cause a healthy person to suddenly develop a psychosis rather the psychotic predisposition was already present in the patient.
I was completely thrown at first by the patient’s different presentation at week 7 when unknown to me the patient started using the Simpson treatment. The fact that cannabidiol can be derived from hemp and can be called hemp oil is a look alike problem with hemp oil that contains 9-tetrahyrocannabinol. Differentiation of these terms is crucial for a public that maybe naïve to the differences. The other related challenge, I deduced, is that the patient thought that the Simpson treatment was the same as smoking cannabis, obviously it is not. The dosing of the liquid Simpson treatment was like rocket fuel compared to bottle rocket used on the fourth of July. The patient with her predisposition for a thought disorder was a poor candidate for such a treatment. This is important in the medical uses of cannabis for non psychiatric conditions that may use high doses of liquid 9-tetrahyrocannabinol and strengthens my recommendation that a patient’s psychological health needs to be assessed prior to such treatments.
Cannabis
Usual method of Cannabis administration
Ingested
Cannabis strain (if known)
Oral liquid for sublingual adsorption called Dew Drops. Patient, secondary to contextual treatment issues of willfulness was encouraged to find here own level of use in the context of cannabis use for the purposes of harm reduction.Secondary to willfulness the patient’s ability to follow guidelines of use was much challenged. Motivational interviewing approaches were beneficial in stopping alcohol use and the start of cannabidiol. The patient was encouraged to find her own level of cannabidiol use. I believe that therapeutic communications that encouraged autonomy and belief in her as competent was beneficial in helping the patient gain influence over her own behavior, as clearly highlighted by the case. I stuck with the patient, didn’t judge her and as such taught her how to nurture and guide herself resulting in her not killing herself. Additionally over a difficult but short time she shifted into willingness, disclosing her shameful secret of having a thought disorder, admitted herself to a hospital for inpatient psychiatric care and was now open to different types of medical interventions anti psychotic medications.Secondary to willfulness the patient’s ability to follow guidelines of use was much challenged. Motivational interviewing approaches were beneficial in stopping alcohol use and the start of cannabidiol. The patient was encouraged to find her own level of cannabidiol use. I believe that therapeutic communications that encouraged autonomy and belief in her as competent was beneficial in helping the patient gain influence over her own behavior, as clearly highlighted by the case. I stuck with the patient, didn’t judge her and as such taught her how to nurture and guide herself resulting in her not killing herself. Additionally over a difficult but short time she shifted into willingness, disclosing her shameful secret of having a thought disorder, admitted herself to a hospital for inpatient psychiatric care and was now open to different types of medical interventions anti psychotic medications.
Frequency of Usage: Time Per Day
6 or more
Frequency of Usage: Days per Week
7

Case Report

Medical Condition:Adverse effects

Description

Congenital nystagmus improved by marijuana
Medical Condition
Adverse effects
Symptoms
Blurred vision related to nystagmus
Abstract
19-year-old high school graduate, works 30 hours a week as a cook in a cafeteria, wears corrective glasses for myopia, has congenital horizontal nystagmus in both eyes. Marijuana slows or relieves eye movements, improving vision and ability to read.
Patient information
Gender
Male
Age
18-24
Brief history and target symptomatology
Patient presented for first marijuana recommendation because of recent trauma to right wrist causing persistent constant pain. He has been using nonmedicinal marijuana since age 15 to relieve eye discomfort due to nystagmus. On examination, horizontal nystagmus OD>OS is confirmed, at a rate of 1-2 movements per second.
Previous and current conventional therapies
None.
Clinical response to Cannabis
Decreased eye discomfort and improved vision.
Additional Comments
References:
Very few peer reviewed. "Toxicology observation: nystagmus after marijuana use." J Forensic Leg Med. 2013 May;20(4):345-6. doi: 10.1016/j.jflm.2012.07.014. Epub 2012 Sep 1
Anecdotal: "Nystagmus Discussion Board: Treatments and Surgeries: Alternative Medicine: Medical Marijuana."

1.Nystagmus Discussion Board: Treatments and Surgeries: Alternative Medicine: Medical Marijuana. (Anecdotes.)
Cannabis
Usual method of Cannabis administration
Smoked
Frequency of Usage: Time Per Day
1
Frequency of Usage: Days per Week
7
Reported by

Case Report

Medical Condition:Sleeping disorders

Description

Marijuana helps narcolepsy
Medical Condition
Neurodegenerative disorders
Symptoms
Short episodes of daytime sleep attacks and poor sleep
Neurodegenerative Disorders
Unspecified
Abstract
A 32-year-old male, furniture mover of 13 years, found relief of daytime sleep attacks and experienced more restful sleep with marijuana.
Patient information
Gender
Male
Age
25-34
Brief history and target symptomatology
Furniture mover for 13 years uses marijuana for relief of chronic back pain, short sleep attacks in the daytime and unrestful sleep.
Previous and current conventional therapies
OTC medication for back pain in the past. Diagnosed with narcolepsy but refused conventional treatment in favor of marijuana.
Clinical response to Cannabis
Alertness throughout the day, ability to work steadily, restful sleep.
Additional Comments
Diagnosed with idiopathic narcolepsy, no history of TBI or other neurological disorders. Patient attributes effect of marijuana on REM sleep for the relief of his symptoms.
Reference: National Sleep Foundation. "For people with narcolepsy, sleep begins almost immediately with REM sleep and fragments of REM occur involuntarily throughout the waking hours. When you consider that during REM sleep our muscles are paralyzed and dreaming occurs, it is not surprising that narcolepsy is associated with paralysis, hallucinations, and other dream-like and dramatically debilitating symptoms. "
Cannabis
Usual method of Cannabis administration
Smoked
Frequency of Usage: Time Per Day
2
Frequency of Usage: Days per Week
7

Case Report

Medical Condition:Adverse effects

Description

Achalasia, status post myotomy
Medical Condition
Adverse effects
Symptoms
Postprandial cramps, frequent nausea, general dyspepsia
Abstract
About 2 years post lower esophageal sphincterotomy for achalasia, this 35-year-old female suffered from general dyspepsia associated with difficulty falling asleep. She used both inhaled and ingested marijuana daily in small amounts which relieved her symptoms without the need of additional medications.
Patient information
Gender
Female
Age
35-44
Brief history and target symptomatology
35-year-old female social worker, married, two teenagers at home, employed full-time. Underwent Heller myotomy for achalasia. Esophagram six weeks postop showed good distensibility of the esophagus, and quick emptying. Postprandial cramps and frequent nausea started in the postoperative period and continue 15 months postop.
Previous and current conventional therapies
The patient was treated with Protonix and Pepcid following Heller myotomy. She no longer takes those medicines and uses cannabis instead.
Clinical response to Cannabis
Relief of GI discomfort and of associated sleep disorder.
Additional Comments
According to NORML ( Main » Library » Health Reports » Recent Research on Medical Marijuana » Gastrointestinal Disorders): "Preclinical studies demonstrate that activation of the CB1 and CB2 cannabinoid receptors exert biological functions on the gastrointestinal tract.[6] Effects of their activation in animals include suppression of gastrointestinal motility,[7] inhibition of intestinal secretion,[8] reduced acid reflux,[9] and protection from inflammation,[10] as well as the promotion of epithelial wound healing in human tissue.[
Cannabis
Usual method of Cannabis administration
Ingested
Frequency of Usage: Time Per Day
1
Frequency of Usage: Days per Week
5

Case Report

Medical Condition:Psychiatric disorders

Description

The use of Cannnabidiol (CBD) and Meditation to reduce Binge Drinking, Anxiety and to improve Emotional Regulation in Long Term Behavior Therapy
Medical Condition
Psychiatric disorders
Symptoms
309.81 (Posttraumatic Stress Disorder), 301.83 (Cluster B Personality Disorder, Borderline Personality Disorder), 304.20 (Stimulant-Related Disorder, Cocaine, in sustained remission, 305.1 (Tobacco-Related Disorder, Moderate in sustained remission, 303.90 (Alcohol-Related Disorder, Severe, in early remission, 9 months), 300.4 (Persistent Depressive Disorder) V61.03 (Disruption of family by divorce).
Psychiatric Disorders
ADD / ADHD
Abstract
This case study focuses on the use of CBD within long term behavior therapy. CBD was used for harm reduction: reduce binge drinking and the associated emotional triggers of the addiction, anxiety and problems with emotional regulation. A very beneficial treatment sequence was revealed in the therapy, the initial use of CBD then the addition of meditation to form a treatment package which increased mindfulness and reflective functioning. This case shows that psycho education is an integral process of CBD initiation.
Patient information
Gender
Male
Age
45-54
Brief history and target symptomatology
The patient presented with distress in multiple areas of functioning, 8/16/2006. He was newly divorced, using alcohol, cocaine and tobacco and depressed and anxious. His patterns of use were masked by his working as an executive in a field related to the entertainment industry where substance use and abuse are common. Behavior therapy was conducted once per week for 45 minutes. Cocaine use was in early remission by 2007. A slight reduction in daily alcohol consumption occurred but alcohol binges, mood swings and interpersonal challenges continued for the patient in 2008. In 2008, the patient was willing to see a psychiatrist and was placed on Sertaline HCI (anti depressant) standing dose 200mg and Acamprosate (curb the urge to drink), which was poorly tolerated and discontinued secondary to side effects. Slight reduction in daily drinking continued no change was noted in binge drinking. Key events of 2009, the patient remarries. The patient was willing to try controlled drinking, trying to stop at two drinks in social situations and at home. Binge drinking continues. Therapeutic issues during 2010, birth of son. The patient is now able to use controlled drinking and remains willful about stopping alcohol altogether. An increase in overall emotional regulation is observed and the patient stops smoking tobacco. He has a binge on a work trip and gets into a fight with a hotel security guard for being intoxicated. The police are called and when the patient gets belligerent he is hit repeatedly by the police. All charges were later dropped. Events in therapy during 2011, the patient is willing to try exercise as an alternate stress reducer, continues to use controlled drinking on a daily basis and still has emotionally triggered binges which last 2-3 days, suicidal ideation with no plan and had painful withdrawal symptoms but the patient was willful about going inpatient. In 2012, the patient states in passing that he is longer working with a psychiatrist, his general practitioner continues the Sertaline HCI. However, he is now willing to stop controlled drinking and on a daily basis, abstain from alcohol. Binges, however, still occur based on emotional triggers. He had one binge that lasted four days and included a fight in a bar resulting in chipped teeth, facial abrasions and contusions, a black eye and severe withdrawal symptoms and suicidal ideation with no plan. The patient refused medical care all but for his teeth. It was at this point in treatment to target harm reduction; reduce binge drinking, anxiety and increase emotional regulation, the emotional triggers of binges that a trial of CBD was initiated.

Target symptoms: Harm reduction, the cessation of binge drinking, anxiety reduction and emotional regulation.
Previous and current conventional therapies
Long term behavior therapy including: Cognitive behavioral therapy, Acceptance and Commitment therapy, Schema Focused therapy, Dialectical behavior therapy, Functional Analytic psychotherapy, Relaxation techniques, and A-B-C functional analysis of drinking patterns. Pharmacological treatment comprised of Sertraline HCI, 200mg, Acamprosate, which was discontinued secondary to side effects.
Clinical response to Cannabis
Cannabidiol (CBD) was first introduced as a treatment option. The patient started oral drops on 1/31/13 to assess tolerability and efficacy. The CBD was well tolerated but no clinical efficacy was noted. On 2/21/13 the patient started 1 CBD pill (range 20-25mg) in the morning. The patient reported a slight reduction of anxiety, an increase in being more present in-the-moment (mindfulness) and a reduction in the urge to drink. Continued progress was made until a binge with suicidal ideation occurred on 4/3/13. On 4/24/13 the dose of CBD was changed from a standing A.M. dose to an as needed dose, based on emotional cues such as anxiety and the urge to drink. In the next few weeks the patient reported improved mood and no binges occured. Between 5/8/13 and 5/22/13 the patient runs out of CBD secondary to cost but returns to its use on an as needed basis. The patient has been continuing to exercise but aggravated an old injury in his shoulder secondary to an old bar fight. The patient compensates by following a prior recommendation, and begins a meditation class on 6/26/13. On 7/30/13 the patient reports “I guess I’m getting better”. The meditation class ends on 8/13/13 and the patient commits to maintaining the practice of meditation. Treatment continues with the patient until again the cost of the treatment of CBD is prohibitive. However, the gains he made from the window of time where CBD was started and then meditation added continue, he is more emotionally regulated, and has stopped the self defeating pattern of binge drinking. He is off alcohol completely and is now in early remission for the past 9 months.
Additional Comments
Psycho-education was an important part of the CBD trail. Psycho-education started off with introducing CBD as per the efficacy, side effect profile, methods of administration, the difference between THC and CBD, specifically that CBD will not produce euphoria, and providing a treatment rationale which allowed the patient to process his attachment to his doctor and his prior attachment to substances. For instance, the patient said, “Wow with my history I can’t believe you are recommending part of the Cannabis plant to me”, “the psychiatrist before this one gave me a benzodiazepine for sleep and I started abusing it”. The patient was provided with a study using CBD to reduce anxiety and instructed to look at the web site the CBD Project and to ask questions. The patient asked if he could share the article with his wife. He came back to the next session stating that he and his wife had read the study and looked at the CBD Project and felt in agreement that the profile of CBD looked much less harmful then Alcohol and anything else he had ever used including medications for psychopharmacology. Psycho-education was integral in shifting from a standing dose to use as needed and increased even more trust in the doctor patient relationship. The patient’s own negative attachment to himself (ambivalent/anxious) as per his impulse control and prior attachment to substances (preoccupied/attached) and to a concurrent style of attachment for safety (fearful/withdrawn) were all addressed therapeutically prior to starting CBD mono therapy.

CBD as a mono therapy then adding mediation/mindfulness training appeared to be a beneficial sequence of interventions and warrant future study as a treatment package. Behavior therapy, as practiced in this case study, has aspects of mindfulness in the treatment (Acceptance and Commitment therapy and Dialectical behavior therapy) and observable present states in the patient were shaped, however, the psychotherapy was not a meditation class. The CBD treatment may have acted as a precursor for meditation by increasing being present-in-the moment and reflective functioning, awareness of awareness, prior to meditation instruction. Thus, this patient benefited greatly by increasing the benefits of CBD with a skill set, meditation, that appeared to deepen the patient not fusing with thoughts and increased reflective functioning in a synergistic manner. While the patient could not afford to continue with the CBD treatment, he has maintained being more present in-the-moment and the reflective functioning and is continuing the practice of meditation. The patient and I agreed that as his economic situation improves he will go back on CBD.
Cannabis
Usual method of Cannabis administration
Ingested
Cannabis strain (if known)
Available in New York: Dew Drops, Hemp Oil Scripts
Frequency of Usage: Time Per Day
1
Frequency of Usage: Days per Week
7