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Case Presentation
Case Presentation
PRESENTATION
Dr Jayasree Cherukat
CT 1 to Dr Abhinav Rastogi
Demographics
• 21 year old
• Caucasian male
• In a relationship
• Third year engineering student
Presentation
• Self referral in July 2021
• Suicide attempt- tied hands with towel and tried to submerge in bathtub
• Close to grandparents
Personal history continued..
• School: struggled to maintain friendships
• Father : PTSD
• Cocaine and cannabis from 14-17 years / last use of recreational cannabis 2020
• Nil forensic
Mental state examination
• Appearance- casually dressed, kempt
• Speech- N
• Mood – euthymic
• Punching walls
• Alcohol- climbs big buildings- 5-6 times / year / decreased 1 year back
• Only 1 RCT
• ADHD patients are more likely to use Cannabis : most studies indicate 2
to 3 times higher than general population
Understanding associations
• Petker et al : 1000 adults in community
• severity of cannabis involvement - significantly associated with greater
endorsement of both hyperactive-impulsive and inattentive ADHD
symptoms
• ADHD predates cannabis effects on cognition
• Self-selection pathway ( individuals with ADHD seeking out cannabis)
• Romo et al:1500 French students: ADHD- substance (alcohol, cannabis,
tobacco) behavioral addictions (gambling, compulsive buying disorder,
eating disorders,Internet addiction)
• Cross-sectional study > 5000 people/self-reported symptoms/ Kola et al
Hyperactivity , particularly impulsivity associated with higher cannabis
misuse in men with ADHD symptoms
• Childhood oppositional behaviour in pts with ADHD -associated with
cannabis misuse in early adulthood
Genomics
• Examined overlap between genomics of ADHD and cannabis initiation
• Four loci
• Soler et al
• ADHD is causal for lifetime cannabis use: odds ratio of 7.9 for cannabis
use in individuals with ADHD in comparison to individuals without
ADHD (95% CI (3.72, 15.51), P = 5.88 × 10-5).
ADHD and Cannabis
• Goldstein et al
• Relationship between cannabis use motives (coping, boredom, and sleep) and
consequences and the impact of ADHD symptoms on these relationships
• Participants - 62 emerging adults (ages 19-25 years)who used cannabis regularly (two or
more times in the past 2 weeks) and completed a screener assessing past-6-months ADHD
symptoms at baseline followed by 14 daily reports on cannabis use, consequences, and
motives
• ADHD symptoms, along with sleep and boredom motives, contribute to increased daily
cannabis consequences and should be considered in developing interventions for emerging
adults.
ADHD and Cannabis
• Online survey of students (n=1738) :Students with ADHD reported improvement in
ADHD medication related anxiety and irritability with cannabis 1. (All self reported,
no objective assessment.)
• Cross sectional survey of ADHD patients-to evaluate differences in reported
parameters between low (20-30 g, n=18) and high (40-70 g, n=35) MC monthly
dose and low adult ADHD self-report scale (ASRS, 0-5) score (i.e. ≤3.17 score,
n=30) or high ASRS score (i.e. ≥3.18 score, n=29) subgroups. N=59, cannabis dose
known for only 27. High dose of cannabis associated with lower scores for
ADHD symptoms. (low numbers, self reported, doesn’t establish treatment effect)
Imaging studies
• Rasmussen et al
• Compared fMRI for Go/No-go task in children with history of ADHD with and
without cannabis misuse with comparative normal group
• ADHD participants : impaired response inhibition combined with less fronto-
parietal/striatal activity
• Cannabis use -did not impact behavioural response inhibition.Was associated with
hippocampal and cerebellar activation, areas rich in cannabinoid receptors, in
LNCG but not ADHD participants-may reflect recruitment of compensatory
circuitry in cannabis using controls but not ADHD participants
Cannabis and ADHD
• Kelly et al :task-independent intrinsic functional connectivity (iFC) within
9 functional networks using a 2 × 2 design in young adults with or without
h/o childhood ADHD and with or without cannabis misuse.
• Childhood ADHD -weakened iFC in networks supporting executive
function and somatomotor control
• Cannabis-no interactions (small numbers)
Early Initiation of Cannabis
• Tamm et al :compared neurocognitive profile of Young adults (24.2 ± 1.2
years) with childhood ADHD who did (n=42) and did not (n=45) use
cannabis use with a N group who did (n=20) and did not (n=21)
• poor cognitive outcomes
• Krista et al : greater right hemisphere superior frontal and postcentral
cortical thickness.
Cannabis and ADHD
• A systematic review of Neurodevelopmental Effects of Cannabis Use in
Adolescents and Emerging Adults with ADHD : evidence is insufficient
and potentially underpowered to support the hypothesis that cannabis
use has a deleterious impact on neuropsychological tasks in transitional
age youth with ADHD
ADHD and Cannabis
• Retrospective study/US: inpatients stay of adolescents with ADHD, Patel et al
• increases the risk and prolongs inpatient stay
• pts with cannabis misuse also had high alcohol misuse rates
• Study using the Wave 2 of the National Epidemiologic Survey on Alcohol
and Related Conditions (2004-2005), Bradnt et al
• Diagnosis of any psychiatric disorder was significantly higher among
those with ADHD and concurrent cannabis use compared with nonusers
(adjusted odds ratio [AOR], 2.8; 95% confidence interval [CI], 1.08-6.41),
as were odds of a lifetime personality disorder (AOR, 4.04; 95% CI,
1.84-8.84)
RCT
• Cooper et al
• 6 weeks/ Single centre/Double blinded
• 100 microliter spraySativex Oromucosal spray -1:1 delta 9 tetrahydro cannabinol and
Cannabidiol
- Underpowered
-Increased drop out in placebo group
- Short follow up period
Summary
• Very poor evidence: cross sectional studies, underpowered or inconsistent methodologies
• Pts with ADHD at much higher risks of comorbid cannabis misuse
• on background of increased risks of other substance/alcohol misuse, gambling and other compulsive
behaviours
• Whether cannabis worsens adhd symptoms or adhd causes cannabis misuse in not clear
• Possibility of genetic overlap in causality
• Some poor quality studies on benefits of cannabis in ADHD: underpowered and self
reported improvement
• Only 1 RCT which didn’t support any benefits
References
• Stueber A, Cuttler C. Self-Reported Effects of Cannabis on ADHD Symptoms, ADHD Medication Side Effects, and ADHD-Related Executive Dysfunction.
Journal of Attention Disorders. October 2021.
• Hergenrather JY, Aviram J, Vysotski Y, Campisi-Pinto S, Lewitus GM, Meiri D. Cannabinoid and Terpenoid Doses are Associated with Adult ADHD Status of
Medical Cannabis Patients. Rambam Maimonides Med J 2020;11 (1):e0001. doi:10.5041/RMMJ.10384
• Rasmussen, Jerod; Casey, B J; van Erp, Theo G; M; Tamm, Leanne; Epstein, Jeffery N; et al. ADHD and cannabis use in young adults examined using fMRI
of a Go/NoGo task, Brain Imaging and Behavior; Indianapolis Vol. 10, Iss. 3, (Sep 2016): 761-771.
• Goldstein, Abby L; Shifrin, Alexandra; Katz, Jasmin L; Iu, Lap K; Kofler, Danielle Exploring the Relationship Between ADHD Symptoms and Daily
Cannabis Consequences in Emerging Adulthood: The Role of Cannabis Motives. Journal of studies on alcohol and drugs; Mar 2021; vol. 82 (no. 2); p. 228-
236
• Kelly, Clare; Castellanos, F Xavier; Tomaselli, Olivia; Lisdahl, Krista; Tamm, Leanne et al. Distinct effects of childhood ADHD and cannabis use on brain
functional architecture in young adults. NeuroImage. Clinical; 2017; vol. 13 ; p. 188-200
• Lisdahl, Krista M; Tamm, Leanne; Epstein, Jeffery N; Jernigan, Terry; Molina, Brooke S G et al. The impact of ADHD persistence, recent cannabis use, and
age of regular cannabis use onset on subcortical volume and cortical thickness in young adults. Drug and alcohol dependence; Apr 2016; vol. 161 ; p. 135-146
• Cawkwell, Philip B. MD; Hong, David S. MD; Leikauf, John E. MD Neurodevelopmental Effects of Cannabis Use in Adolescents and Emerging Adults with
ADHD: A Systematic Review Harvard Review of Psychiatry: 7/8 2021 - Volume 29 - Issue 4 - p 251-261
• Notzon, Daniel P; Pavlicova, Martina; Glass, Andrew; Mariani, John J; Mahony, Amy L et al. ADHD Is Highly Prevalent in Patients Seeking Treatment for
Cannabis Use Disorders. Journal of attention disorders; Sep 2020; vol. 24 (no. 11); p. 1487-1492
References
• Kolla, Nathan J; van der Maas, Mark; Toplak, Maggie E; Erickson, Patricia G; Mann, Robert E et al. Adult attention deficit hyperactivity
disorder symptom profiles and concurrent problems with alcohol and cannabis: sex differences in a representative, population survey.
BMC psychiatry; Feb 2016; vol. 16 ; p. 50
• Soler Artigas Et al, Attention-deficit/hyperactivity disorder and lifetime cannabis use: genetic overlap and causality. Molecular psychiatry;
Oct 2020; vol. 25 (no. 10); p. 2493-2503
• Patel, Rikinkumar S et al. Is Cannabis Use Associated With the Worst Inpatient Outcomes in Attention Deficit Hyperactivity Disorder
Adolescents? Cureus; Jan 2018; vol. 10 (no. 1); p. e2033
• Attention-deficit hyperactivity disorder and addictions (substance and behavioral): Prevalence and characteristics in a multicenter study in
France. Romo, Lucia; Ladner, Joel; Kotbagi, Gayatri; Morvan, Yannick; Saleh, Dalia et al. Journal of behavioral addictions; Sep 2018;
vol. 7 (no. 3); p. 743-751
• Childhood trajectories of inattention, hyperactivity and oppositional behaviors and prediction of substance abuse/dependence: a 15-year
longitudinal population-based study. Pingault, J-B; Côté, S M; Galéra, C; Genolini, C; Falissard, B et al. Molecular psychiatry; Jul 2013;
vol. 18 (no. 7); p. 806-812
• Cooper RE, Williams E, Seegobin S, Tye C, Kuntsi J, Asherson P. Cannabinoids in attention-deficit/hyperactivity disorder: A randomised-
controlled trial. Eur Neuropsychopharmacol. 2017 Aug;27(8):795-808
THANK YOU!!!
Open to questions/ discussion