Cannabis and Khat abuse-EP1

Khat and cannabis are commonly used substances, however chronic use leads to addiction and development of substance induced psychosis. Dr. Rajab Saddam highlights the impact of these substances on mental health and wellbeing.

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Transcript

SPEAKER_00 0:16

Welcome to the mental wellness podcast. This podcast is aimed at addressing the mental health literacy levels in our country. What I mean by this is that most of the people in the society do not have a very good understanding of what mental illnesses are. Stigma is very high in the society. It's common to hear someone who's suffering from a mental illness being called as a cheesy mandawazimu. These are stigmatizing terms. And what we're trying to do today here and moving forward is to basically create awareness, educate the society on what mental illnesses are and what are the treatment options and what can we do to prevent and improve our mental helping. Kenya as a country has a significant mental health burden when it comes to the illnesses that we see. Among the top five mental illnesses is anxiety, depression, substance use disorder, schizophrenia, and bipolar disorders. For us in the clinical setting, it's common to have a patient and ask a patient, what are we treating you for the day? Either depression. I don't know. What I was told, I'm crazy. Terms of which are really strict. And so our role as clinicians in the mental health space and psychiatrist is to educate the community and society on what these mental illnesses are and impact it has. So we will be having different guests on the show to come and shed light on mental illnesses in Kenya and social determinants of mental illnesses and health and generally and what we can do collectively as clinicians and the society at large to improve the mental well-being of our country. My name is Dr. Chibanzi Machonda. I'm a consultant psychiatrist in Kenya, and this is the mental wellness podcast. We've seen significant steps being made by the government when it comes to mental illnesses, uh, war on drugs and narcotics. But also, we do have a challenge where certain factors come into play when it comes to substance use. In this specific episode, we just narrow down to which is cut and cannabis use. And we know that our country is one of the countries that produces um a lot of the product, especially the cut products. In as much as it has an economic impact in the country, it also has an impact that is negative when it comes to the health of the people, and that is specifically mental illnesses and the prevalence of mental illnesses in the country. With me on the show today is uh psychiatrist who is also a colleague. He's a consultant psychiatrist. Um, he's also uh the CME coordinator of the Kenya Psychiatric Association. Um his name is Dr. Rajab Saddam. Welcome to the show. I think we're going to have an interesting discussion and also to educate the society about what we see at the clinical setting and how this is important when it comes to the society. Substance use in the country specifically is um very rampant. I think statistics, according to the WHO report 2017, that is also part of what is the substance use disorder national treatment and protocol, that more than half of the users were aged between 10 and 19 years. So that's a youthful population of the country. I'd like to welcome you on the show. Just to start us off, as a psychiatrist who treats patients on a daily basis, attends to different patients. And in the clinical setting, what do you have to say about CART and cannabis? As a start here.

SPEAKER_01 3:57

Thank you, Dr. Machonda. It is a privilege to be here. I am delighted that uh these uh efforts of advocacy are going to another level so that we can help our country uh improve the literacy levels when it comes to mental illnesses, mental wellness, and uh uh subjects of mental wellness in general. And indeed, substance use is one of those uh subjects that we cannot ignore when we talk about mental health. It does intertwine itself with a lot of other mental illnesses. My name is Dr. Rajab Saddam, and uh it is a privilege to be here. Um if we dive in uh to the topic of substance use and specifically heart and uh marijuana, you find that like any other mental illness, it is not unique in the age groups in which we start. Almost all mental illnesses have tracings in the early child and adolescent period. This is a very vulnerable period. Uh, the brain is still maturing, there is experimentation happening, and also sometimes peer pressure uh plays a big role in what uh uh this population does. And indeed, uh a lot of patients, even those you meet in in older ages or adulthood, is that they will trace their problems with substance use very early in life. Uh, heart or mirror, in our case, usually is either mogoka, the the leaves or the sticks now, the mirror, um, common use. And actually, the mogoka is now actually the more uh problematic pandemic because of just how cheap and accessible it is. Yet it is a very potent formulation as well. Yeah. And uh kids start using this as early as six years, and it also goes to the community because of how much access it has been given. It is not illegal in our country. Uh, adults send their children to buy these uh products for them. So a lot of kids grow up knowing very well that this is not a problem. It is something the community where they live has accepted and embraced. It is used in the verandas of the home, in the living rooms, as as as stories are made, as as cooking is done. It is very much embraced, especially for homogoka and mirror.

SPEAKER_00 6:19

So, one of the questions we ask our patients when they're sitting in front of us, or even the relatives that they've accompanying the patients, is substance use history because this is significant and we it helps us tie down the symptoms that the patient is presenting with. So, what are the common symptoms that you normally see in the clinic setting for patients who have a history of one magoka and migra, which is cut, and then two cannabis?

SPEAKER_01 6:45

Okay. Well, first of all, we have to understand that we have a very poor health-seeking behavior in our country, which needs to improve. A lot of times, patients and their relatives will never come to hospital until day-to-day productivity has gone down. Yes. And that becomes the first symptom, really. Okay. The second one then becomes behavior change.

SPEAKER_02 7:06

Okay.

SPEAKER_01 7:07

You find that someone who used to be early, report to work, or go to school in good time, they are late, they are missing work, they are not going to school, their performance is deteriorating. Um, then, especially when it comes to heart, if I may now concentrate on that, is someone starts to lose weight, uh, they become very irritable. Okay. You find that their concentration becomes very poor. Um, they cannot explain a lot of their finances, where they're going. If they are the breadwinners or people who've been supporting at home, you find that a lot of resources have gone uh unexplained. And that is when most of the time these patients show up, when there is a problem. When it comes to cannabis use, especially for men, is that psychosis is what brings them to hospital. Hardly will they come when things are okay. And uh the other problem is anxiety for cannabis, that excessive use of it eventually, eventually does cause a patient to start having um a lot of worry, a lot of paranoid thoughts, and uh that anxiety, that restlessness that is now uncomfortable. Yes, which initially uh ironically is that marijuana used to help settle down. After prolonged use, it now becomes the cause of the exact same problem.

SPEAKER_00 8:24

Yes. So you you document something called psychosis. For the sake of our audience who don't really understand what this term means, just briefly, what exactly is psychosis? What would you see or what would the patient, what would the relatives tell you that you'd say this is psychosis?

SPEAKER_01 8:38

Okay. Psychosis is what um in the general population has been stigmatized as someone going mad, okay, which is basically losing touch with reality. You find that a patient starts to have sleep disturbances, they can go the whole night without sleeping, they can wander around aimlessly, they will speak things that are not in reality, they can tell you they hear voices, or you can see them speaking to someone who is not there, or they can insist they are seeing something in the house that no one else can see, which we call uh uh a hallucination. Or they can start having very strong beliefs about something that is not true. We've seen patients who come to hospital with the insistence that someone has implanted a chip in their in their brain and they are being, you know, tracked, or they are billionaires, okay, delusions of grandiosity, very big dreams that are not real. Those are the kind of symptoms that then tie it down to psychosis.

unknown 9:39

Okay.

SPEAKER_00 9:39

Yeah. Okay. And so, of course, once you you you've picked these symptoms, um, the next step, obviously, as a doctor is to do some certain tests and investigations. So, is there a confirmatory test for both cannabis and moboka? And what what what samples from the body would you require to say now this confirms that this person actually is taking these substances?

SPEAKER_01 10:01

Okay. Um, when it comes to investigation or just trying to go on the fact-finding mission as regards uh substance use, heart or marijuana, our biggest laboratory is actually still the clinical information. You find that uh it is from the discussion with the patient, if they are truthful and for coming with information from their relatives, that a lot of our clinical diagnosis actually comes from. A lot of the times we send uh patients to the lab not to be able to get new findings, but just to confirm, or even now to rule out other things that now the consequences that these substances have caused to the body, aside from the mental illness. For example, uh heart can still cause a lot of cardiac problems, diseases of the heart. Um, marijuana can cause a lot of lung problems, especially because of uh the smoking, if that is the mod that it was used. So laboratory investigations usually go to help us see how severe has the body been affected, aside from the mental wellness. But still it's important to do them. The most important uh test as regards the substance use is usually a urine toxicology. Okay. You find that when you do the urine screen, then it can be able to tell you what is positive in in the in the blood or sorry, in the urine that has been in the system. And importantly, when it comes to cannabis, is that you can also do the levels. Other than being told it is positive, then again, what are the quantities?

unknown 11:33

Okay.

SPEAKER_01 11:34

And uh we've seen patients with very high levels uh of marijuana in their system, and they didn't know because they have taken it over over a period of time, especially those who don't smoke, which is the ironical thing, those ones who use it as edibles, a cookie here, a chocolate bar here, very high levels of marijuana in the system.

SPEAKER_00 11:55

Yes. Yeah, so doc, as you rightfully said, you you ask the patient uh the symptoms experiencing, or even those who have accompanied them, and then taken the patient to the lab, and you've been able to do the tests that you do, especially like the urine toxicology, just to see if it's positive and then turns out positive. And you do the tetrahydocannabidal levels, which is the levels of cannabis in the body, and also shows you the levels. So the next step, of course, becomes treatment for this person or this uh patient that you have in front of you. What is the role of medication in treatment of these two specific substances?

SPEAKER_01 12:29

Okay, thank you. I would like to take you back a little bit. There's usually about 11 symptoms that actually I think it's important for the public to know.

SPEAKER_02 12:37

Yeah.

SPEAKER_01 12:38

For us to even make a diagnosis of any substance of use. Yes, yes. The first one is first of all, is that there's a problematic use of any of this substance. Put any name there. You find that someone spends a lot of time looking for this substance, a lot of time using that substance, and a lot of time recovering from the effects of this substance. You also find that someone uses a lot of resources, again, looking for this substance and a lot of resources to recover when they say, you know, now hangovers or detoxing by themselves. You also find that a lot of uh individuals then start to forgo other important uh activities in their lives to prioritize the use of substances. They use these substances in dangerous situations. You find that someone, and it's a very common practice, someone will use Mogoka or Mira and want to drive and want to operate uh heavy machinery, or someone will use marijuana and go to work in a construction site, very dangerous behaviors, both to themselves and the colleagues they are working with. You find that someone continues to use these substances despite having been told before of the risks to their health that this causes. Also, you find that they have a need or they have shown desire to cut it down, but it has just been very problematic for them on their own to cut it down. And that is when they show up to hospital. Majority of them actually come involuntarily. So even as treatment starts, you find that the first goal of treatment is to try to actually win the patient over, to show them the importance of this journey for themselves, not because of the parent who brought them there, not because of, let's say, the colleague from work or the HR profession who directed they come to the hospital so that they own the journey for their own sake. Is there a role of medication? I would say yes and no. Specifically for marijuana and Mogoka and Mira, there is no specific medication towards treating that. A lot of the treatment that is needed is more on the psychological aspects and then the social aspects of treatment. Yes.

SPEAKER_00 14:58

But what about the symptoms that you spoke about, the psychotic symptoms? What do you do with that?

SPEAKER_01 15:04

So now the treatment actually is for the associated problem. But for the the specific substance, there is no medication per se for that. But then for the psychosis, for example, is that for a while you will have to give this patient medication to treat the symptoms. Most of the time it is an antipsychotic. If they have symptoms of anxiety, is that you will help them calm down by giving them medication that addresses anxiety. Sometimes it also, the substances and even just how now it has affected life, is that these patients actually present with symptoms of depression, then they have to be treated for the depressive symptoms. So that is the underlying problem. Uh or the duality, like we'll say or we'll look at later. Okay. Yeah. But uh for that this medication is going to cure or treat the marijuana or the heart in itself, there isn't.

SPEAKER_00 15:58

Basically, for people to understand is that if you're using cannabis, if you're using, there's no drug we'll give you to make you stop using that. But because you'll have developed symptoms because of the chronic use instead of the use over time, then you'll be given medication to address the symptoms that someone is experiencing. And I think this is important because um we tend to see most of our patients uh ask certain questions about medication. How long will I take medication? This medication be addictive. Yes, I don't know what what would you like to say about that?

SPEAKER_01 16:32

Okay. Um, there is medication that we do give, and for sure they can't be addictive, and any clinician will offer you that information. Yeah, and even as we are giving you this medication, we will also tell you we are giving you this medication for a very specific time, usually no more than 14 days, especially the ones we use for anxiety. But a lot of the medication that we use to treat most of the other chronic mental health conditions are not addictive. There is misinformation out there, and it would be very important that people know these medications are safe if given in the correct doses, if taken in the correct instructions, they are not addictive. In fact, they're the ones to help you restore functionality, restore productivity, so that then you can be able to go back to day-to-day life.

SPEAKER_00 17:21

Okay, okay. And so we go forward and now look at the substances themselves, especially. It's common to see that a patient comes to you with the associated symptoms, treat the symptoms, put them on medication. Then, because at that point they stop taking the substance itself and now take on take the medication after some time, they're okay. But then one reason or the other, after some time, the same patient presents, they've gone back to the same substance. Yes. Which brings the point of addiction in this case. And um what are so you have it's a patient you're treating, then they relapse back to that to the substances they're using. So, what are the most likely causes of of relapse that we see in most of these patients?

SPEAKER_01 18:08

Okay. Um, relapse happens because of several reasons. Yeah uh one on the list is just because of a lack of information or what we call insight on the patient themselves. Insight means has the patient understood the problem fully? Have they been able to see the A to Z? And that usually is the honors of the clinician, both the psychiatrist, the clinical psychologist, the psychiatric nurse, and even the social workers that are dealing with these patients. Have we been able to walk this journey properly so that they can understand the cause and effect of the substances? If we do this properly, for a lot of patients, then insight develops. But remember, I said that a lot of these patients are brought in voluntarily. They don't want to be here. They do not even think this is a problem. Maybe someone else has noticed it's a problem and they have been forced to come. If despite being forced to come by the time they are leaving uh the clinic or if it is an admission, the discharge is happening and they have not on this journey by themselves, yeah, 100% a relapse is going to happen. Um, another reason is peer pressure. Yes. Someone still wants to associate with the same group. Okay, the friends that they are with, there's no way I'm going to go back chilling at the base and watch my friends, you know, chew and I'm not chewing. Yeah. Very common problem. Another problem is if the social stresses, a lot of people start using substances because of other economic and social stresses. Maybe a marital problem, maybe financial problems, maybe the kids are being a problem at home, or maybe the parents are being a problem at home and the child is actually affected. And if these stresses at home are not addressed, then it's very easy for someone to go back to what they know, help them cope.

SPEAKER_00 19:56

So basically, what you've also brought out is the factor, the role of environmental factors. Very important. The environment which one comes from. Yes. Because when they are they are admitted um for treatment, um, then it's a different environment. Hospital environment is very different from the home environment. Now, there's something about rehabilitation as part of treatment. Yes. Could you please just shed light on what rehabilitation is and how long is it? Okay.

SPEAKER_01 20:23

Uh rehabilitation is a program um that helps patients going through any form of addiction, yeah, whether it is substance or even gambling, anything that can be addictive to try and bring them back to normalcy, to try and break the chains of the dependence. And why this program is there is because addiction comes because the reward centers in the brain have been affected. You find that the body and the reward centers in the brain have learned to um get rewards from these substances. So to try and eliminate this connection, for some time they need to go away. Be away from the environment they know, the stresses they know, be supported in therapy, and maybe continue with medication for some time. And remember, the medication we are not talking about. We've said there's no medication for Mira, there's no medication for cannabis. But sometimes is that there is depression that needs to continue being treated, anxiety that needs to continue being addressed, that there was psychotic symptoms that need to continue being treated. But more importantly, the cornerstone of rehabilitation programs is actually canceling psychotherapy. So therapy is very important. Therapy cannot be overemphasized here. A rehab program, as per protocol guided by the NACADA, is actually 90 days. Yes. Okay. And sometimes actually where the problem happens is because either the patient or the family think they can beat this. system. That someone goes for rehabilitation for two weeks and then they want out. One month, then they want out. Which is not the correct way to approach it. Any patient who is struggling with addiction, the first process is to do a detox, which is usually a short stay in a hospital, then proceed to a rehabilitation center. And rehabilitation program is 90 days where therapy goes on, treatment goes on, and then hopefully there's even now post-rehabilitation follow-up so that care can continue even as they now integrate back to society. Okay.

SPEAKER_00 22:35

So you did talk about um certain illnesses such as anxiety, depression and even psychotic illnesses as presenting with these symptoms. So what exactly would you say when it comes to this twin intersection between these illnesses primarily depression, anxiety and the substance use? You said initially when we're discussing this that um some of the patients normally use the substance such as cannabis when they're feeling anxious it calm them down. But those who tell you when they use it they actually get creative. That's a common thing that I've also had in the clinic setting. So when it comes to the substance use and these other conditions what what exactly is the link between the two?

SPEAKER_01 23:19

The duality of substance use and the other mainstream mental health problems has existed since time immemorial. You find that sometimes it is either or one can lead to the other. You find that a patient with depression a patient with psychosis a patient with bipolar disorder anxiety can in the initial phases decide to use substances to try and treat themselves so to speak so that a substance of abuse becomes what they know best to try and calm themselves down, to try and find sleep to try and what they usually say I find my mind is very you know scattered. I just need to calm it down. So someone goes for a substance and there's usually very good suggestions in the streets. Okay. And the other opposite of it is that someone can start using substance even just because of peer pressure or fun, recreational purposes and then it spirals into now the dependence. Now like we mentioned the the signs and symptoms of dependence you find that naturally they have consequences. Once you start uh missing work, once you start dropping your performance at school once you start you know severing relationships with your friends and family it naturally starts to distress you. And it's it can lead to anxiety and depression. And like we've said some of these substances then not actually some all of them have the potential of causing now the psychotic symptoms and you cannot predict who is who and there's also a genetic component it's very important to talk about if you have an uncle a father a cousin who is using substances there is a high likelihood that then the risk is also that you can have uh dependence to eat as well.

SPEAKER_00 25:08

This genetic component is is very interesting because I think some of the some of some of what we come across uh especially is when you ask about this and people look at you and like what do you mean genetic you know so if my uncle or if my father if so and so had this does that how is that related to me?

SPEAKER_01 25:27

That's the question that you you're likely to get as a clinician yes and so how would you just maybe to clarify simplify it so that so people can actually understand that link between the genetics and substance use um genetic risk for anything does not mean you're guaranteed to have it but it means in your lineage if it has been seen your grandfather struggled with substance use an uncle struggled with substance use maybe one of uh your cousins has struggled with substance use sometimes one of your parents has struggled with it or an older sibling it already tells you that if you walk that path it is very likely that you will also struggle with it. It just means that as a family your genes are easily can gravitate towards addiction.

SPEAKER_00 26:15

What we call genetic loading what we call genetic loading yes and so now beyond treatment what are the effective interventions and strategies that we can adopt as a society to conquer this menace because clearly as a country we have a big job and a big big big role to play when it comes to substances especially kokoka and cannabis it's it's very common in the country.

SPEAKER_01 26:40

Yeah cannabis it's interest it's illegal but actually the access is massive. Yes yes yes and to try and uh curb this problem it will need that we all hold hands yeah and it starts with forum like this because the first job is to try and prevent okay it needs that the masses need to hear to know the dangers and to try and work from a point of can we even avoid having to treat and prevention starts at policy level and then it starts at society level then uh school level before it comes to the clinic. Okay. Okay. So it means that at policy level what what as a government uh what policies do they have to be able to promote advocacy okay we need that in school there must be lessons about substance use and the effects negative effects specifically they have so that as kids leave primary high school they already know they don't go finding out from the streets. In campus, how do we support them? Because now that is the most vulnerable age okay you are mostly free not in in in very close supervision of parents you have time you have some money it is very easy to gravitate towards substance use um then from we we still have media radio is actually still very much uh accessible to many of us it is that we have these programs rolling out where the masses can always be educated prevention. Then in the unfortunate event that then someone has gotten ill then we we actually also inform them of the steps towards care and we are now at universal healthcare it means the services have to be integrated from primary care. We shouldn't wait for someone to go to a referral hospital that that is the only place they can access help for substance use. How do we empower our primary health caregivers, the clinical officers, the psychiatric nurses at the health centers at the county hospitals so that care starts and is accessible from a very, very local geographical area.

SPEAKER_00 28:51

Yeah so I think just just to to bring you when you were speaking about this um interventions I I I I grew up in a in an environment where substance use was very common in the coastal region of Kenya. Yes um I remember I think at the time that I was in class seven um one of the things we used to do was play football. Yes but then it was common to go for football and find that some of your peers have actually uh taken cannabis yes yeah and so it it it was almost like a normal thing yeah but uh so then I think at that point um there's there's something that I think needs to to be done because for me uh and as much as I could see them smoke the cannabis an important thing had happened in my school where we'd been taken through cannabis use what marijuana is what are the effects on the body I think around class five, six so by the time I'm getting to my teenage years um it's something I already know taught in class that this is the effect. So what do you think we can do when it comes to education in schools especially for the school going children when it comes to this specific uh substances second to the parent nobody is listened to more than the teacher.

SPEAKER_01 30:06

Yeah if the teacher and actually I would argue sometimes the teacher is listened to more than the the parents if the teacher tells you and teaches you about the bad things to avoid a lot of kids do adhere to these. Okay. And you find that now with this competence based uh curriculum it's it's actually a very easy way to incorporate it. They have a lot of practical classes you know environmental there's actually a whole subject called environmental and social education these are the avenues and sometimes they can actually invite professionals to start talking to these children. They can pick whatever grade they feel is is is is is safe and we are saying exposure is at around six years. So that means from the time we're in grade one grade two somehow this conversation needs to have started and then it needs to be something that goes on. Repetition, then it solidifies the information and then now we will graduate students who will have learned and over time then it snowballs that everyone has the information to teach even the other generations to come.

unknown 31:12

Okay, okay.

SPEAKER_00 31:13

So I think it's it's been a great discussion um especially on these specific substances and uh I think we look forward to having more of such forums I think in the future we could even think about going down to the community level just to have to have these discussions. I remember a few weeks back I went and sat with a few of my friends back in the village where I grew up and they're chewing Mogoka. And I looked at them and I was like do you know the impact of this because I'm a doctor and they know that I'm a psychiatrist they were like so tell us what exactly is what the role of this and so we had a very interesting discussion about this Mogoka. I kept telling them these are the symptoms you'll experience and so there's interestingly what I found very interesting during that session was that someone told one of them told me by the doctor it's true there are days when I've not taken Mogoka for three days I just make noise in the house they start screaming and so now like I was looking at them like okay these are symptoms of already withdrawal and those were like um when I don't take mogoka my head can't think clearly I was like yeah these are symptoms I told them yeah you you see these are symptoms so these things are not imagined I'm not a user you are a user but whenever I've just experienced symptoms you actually experience yeah so I think that that that specific uh moment made me realize we actually have a role to play when it comes to educating and talking to people about these substances.

SPEAKER_01 32:36

So Doc you've talked about treatment and medication and therapy do you have any successful story of of patients you've treated and who you were able to successfully treat and they got off substances yes there is a lot of successful stories and successful stories will tie up with all the interventions you've said they will need a good social support they will need good insight and with support with medication which usually is actually a very short stint yeah a lot of patients don't need medication lifelong okay they are supported for a short while then therapy is actually the backbone of of treatment those ones who remain consistent those ones whom we have been able to you know make them understand and on the journey there is a lot of good success stories people who've gone back been productive families have been restored uh people have gone back to work students who've gone back to perform well graduated now they're in the job market so it is very possible um all we need is to work together and be able to continue supporting them and uh if I may say addiction in itself does have a lot of disappointing stories as well you find that there is um those ones who will keep relapsing and uh all I can encourage especially the families and caregivers that it's the job of all of us not to give up on them. Because there is one who will you know recover after the first cycle of rehabilitation another person may need three another one may need seven but if we can be able to let's keep supporting them let's not give up hope on the journey and uh there is always light at the end of that tunnel.

SPEAKER_00 34:16

So thank you very much uh for being on the show I think we look forward to having more discussions moving forward we we we'll we'll actually have you back on the show to tell us more about several other issues about mental illnesses thank you for having me I look forward to the next one thank you so this has been the Mental Wellness Podcast with Dr. Rajab Sadam he's a consultant psychiatrist we've had a very good discussion very educative insights on Mogoka and Mira which is cut and cannabis for questions comments uh queries any feedback you can comment on our social media platforms and for the recording of this full episode the link is in the bio my name is Dr. Chibanzi Machonda I'm a consultant psychiatrist in Kenya and this is the mental wellness podcast