ADDICTION-
Believe It or Not, You Can Overdose on Weed.
If you think cannabis is basically harmless, you may need to think again.
Reviewed by Ekua Hagan

KEY POINTS-
As more states legalize it, the overuse and abuse of cannabis products will inevitably increase, resulting in more cases of cannabis toxicity.
Although eating cannabis, or edibles, doesn’t affect the lungs compared with smoking, accidental overdoses are more likely to happen.
While most legal cannabis products list the amount of THC they contain, understanding what this means in terms of potency can be a challenge.

You may have some familiarity with the term “blacking out” due to alcohol consumption. The phenomenon refers to gaps in a person’s memory for events that occurred while they were intoxicated and involves memory loss even while they are awake and conscious (they can be moving around, interacting with others, and may seem okay to those around them). A fragmentary blackout, also known as a “grayout” or “brownout” combines gaps in memory with some recollection of events, rather than no recollection as is the case with a total blackout.[1]

If this is your first encounter with the term “greening out” it’s unlikely to be your last, as cannabis use becomes ever more accessible and mainstream. It refers to an acute anxiety- or panic-inducing high, more frequently involving edibles (cannabis-containing food products that you can buy or make yourself) than smoking weed. Greening out is actually a form of overdose or toxic reaction caused by consuming too much of a cannabis product, and can include symptoms such as confusion, dizziness, disorientation, visual impairments, weakness, anxiety, panic, paranoia, increased pulse rate and blood pressure, nausea, or vomiting.

The psychoactive ingredient in cannabis is tetrahydrocannabinol (THC), which causes a euphoric high but can also cause psychological reactions that include anxiety, fear, panic, or depression. The way it enters the body, whether by smoking weed or eating or drinking cannabis products in the form of gummies, chocolate bars, or baked goods, affects how much THC is absorbed. The amount of THC, or its concentration in edibles can be difficult to measure and is often unknown. Consequently, people who use edibles are sometimes unpleasantly surprised by their strength and long-lasting effects.

According to the World Health Organization, around 2.5 percent of the world’s population, or 147 million people, consume weed. As more and more states legalize it, the overuse and abuse of cannabis products will inevitably increase, resulting in more cases of cannabis toxicity, and in turn more emergency room visits and hospitalizations.[2]

A 2022 study that looked at more than 35,000 people in Canada found that people who reported using cannabis in the past year were more likely to have an ER visit or hospitalization than those who didn’t use it.[3]

How much is too much?
While most cannabis products that you can buy legally list the amount of THC they contain, understanding what this means in terms of potency can be a challenge. Moreover, if you’re consuming an edible that isn’t packaged commercially, it’s almost impossible to tell how much THC is in it, or in cannabis that is smoked. Generally, the likelihood of experiencing uncomfortable and potentially problematic effects is higher for first-time or infrequent users. However, even regular and veteran cannabis users sometimes experience anxiety, panic, and/or paranoia, with some (including professional clients as well as personal friends) reporting the sudden onset of these and other adverse effects, even after years of use.

A 2023 study in the journal Molecules at the Institute of Nutrition at Mahidol University in Thailand suggested that smoking 2 to 3 mg of THC can impair attention, focus, short-term memory, and executive functions including memory, thinking, and self-control.

More severe symptoms affect people who smoke more than 7.5 mg of THC, such as low blood pressure, panic, anxiety, delirium, jerking movements, and difficulties with balance and speech. The same study suggested that an oral dose of 5 to 20 mg of THC can impair short-term memory and executive functioning.[4]

Although eating cannabis, or edibles, doesn’t affect the lungs compared with smoking, accidental overdoses are more likely to happen. Also, it generally takes considerably longer for the mind- and mood-altering effects of edibles to begin to manifest—usually 30 minutes to two hours. As a result, people may take more, thinking they haven’t consumed enough, sometimes precipitating taking too much and greening out. Moreover, the high also lasts longer when eating cannabis relative to smoking it; depending on dosage the effects can last 6-12 hours before they subside. The duration of effects depends on several factors, such as body size, amount ingested, when food was last eaten, and interactions with medications or alcohol.

If cannabis use results in out-of-control behaviors, injury, or suicidal thoughts, people should seek medical help by calling 911 or going to the hospital. Those with underlying medical conditions or chronic illness, such as heart or lung disease, or diabetes, need to be especially aware of any symptoms of overdose, especially if these include shortness of breath or chest pain. Since THC intoxication can amplify symptoms of psychiatric disorders like depression, anxiety, PTSD, ADHD, bipolar disorder, and schizophrenia, it’s important for people with those conditions important to get emergency care in cases of overconsumption.

While psychotic episodes and serious medical problems are rare, cannabis-related reports to the U.S. National Poison Control increased from 2,951 cases in 2016 to 11,569 cases in 2020. From January to July 2021, 18 percent of exposures (119 of 661 cases) required hospitalization and 39 percent of the cases involved people under 18 (258 of 661 cases).[5]

What to do in the event of a "greenout"
Generally, cannabis toxicity improves on its own over time without medical intervention as cannabis is gradually and progressively metabolized and its effects subside. Unlike certain other substances, notably opioids—in the absence of other medical complications related to co-occurring conditions—an overdose of cannabis is highly unlikely to be fatal and most people do not need hospitalization. As long as someone can remain in a calm and safe environment, they will get through the greenout and be fine. When in doubt, it’s always advisable to seek medical assistance, and in more extreme cases of anxiety, panic, or paranoia, going to a hospital for observation with or without the administration of anti-anxiety drugs may be indicated.

When young children inadvertently consume cannabis products, rather than becoming agitated or paranoid, they tend to get lethargic, sleepy, and sometimes comatose. For them, observation in an urgent care or hospital setting is advisable for monitoring and to make sure their airways are not compromised. To prevent overdose and medical emergencies related to pets and children, the best practice is to keep cannabis secured and with its original packaging.

For those experiencing a greenout in the absence of a medical emergency, the following actions that create a calming environment can be beneficial:

Decrease the overall amount of stimulation by dimming lighting, reducing the volume of music or other sounds, and turning off the TV. That said, soothing/relaxing music or calming sounds at low volumes may be helpful.
Breathe intentionally by making your breathing slower and deeper, and breathing through your diaphragm/stomach.
If you're familiar with them, practice meditation, utilizing a guided meditation app if necessary.
If you can, call or text someone whom you are comfortable talking to about what you’re going through. If they can be with you in person, even better. Connecting with someone you trust and feel safe with can help to reassure you and decrease your symptoms of anxiety.
Keep in mind, and remind yourself as necessary, that this experience is temporary—even if it lasts longer than you would like, it will pass.

RESILIENCE-
What I Learned About Resilience When My Desk Buddy Died.
A Personal Perspective: Finding resilience through others.
Reviewed by Michelle Quirk

When asked to recall the formative moments in our lives, few of us will describe the luxury holidays we were lucky to go on or the lavish gifts that our parents indulged us with (if we were fortunate enough to receive them—I’m just imagining here). It’s rare to hear someone relating tales of their character being forged while sipping cocktails at a poolside bar. There’s something about the experiences that feel the hardest to experience that make for the most potent memories. I know this well; I learned important lessons about resilience when the colleague who sat next to me fell ill and died in a month.

Where's Our Resilience Switch?
The concept of resilience is so casually bandied about that it can feel hackneyed. "Be more resilient," children are schooled. We’re all advised to show a resilient bounceback response in the face of personal setbacks. But the term is so liberally invoked that even a keenest intent to be resilient can stumble for fear of not knowing how. Someone telling us to show more resilience can elicit helplessness if we feel unable to activate the elusive strength when asked. Where’s our resilience switch? I’m certain that I would have had no idea of how to demonstrate greater personal fortitude if asked before I found it being thrust upon me. I learned that resilience is the strength we draw from the people around us.

For a British person, one of working life’s simple pleasures is finding yourself in the synchrony of being in a "tea round" with like-minded desk neighbours. Yes, we really do drink lots of tea, and we tend to take turns making cups for each other in "rounds." To look up from an email or to wrap up a call to see a hot steaming mug of perfectly coloured tea being gently laid down is an under-celebrated joy. When people talk about what we lost in the pandemic, this was our quietest loss. One Monday morning, my tea buddy was gone. I’d been prepared for her absence: an unrecognised number appearing on my phone screen the day before, her anxious partner telling me of an unexpected cancer diagnosis after a visit to the emergency room.

I was part of a small team, with around 50 or so colleagues in a slightly tatty serviced office in central London. The colleague I’d made hot drinks for was also a friend and colleague to the group who worked in the tightly packed space around us. When someone’s health takes such an alarming turn for the worse, we’re so consumed with distress and sympathy that even acknowledging our own distress can feel indulgent. People cried together and hugged each other but didn’t want to dwell on their own feelings; rather, we wanted to hold our colleague’s well-being at the top of our minds.

Anyone familiar with cancer care in the United Kingdom will know that most hospital wards prohibit gifts of flowers and chocolates. In the fog of emotional confusion, it’s not immediately obvious what token of love that you can send to a sick friend. One colleague (who sat roughly two tea rounds down the office) suggested we could collectively knit a simple woolen blanket. Knitting lessons were arranged, and size-10 needles distributed with balls of soft yarn. Meetings developed a gentle click-clack percussive soundtrack as colleagues raced to complete their pledged commitment of knitted rows. There’s something therapeutic about working with one’s hands. It felt that we were trying to mend our friend with our slow and deliberate stitchwork.

We Were Bonded by a Powerful Shared Experience.
Heartbreak soon followed, our friend slipped further into sickness and then, within days, was gone. To compound the breathless urgency of the few weeks, we’d not even been able to visit or say goodbye. In such grief, it would have felt indulgent to observe on how the month had changed us as a group. We survivors—knitters, stitchers, and nonparticipating supporters—had been bonded by a powerful shared experience.

When we look for resilience, we make the mistake of going in pursuit of tales of individual valour and bravery. The US Army has spent the last decade desperately trying to teach combat soldiers how to switch on their personal resilience mode in exactly this manner. (And this has been an endeavour that research would suggest has had no impact.)

In contrast, so often when we do observe resilience, it comes quietly, like an enveloping hug. It comes as a sense that we’re all in it together with those around us. When we hear stories of the resilient bravery of Ukrainian citizens and soldiers, it’s this sense of shared experience that seems to embolden them. We witness it in the bravery of survivors of natural disasters. More mundanely, my colleagues and I learned our own lessons of drawing on the strength we gained from each other— the tea rounds grew bigger, and the bonds grew stronger.

Bruce Daisley is the author of Fortitude: The Myth of Resilience, and the Secrets of Inner Strength.

KETAMINE-
Update on Ketamine via Telemedicine Delivery.
A breakthrough treatment for depression or a risky precedent? Here’s the latest.
Reviewed by Tyler Woods

In 2020, the federal government changed the rules to make it easier for providers to treat patients via telemedicine. One rule change allowed providers to prescribe controlled substances like ketamine without first seeing the patient in person.

The thinking was that, because the pandemic was raging, it was too dangerous for people to go to doctor’s offices for visits and to get their prescriptions.

Since that time, the number of people receiving ketamine via telemedicine has soared. The reason is clear. Several studies, as well as anecdotal evidence, in the last few years have shown ketamine to be highly effective for some people with treatment-resistant depression (TRD). It is also showing efficacy for bipolar disorder, PTSD, and certain other mental illnesses.

But depression seems to be the sweet spot. Many who have been suffering from debilitating TRD for years, and who have tried other medications with no success, are finally seeing their symptoms improve with ketamine. Some see a dramatic improvement over a period of days or even hours.

Another positive development? Ketamine obtained in this way—it usually gets sent in the mail in lozenge or tablet form when the prescription is filled—often costs far less than when a person receives the medication in person at a clinic.

So far, so good. However.
The risks of ketamine via telemedicine delivery
There are several serious downsides to this development. For one, when ketamine is taken chronically in high doses (which can happen when it’s taken at home in an unsupervised manner), it can cause severe bladder damage. In some cases, the damage requires surgical reconstruction of the bladder.

Ketamine can also be highly addictive for some individuals, and you can overdose on it. It can also dramatically raise heart rate and blood pressure when you take it, and it’s risky for those who live with certain kinds of psychiatric illnesses.

Maybe the biggest downside of all is that there is virtually no data on the long-term health effects of taking ketamine daily or every other day, as many who get it delivered via telemedicine do. (Many people receive their monthly dose of lozenges or tablets, take more of the medication each day than is prescribed, and run out early.)

Compare that lack of oversight to ketamine’s FDA-approved nasal spray form, called esketamine or Spravato. This is normally taken in a controlled clinical setting only once or twice a week for a set number of weeks under medical supervision.

Given all these upsides and downsides, what’s the best way forward with ketamine? Let’s start with the basics.

What is ketamine?
A synthetic substance, ketamine (pronounced “KEH-ta-meen”) was developed in the early 1960s as an anesthesia treatment to keep people from feeling pain from injury or during surgery. It’s still used today and is especially common in veterinary hospitals.

Classified as an anesthetic, ketamine causes feelings of dissociation and sedation in higher doses. It gained notoriety in the 90s as a club drug—people inject it, snort it, or add it to marijuana or cigarettes. Nicknames include "K," "Special K," and "Super K." Ketamine has also shown benefits in pain management for both chronic pain and acute pain in emergency room settings.

When taken to combat depression and other mental illnesses, ketamine can produce hallucinatory effects, visual and sensory distortions, out-of-body experiences, and euphoria or a “buzzed” state. Often, a ketamine “trip” lasts about two hours, though occasional side effects, such as unconsciousness and high blood pressure can be severe.

Many ketamine patients say that their sessions with the drug can act as a reset button for the brain. The drug allows them to detach from themselves, and many report profoundly pleasant thoughts and visualizations. Afterward, your daily problems can feel less oppressive, and the improved mood can last for weeks or longer.

A few cautionary words on telemedicine as a delivery method
As an addiction treatment clinician, I am wary of working remotely with patients, prescribing medications to them via telemedicine, and monitoring their progress and recoveries via videoconference. Why? Because it’s harder to do all those things remotely than if you’re seeing someone in person and can assess body language, attitude, hygiene, and other behaviors. It’s also easier for patients and providers to abuse the “virtual” delivery system.

So yes, in a perfect world where quality in-person care was available to everyone, that delivery method would win every time. But that’s not the reality. To extend our health and medical reach to those who otherwise wouldn’t access it, telehealth is vital, and it’s here to stay. On balance, that’s a great thing.

Telemedicine and ketamine
Here’s my take: Telehealth-based care (usually via video) works well for physical ailments like strep, skin rashes, or sinus infections. But things get more difficult with mental health because there are fewer physical symptoms to guide you. It gets dicier still when the medication that is prescribed for the illness is itself risky, as is the case with ketamine, because it’s harder to monitor remotely.

That said, the answer isn’t to shut down this delivery method for ketamine. Rather, we need to create regulations and safeguards that allow for the medication to be prescribed and monitored by a certified provider in a safe manner.

With that goal in mind, I offer the following.
4 recommendations on ketamine
Put clear, enforceable rules around that first visit with the provider. If the government doesn’t require a return to an in-person visit before prescribing controlled substances like ketamine, that first virtual visit must be comprehensive, recorded, and trackable by an oversight body. I hear all the time that these initial visits are as short as 30 minutes, and I can say with certainty that it is impossible to do a thorough mental health assessment with a patient in that amount of time.
Require certification of all providers and companies that offer ketamine via telemedicine delivery. This is how it works now with clinics that offer in-person FDA-approved Spravato nasal spray. Similar regulations need to be in place for the new providers offering ketamine via telemedicine.

Require addiction screening for all patients. Because ketamine can be addictive, providers and patients are playing with fire if patients aren’t thoroughly screened (this takes more than 30 minutes!) for addiction use past or present. This needs to happen, no exceptions. My recommendation is that a patient must be sober from drugs or alcohol for at least six months, if not a year, before a ketamine prescription is considered.
Make it mandatory that providers do frequent video checkups with their patients who take ketamine. This oversight is vital. Providers need to see how the patient is doing in order to make dosage adjustments. Video chats also allow for visual evidence to be shared, for example, the provider can ask to see a patient’s remaining dosages.

Key advice for patients
Always advocate for yourself, and remain vigilant about fraudulent or suspicious activity by your provider.

Remember, providers are not infallible. They sometimes make mistakes in judgment—or worse. There’s money to be made in this new-frontier area of medicine at the moment, which means you’re always going to get some bad characters involved.

If something smells fishy about the way medications are being prescribed by your provider, ask about it. Push back. Ask direct questions. Make inquiries. Do your due diligence. Google your provider to check on their credentials.

Bottom line: Be careful. Hold your provider to the highest possible standard. This is your (or a loved one’s) mental health we’re talking about, and there’s nothing more important than that.