Is Cannabis or Marijuana Safe to Use?
Welcome to Kemah Palms Recovery’s YouTube channel, where we post continuing education videos to keep you up to date on relevant information in our field. This presentation is for educational reference only. You must attend our live presentations for continuing education credit. For more information email CEU at Kemah Palms. Thank you to our presenting partner, medical director at Yellow Brick, Dr. David H. Baron, MD. This presentation is on not your parents’ cannabis. Don’t forget to hit the Subscribe button to stay up to date a more continuing education videos, just like this one. Hope you enjoy my delight to introduce you to one of my favorite people, Dr. David Baron, who is our chief medical director at Yellow Brick. And I’m just going to give you a little bio about him. He was born and raised in part of New York City and later in Livingston, New Jersey. He received his B.A. in Psychology, Magna Cum Laude and MD Degrees from Case Western Reserve University in Cleveland, Ohio. Dr. Baron went on to complete his psychiatric residency at Tufts New England Meadows Medical Center in Boston, and he is a clinical assistant professor at Rosalind Franklin University and part of the Chicago Medical School. In that role, he supervised psychiatric residents in their community psychiatry rotation for 15 years, and during that time, he also served as administrative psychiatrist and interim medical director of mental health services for the DuPage County Health Department, supervising 50 psychiatrists and over two hundred other clinical staff. Dr. Baron’s clinical and administrative experience and practice, since completing his training in eighty nine, has been within a developmental and neurobiological understanding of mental illness over the course of his career. He’s worked to understand mind and brain as different languages for the same essential human experience, including the complexity of neuroscience, the evolution, the evolutionary basis of the human brain and behavior and the deeply personal, subjective experience of every individual. Dr. Baron, certified by the American Board of Psychiatry and Neurology and is a distinguished life fellow of the American Psychiatric Association. He served on the Ethics Committee of the Illinois Psychiatric Society as a member from 2001 to 2006 and is chairman from 2006 to 2011.
Dr. Baron, I will turn things over to you. I am very excited about this presentation myself. Thank you very much, Tracy, and thank you, Krystle, and my gratitude to Kemah Palms for hosting today. And it’s a pleasure to I was going to say to see you all, but we don’t get to have that pleasure today. I get to see Tracy and Krystle, which helps me to feel like I’m talking to people. Thank you for staying on the video, but I know it’s a large number and this is this is what we can do know. We adapt and we’ll keep adapting until we don’t have to anymore. And in the meantime, I’d like to talk to you about cannabis and. Uh, some things that you may know and maybe some things that you don’t know and hopefully learn some things together. I would like to request that if you have questions, please send them through the chat to Krystle and I will respond to as many as I can at the end. And if we don’t get to everything, I will respond by email to any pressing questions. But I do want to try to get the whole presentation in before Noon Central, which is what we’re aiming for so I can stay a bit after that to respond to questions, and I’m happy to do that. If we can use the Q&A box, that’s even better. Sometimes they get too and they get lost in the chat sometimes, so it’s easier for me to keep up with all. The chat also includes everyone being so polite and introducing themselves, and I appreciate that. But yes, the Q&A, please for questions. So let’s get on with the. With the show. Ok. If I’ve done everything right, you should be able to see the first slide. Not your parents cannabis does legal mean safe? It’s a kind of a leading question, of course. My answer is going to be not so much. It doesn’t mean safe as much as a lot of people think so. I’ve actually decided to co-opt somebodies book. At least the cover of their book, this is the book What’s Wrong With My Marijuana Plant? Their intention was to help people grow marijuana.
Cannabis is Not as Safe as People Think
I have a totally different intention, which is that I’m going to be telling you there’s actually quite a lot wrong with it, whether you’re trying to grow it or use it or not. There may be some helpful things about cannabis. There are some medical indications things like glaucoma, terrible nausea from chemotherapy, and those have been established for a long time and their particular circumstances. But trying to find indications for this as a therapeutic agent in the world of psychiatry and substance use, I believe is a failing task. And it’s not just my belief. There’s a lot of science behind that, even though there are going to be people who disagree with me and there are people who prescribe it for such things. But now it’s gone way beyond medical cannabis. Many, many states have legalized recreational use in Illinois not long ago. Did that the dispensaries are? Popping up like weeds all over. And so we’ve got a whole different issue on our hands. Of course, it’s been a widespread drug for, you know, hundreds and hundreds of years, maybe longer. But now it’s it’s taking a more prominent place because there’s no fear of legal consequences anymore, at least where it’s legal. The derivation of this talk is from an old Oldsmobile commercial. This is not your father’s Oldsmobile. If you remember this commercial, then I know how old you are. And I’m that old and older. This ad campaign was from the late 80s. It was right before they made the last Oldsmobile. It was their last ad campaign and I chose it very deliberately. And I think that there’s there’s a lot of reason to be concerned. So we’re going to go back in time again, if you remember this cartoon, then you’re dating yourself, but you don’t have to say so. And plus I can’t see you, so I can’t even see if you’re reacting. This is Mr. Sherman, the dog, Mr. Peabody, the dog, and Sherman, his pet human. And that gadget behind them is the Wayback Machine, and I was an avid fan of this when I was a kid. This is from the 1960s where it says 1972, but this is from a remake that was made after that the original series of some of the 1960s, where they would go back in time and encounter historical figures, and then they’d spoof them and make jokes about them.
But I actually learned a little bit of Greek mythology and some Western European history from this show. Mm hmm. I think there were probably people who in the 60s who preferred to watch this show while they were high because it had a little a little bit of a surrealistic bent to it. This is something else from the past. This is from the 1930s. So we can thank a man named Harry Anslinger. He was the commissioner of the Federal Bureau of Narcotics. For demonizing the cannabis plant, and he did that in the 1930s by ignoring all the available science at the time that didn’t support his personal views, I don’t know when I’ve heard of that happening recently, but some people are prone to doing that and. There’s a complicated history, but he was actually he had a very profound personal view that there was no good that could possibly come. People smoking this or using it. And he wanted to get rid of it. He wanted to eradicate it. And so he linked this plant through the name marijuana, which is a name used in other parts of the world, especially in Latin America, for the cannabis plant. His ad campaign, which included posters like this one, linked it to foreigners, particularly foreigners from Mexico, as part of an overall very racist attitude on his part, and when he was speaking in public, he was a regular user of the N-word in official government memos. He used that word. So this is why I and we at yellow brick and most people in the science community usually refer to it as cannabis, that is the Latin official name for the plant. And I have really moved away from using the word marijuana since I learned about this. They never got to go to any of those wild parties or weird orgies. I just don’t think the real. Let’s go back. Ok. Some more cannabis history. These could have been the poster children for cannabis in the 70s, Cheech and Chong. This is their oversized joint right there. There they are many years later. This is Tommy Chong on his way into prison for dealing cannabis. He actually went to a low security federal prison for distribution before it was legalized.
And he actually had cut a deal. He went to prison to keep his family out of prison because they were involved, too. And he basically took the fall for them. A little more complicated than that. But they were. I think they threatened Tommy with charging his wife and one of his kids. He chose to spend some time locked up instead. Ok, what’s changed since then? Well, in 1975, let’s say I was in high school, you could get an ounce of cannabis for $20. Uh, you know, as of a month ago or two months ago, the national average is about in the mid $200 for an ounce. And there’s a reason for that, it’s not just because it’s a booming industry and this is way beyond the rate of inflation. It’s because it’s changed, it’s not the same plant, this is why it’s not your parents cannabis or your grandparents, depending on where you are in that that sequence. So here’s something else that’s changed. The main thing that’s changed, by the way, is there is a lot more THC in the cannabis being sold and used today than there was 50 years ago or 40 years ago or 30 years ago. It’s gotten progressively up even before there was medical cannabis legal use and before there was legal recreational cannabis. The people selling it illegally learned that there are a lot of reasons to increase the concentration of THC in the plant you’re selling. Not least of which is, it’s actually more addictive. The more potent it is, it gives a more profound effect, even if it’s the desirable effect. But it also creates a lot more of the undesirable effects, and I’m going to get into that in a little bit. But there’s something else that’s changed, too. It’s not all it is, actually, it appears to be a kind of a zero sum formula that if you hybridize cannabis, which is what they did before genetic engineering, they were just taking the plants that got them the highest and breeding those together and making them more potent plant. Since genetic engineering, it’s gotten even more profound. But. Cbd is cannabidiol, and CBD, for the most part, is not a psychoactive substance, it does seem to have some beneficial effects in some.
THC Levels in Cannabis are Higher Than Ever Before
Contacts, possibly for some psychiatric diagnoses, I think the the jury’s still out on how helpful it might end up being, but it probably isn’t all that harmful for most people, for most circumstances by itself. And and this is really fascinating. The absolute percentage of THC in cannabis since the 70s has gone up, at least by a factor of four in some studies. It’s up by a factor of 10 to 15x, so it’s much, much more potent. The methods of testing in the 70s were not quite as accurate, and the randomness of sampling has not been all that consistent. But also the ratio of THC to CBD. Has gone up to by a factor of seven or eight. So and that’s what this curve is. This is this is actually a calculation, so it’s how many grams or milligrams of THC per milligram of CBD is there in a particular plant over time or an average of the plants over? And it turns out that when there’s more CBD in the in the weed and the cannabis. It mitigates it reduces the effects of the THC. It makes the THC a little less likely to cause some of the negative and undesirable effects like psychosis. So CBD, when mixed with THC and you’ll see shortly mixed with a whole bunch of other psychoactive or potentially psychoactive chemicals. They have some protective qualities. This does not mean and I want to say this very affirmatively, we do not have the science to say if you want to smoke as much weed as you as you care to. And not get psychotic and not have complications of any psychiatric disorder. Just take some CBD with it, that’ll mean you’ll be fine. The statement I’m making here is very far from that statement that would require some very specific science, and no one has undertaken it, to my knowledge. So, but that it is it is probably one of the reasons that the drug is so much more potent that the plant is so much more potent. This is a standard dose response curve. And for those of you who may not have seen it, this is kind of med school pharmacology 101 if you look at this graph.
Let’s think in terms of the topic at hand. This is degree of highness. And this is dose. So you smoke one joint per day where you take three hits per day from your vape, where you do one bowl per day or whatever version you’re down here and you get this much response now you go up to two, you’re at this much response. And when you get up to, you know, you’re smoking all day, you’re up here. And then at a certain point, you can keep smoking all you want, and it doesn’t get to be any more intense so. Higher dose, higher response and it follows a predictable pattern. That’s all this means. But this is for one chemical. Dose response curve is always for a single chemical, it might be Tylenol, it might be Prozac or it might be THC. It’s not cannabis. Cannabis is a plant. Plants have lots of different chemicals. So here’s what it looks more like for cannabis. There are multiple dose response curves for multiple components of the cannabis plant. So let’s say this is THC, this is CBD and this is some other cannabinoid. I’m going to show you a list of cannabinoids in a moment, but each one has its own dose response curve. So that’s important. Tell you why shortly. Also, there’s a different dose response curve, not just for different chemicals, but for different responses. So if one of the responses for cannabis is I smoke a bunch of cannabis, the THC helps me because I’m having chemotherapy and I can’t stop puking and after a certain amount, I stop puking. That’s the dose response curve for THC, for nausea. Nausea control. If it’s that, it helps reduce the pressure in my eye, so my glaucoma is not as severe. And that’s the dose response curve for glaucoma. And then there’s another dose response curve for getting high. And the one we’re most concerned about in my work, there’s a dose response curve for becoming psychotic also. That’s one of the responses, and it has its own curve. Here are some of the cannabinoids that are found in the plant. We have cannabidiol, we have. Kind of a crow mean, we have cannabinoid all THC, we all know about tetrahydrocannabinol, this is what we test for when we do talk screens and get a urine from somebody.
The Half-Life of THC and Cannabis
See if and this will tell us if they’ve been smoking in the last couple of weeks because it has a very long Half-Life sticks around a much longer time than the time you actually feel the effects. There’s cannabigerol. There’s tetrahydrocannabivarin. Um. You know, this is sort of the view of six cannabinoids that exist in the cannabis plant, but. Wait, there’s more. And those old infomercials. Wait, there’s more. Wait, there’s more. Ok. Here are some of the compounds found in the plant known as cannabis sativa. I’m not going to name them all. I’d need a little practice for not to pronounce them all, but here’s just a few. Was this the beginning of the list? A lot more than six already. Now we have some more of the list. These are minor constituents, but they’re all present. And here’s a little more of the list. And here’s the rest of the list. Now, this list, this particular list, by the way, different sources will give you different lists, they’re all overlapping, but depending on which lab tested it and how closely they’re looking. There had been as many as 110 different chemicals identified. In the cannabis plant and at least a half a dozen of them are known to be psychoactive, and probably more than half of them have never been studied. No one has done research to isolate the chemical. Try it out on some animal model. See if it changes the animal’s consciousness or has some other effect. No one’s done that with many of the components of this plant. This particular one comes from the botany and chemistry of hallucinogens. But wait, you say cannabis is not a hallucinogen. Yes, it is. In fact, it is. If you’re on the right dose response curve, if you use enough of it and your sensitivity to hallucinating is higher than some people’s. You will hallucinate on cannabis. Who does that? People who have genetic vulnerability to psychosis typically. And what’s the percentage? Well, in the 1970s, it was three to five percent. Now it’s 15 percent. Why is that the potency has gone?
Health Effects of Long-Term Marijuana Use
So why be worried, you know, what’s the problem, it’s not addictive, I mean, even if you know, but just use a little, I’m not going to get psychotic, it’s not going to kick off a manic episode. You know, and it doesn’t cause mental illness, does it? But you can kind of see where I’m going with this. So this is a this is a graph that looks at its complicated graph, but basically. Um, this is looking at if you have a psychotic illness and you smoke weed or use cannabis in some form or THC. What’s the correlation between your use of that drug? And how long you stay out of the hospital for your psychotic symptoms? So basically, it’s a kind of inverse of how often do people get hospitalized if they’re using and. Basically, the people who use the most get hospitalized the most. If you had a totally flat line here, you never go to hospitals, so the higher the line goes, the higher the tracing goes here, the more you’re getting hospitalized and the sooner you’re getting hospitals. This is time. And this is how many people have relapsed and needed hospitalization. I’m sorry, this one is not specifically about hospitalization, this is just about relapsing symptoms. There’s another graph which I didn’t include that shows when do those symptoms lead to hospitalization? It actually looks very similar to this one. But the numbers are a little bit lower because not everyone with symptoms gets hospitalized. So this is, you know, if I was psychotic. I got some treatment I’m using. How soon before I get psychotic again? And the Green Line. Is the people who use the most? Look, what happens. They get symptomatic sooner, they stay symptomatic longer and more of them get symptomatic. What else can it do? Ok, if you’re young and you have a mood disorder. And you use you are more likely to self-harm and you are more likely to die. That seems fairly serious. This is a new study to. Just about a year old. Very reputable journal, too, this is Journal of the American Medical Association, pediatrics specialty. There’s another one. So this is from March 2020.
Marijuana Use Impairs You
They looked at. I’ll go into the details, but basically it’s from the journal Drug and alcohol dependence. Recreational cannabis use impairs driving performance in the absence of acute intoxication. So. Users had poorer driver simulator performance compared to non-users controls. Users were not intoxicated during testing, meaning that these are residual effects, you don’t have to be high to be affected. The impairment was primarily localized to the people who started using the earliest. Before age 16. The earlier you start, the more impaired you are. Again, this is not while you’re high. This is not like drunk driving. It was. It would be as if somebody who gets drunk every weekend has more impairment in their driving on Thursday. When they haven’t driven, they haven’t drunk for three or four days. Although there’s an important difference between the two covariate analysis means analysis means that they take a statistical look at different findings and see where they how they compare to each other and what they correlate with. And people who are more impulsive. Are more likely to have these performance deficits in differences. The overall impulsiveness influences. Who’s going to be more impaired by their regular, but not daily and not very recent cannabis use? Well, kind of makes sense. What do you have to do when you’re driving? You have to stop yourself from doing stuff a lot. Literally, you have to stop yourself by hitting the brakes. What the 16 year olds have less of than many of the people, I would say, any of the people on this call. They don’t have as much of a prefrontal cortex because it’s not fully developed yet. And what does the prefrontal cortex do? It tells your limbic system, your emotional brain, slow down. Wait a minute, this is dangerous. Don’t do that. Or even just I don’t think this is such a good idea. And when parents say that teens often say, No, I’ll be fine. Leave me alone. And if you have more of that, I’ll be fine. Leave me alone if you’re more impulsive. And you don’t have as much of a frontal lobe because it’s not developed yet and you’re impaired by cannabis, even if he used it a week ago.
Marijuana Use Leads to Poor Decision Making
If this inhibits you, it makes you more likely to make the poor decision in the driver’s seat. And that’s why they show more impairment. Ok. Let’s look at another finding. So traditional marijuana that means, you know, sorry, your parents cannabis. High potency cannabis, that’s today’s synthetic cannabinoids, you know, labs have come up with synthetic versions of THC, which is the main synthetic cannabinoid. All of them are associated with an increased risk of psychosis. So epidemiological evidence means population studies that cannabis use is associated with increased risk of psychosis. There’s a dose response relationship like that curve I showed you a few slides ago between how much you use and the risk of later, not only immediate but later psychosis, high potency cannabis and synthetic cannabinoids have the greatest risk. Remember, if you’re taking a synthetic cannabinoid, it’s one chemical. So if you take THC that was made in a lab and there’s no CBD and none of the other chemicals, the value or danger of which we don’t know among those 100 or so that are in the plant are present. When you’re taking the synthetic cannabinoid, you just take the pure drug. It’s like mainlining pure, uncut heroin would be the analogy. That has the greatest risk. Well, it’s not shocking, but there’s evidence for it. So. There’s not convincing evidence that cannabis use increases risk of other psychiatric disorders, what that means is not that it doesn’t make things worse if you’re already depressed or anxious or have PTSD. It may be a short term relief, you know. Let’s not kid ourselves. If you’re having a flashback and getting high helps you calm down, then getting high helps you calm down and that can become reinforcing. But it can become problematic because you don’t have any other means of calming down. So that’s that’s why there’s such a correlation between drugs and psychiatric disorders. But it doesn’t necessarily make the PTSD worse over time, if you have a psychotic illness, it does make the psychotic disorder worse over time. But there’s no doubt that it detrimentally affects cognitive functioning and cognitive functioning is something you need to manage any psychiatric disorder or. If you have trouble with other substances and you say, well, the weed isn’t so bad.
Marijuana and Substance Abuse Disorders
It’s going to make you have trouble managing your substance abuse disorder. And all of this is worse if you start in early adolescence. And there’s a reason for that. There’s a neurobiological reason it is known from good research that regular use of cannabis, especially in adolescence, impairs your brain’s ability to form myelin, and myelin is like the insulation on the wiring in your brain. It’s the coating around your neurons. And the faster firing nerve fibers and the ones many of those that have to grow as you mature and that we all need to grow every night to do our neuroplasticity changes. It’s how we learn things. We need that myelin in order to have a robust. Brain development system in our own head. And adolescents in particular and young adults need that more than most, because it’s the most active time of neuroplasticity change in life after the first three years. Cannabis interferes with the formation of myelin. It’s it’s like putting a roadblock in front of the developmental. Truck. You can’t get down the road. So what about addiction? One of those questions? Well, cannabis is not addictive, right? Not so much, what’s the strongest predictor of addiction in general? So all of these are candidates, right, genetics and family history. I mean, everyone has worked with addictions knows that the likelihood that a person with an addiction has another family member with an addiction is pretty high usually. A weak character. That’s what a lot of people think, Paul stuff does talk about character defects. They may not say weakness, but you know, it’s not a completely foreign concept that character defects can contribute to addiction, vulnerability and and to perpetuating addiction. What about non substance related psychiatric diagnosis? Well, it’s certainly a high correlation a yellow brick. Two thirds of the people coming in have a substance abuse disorder, whether it’s a primary or secondary diagnosis. Upbringing and parenting, it’s my parents fault. The nurture part of the nature nurture question, by the way, the answer to the nature nurture question is yes, let’s put that behind us. It’s 50 50. Plenty of research to back that up. Oh, sorry, trauma. Well, yes.
Marijuana Use and Trauma
Of course. Um, how do you define trauma if you define trauma on a spectrum? A lot more people have had trauma than. We might otherwise conclude. And what does epigenetics so epigenetics is the way your environment changes your genes. We all have genes we’re born with. But actually, they start getting modified even in during pregnancy, in the uterus. And they get modified by chemical changes and the chemical changes are associated with stress. And so if you draw up, grow up in a much more stressful environment, whether it’s because it’s abusive or the sexual boundary crossing or violation or you grew up in a war zone, literally like many people have to. It actually modifies your genes and causes them to be expressed differently, so if the genes are the. From which your body creates the proteins that then run your brain and your body. Stress actually changes the wording of the encyclopedia and then it gets read differently. And then we operate different. And so so this helps us understand why, just to use a classic example from my field. Schizophrenia is known to be an illness with significant genetic underpinnings. But if it were a purely genetic disease, you’d expect that identical twins, if one identical twin had it, the other would always have. And that’s not the case. It’s actually only 50 percent. And it’s independent to some extent of whether they were raised together or raised apart. We can thank the socialized medicine system of Scandinavia for finding many years ago because they track health care, they track psychiatric admissions, they track diagnosis and they track adoptions. They knew exactly which identical twins were being raised together and which were being raised apart and who ended up having schizophrenia. And it remains about 50 percent, there are some differences, but the average is still 50 percent, not 100 percent. Why not epigenetics? Because even to people being raised in the same household don’t have identical experiences. Even if they’re always in the same place at the same time, they don’t have identical experiences. So that’s epigenetics. It’s really important, has a huge impact on everything we do. So what is the single strongest predictor of addiction, which one of these is it?
It’s a trick question. It’s none of the above. This is it. This is it. All those other things matter, of course. You know, if your entire family of four of your grandparents and 16 of your great grandparents or eight of your great grandparents, you know 100 percent of your family going back three generations were alcoholic. You know, you’re going to be really lucky not to develop alcoholism. The only way you would avoid it is don’t ever drink. And it doesn’t have to be that profound to be true. You don’t have to have the family history if you drink enough, if you use cannabis enough, you will become addicted. Now does cannabis have a physical withdrawal syndrome? Well, it turns out it does. And it’s much more evident. It’s not for 100 percent of people, and it depends on how much you’ve been using. But as the plant gets more potent, more people have the withdrawal syndrome, is it physically dangerous? No, it’s not like barbiturate withdrawal. It’s not like alcohol withdrawal. Those can kill you. Opiate withdrawal usually doesn’t kill you. It’s miserable. It doesn’t kill you. Cannabis withdrawal doesn’t kill you, either, but it also has a post-acute withdrawal syndrome, can go on six to 12 months with no use. This is an addictive drug. It’s just no question about it. Saying otherwise is mythology. So we each get one of these, this is a brain. This is your brain, let’s say, before drugs. Not like the frying pan commercial some years ago. Our brains have a very powerful reward system. And it’s part of why we still exist as a species, because if we didn’t know what was good for us and what wasn’t. You wouldn’t have survived. And what is this? This is a stick figure model of a dopamine molecule. And why is it important? By now, I would guess almost everyone, if not everyone on this call has heard of dopamine. Well, the reward system uses dopamine as the main chemical messenger. It’s been around for a really long time. You know, if you if you live in the south and you occasionally see lizards running through your yard, this little, you know, cute little lizards, not the big, dangerous ones.
They have the dopamine system. Snakes have a dopamine system, rabbits have dopamine system, you know, pick of species that has a spinal cord and they’ve got a. And what does it do? Well. It tells an organism. Something about what’s in its best interest. It helps you buy reinforcement to remember. Can I recreate the situation that did something good for me? Um, can I suppress my fear in order to seek out this thing that feels like it’s good for me because otherwise my fear might keep me from going after it, so if the thing that feels good to you is getting honey and you’re a bear? You have to put up with the BS. But the honey tastes so good it makes you feel so good. Sugar rush is so great and it enhances dopamine activity that bears are willing to put up with the bees and suppress their fear response and their threat response to go after the honey heart, the beehive and get the honey. How do you how do you tell between what’s good, you know, what’s just wasps, let’s say who don’t make honey and what’s bees? Well, if you just go to the wasp nest, you get stung and no honey not reinforcing, not positively reinforcing. And then later on, and this is where we have some advantage, you’d think, how will I problem solve finding this fitness enhancing fitness in this case means evolutionary fitness not. Are you in good shape, although that probably helps to. How can I recreate it and how will I problem solve recreating it in the future and dopamine plays a role in all of these? So that’s why we have a reward system. This is a dopamine receptor, it’s a different modeling system, but it’s a it’s a model of a protein that lives on the membranes of your neurons and dopamine molecules. And this fit together like it’s like a jigsaw piece. So there’s a guy named Kenneth Bloom, Dr. Bloom, and he came up with a term reward deficiency syndrome. And actually, the terminology in the field of addiction medicine has been changing. They did some years ago, officially adopt this as the preferred language over the word addiction because reward deficiency syndrome covers anything.
For which some people have a vulnerability to not feel as easily rewarded. And one of the basis of that for many individuals, not everybody is that you have different dopamine receptors, your dopamine receptors, if you’re more prone to addiction, it’s likely that they are less sensitive to dopamine. And you need to do more stuff to get that dopamine response. If I have that good feeling. So if a person without this genetic variation. Smokes a joint and says all that was kind of nice. Yeah, I like that, you know, maybe I’ll go watch a movie next time. Um. You know, that’s kind of ordinary, and they may not start to get attached to or seek out or become addicted to cannabis. But if a person with this variation in the dopamine system does the same thing, they may say, Yeah, that was kind of good, but I think I need more because I, you know, it just left me feeling kind of flat. And so the next time they do more, is it? Well, that was I was OK, but it’s still not quite good enough, and they keep ramping it up and remember that slide. That said, the more you use, the more likely you are to get addicted. This is one of the ways it can evolve. This is the neurochemical part of it. Of course, people are a lot more complicated than that. And I don’t mean to reduce it to a single molecule, but that molecule does actually play a big role. And talking about reward deficiency syndrome is another child. So for another day. And to finish, it looks like we will have time for questions before before noon. This is the best fortune I’ve ever seen. Think of this as. Food for thought, if you look at what it says here. It’s really kind of eerie, we’re at a Chinese restaurant some years ago, my son was a teenager and he got this fortune and he picked it up. He showed it to his mom and me, and he said, I think I should be worried when I get a fortune about this says, you know, I don’t have a future. The point is think critically when you’re learning and when you’re trying to help people.
Read between the lines. Thank you very much. Thank you. Wonderful, wonderful. We have quite a few questions, and I will not be shocked if we don’t have a couple more pop in as we kind of progress through these, but we’ve got enough time. You all remember, do not sign off until noon. I know sometimes when the presenter is done early, people sign up, but you do have to be here for that full hour to get the hour. So just a reminder on that. And then we’re going to I’ll just start at the top because I think we can probably get through most of these if we don’t. Dr. Baron has agreed to share his contact information. So, says Desmond, all have the same types of effects as more potent cannabis. Uh, yes. Asterisk, the asterisk is that because it’s because of what I said during the talk that Marinol is a single chemical, it’s meant to resemble THC very closely and it does pretty closely. It’s not identical. And of course, it isn’t identical to the plant. So cannabis is a plant with all those many dozens, maybe 100 or more chemicals in it. Some of them are probably not psychoactive, but we don’t know about many of them. We don’t really know how much each of them is contributing to the high or to other negative effects. So is it is it the same in the sense that it’s potent THC? It’s very similar, but I wouldn’t say it’s the same. So they also asked, is it safer than cannabis? That depends, not it’s a simpler molecule, but it’s not necessarily a simpler answer because, you know, having it that potent may be much more dangerous for some individuals, but getting rid of all the other chemicals might be safer for others. The absence of the CBD probably makes it less safe for people who are prone to psychosis. And by the way, we don’t always know in advance. In fact, the individual trying it probably never knows in advance how prone they are to psychosis. It’s a it’s a roll of the dice. You’ve got about a one in six chance that if you smoke weed now in twenty twenty two and you’ve never tried it before, and especially if you were in the pre-teens to mid-20s, late 20s, age range, you’re going to start hallucinating.
You get paranoid and not just while you’re high, not just while you’re humming. Yeah, it’s between one and 10 and one and six, depending on which studies you look at. So if you if you’ve got a hold of some Marinol and did that remember it’s potent THC like substance and no CBD, which probably mitigates the effects and none of those other chemicals that we don’t understand, it might be much more dangerous than. Yeah, that’s it’s wild to me, someone said, are we going to get a list of references from this great presentation? So they’re mostly embedded in it and you can get the slides. I tried to put the reference information on the slides if there are any that I didn’t do that on. When you get the slides, feel free to email me and I’ll pick them up and send it to you. But I think they’re all. And for those of you that have asked. He just said, You get the slides. Yay. Thank you, Dr. Baron. Of course. That’s that’s Dr Baron. That’s miss Tonda Chapman. If you didn’t catch it from that accent, I picked it up on the on the idea that that was that little Alabama. That was the roll tide, you know? Yeah, we were humbled this week and that national do for you guys to know. I love my tie, but yeah, I’m here. Thank you so much, Dr. Baron. What an amazing, amazing presentation. I have these questions that you answered in just an amazing way. Parents ask me every day they call they they know what we do as an industry. So man, what you’re doing is just absolutely wonderful. Thank you so much for sharing with us. My pleasure. We’ve got a couple more here. So it says one of my clients I work with states he smokes cannabis to help with his anxiety. Is smoking cannabis counterproductive to managing anxiety, managing anxiety in the long term? You know what a hanging curveball is? That’s a hanging curveball for me. Yeah, yeah. So yes, but to be a little more complete if you think about. Using any substance, including well-established so-called safe anti-anxiety medicines, and there’s an exception to this, I’ll say at the end, any immediate acting anti-anxiety medicine, which means all the benzodiazepines, Xanax, Valium, Ativan or the three leading ones these days.
You know, lots and lots of old drugs that don’t get used much anymore barbiturates, opioids. You know, some of them have their own dangers, but even the drugs that in and of themselves taking a single dose might not be dangerous. The danger is that becomes your only way to deal with your anxiety and to the extent the drug itself. That’s one of the reasons the drug itself can become an addiction or a reward deficiency syndrome. Issue, but it’s also it’s just an inherent behavioral loop. I get anxious. I smoke. Next time I get anxious, I smoke. Yep, the next time and the next time. And not having any other tools to deal with anxiety and from the kind of treatment we do a yellow brick not knowing more about why you get so anxious. Really impedes your ability to lead a more fulfilling, gratifying and productive life. So I would answer this the same about just about any immediately acting anxiolytic drug. And yes, cannabis for many people is an anxiolytic drug. The exception would be there are many antidepressants, and there’s one category of other pharmacology where they’re not immediately psychoactive. So all of the SSRI is things like Prozac, Zoloft, Lexapro, Celexa. A lot of people get a lot of relief from their kind of baseline anxiety. Their threshold for getting panicky goes way up. It’s much less likely they’re going to get overwhelmed. That’s different. That’s not an immediate relief. Of course, people want immediate relief. Everyone wants that every time we’re uncomfortable. But that’s not always the best way to deal with discomfort, even very intense, overwhelming discomfort. I would still stand by that. One other category is gabapentin and lyrica. Lyrica is still a little questionable, but for many people, it can be taken without becoming addictive and gabapentin very clearly can be taken without becoming addicted. People don’t find it quite as helpful as benzodiazepines, but that’s not surprising. But over time, it also can be quite helpful and doesn’t have that addictive loop. The cannabis and other drugs. Yeah, I think we hear it a lot. Nothing works for my anxiety, except, you know. Right? Well, it’s based on the principle that there it must be something that works, something I can take, something I can do right now that works.
There is a we have a gadget here called an alpha. An FDA approved brain stimulation device that clips to your ear lobes and helps your brain generate more calming alpha waves. That’s actually very helpful against anxiety. It’s not addictive. It helps train your brain to create calm states more effectively. We use that all the time, and it is immediate. It’s not a drug. Yeah, OK, let’s get through a couple more of these. Dr. Baron did say he can stay after to answer some questions. So I know I just want to let you guys know one more time again. The slides will be shared and then two, if you have to sign off at 12, which is Central Standard Time 12. That’s fine. You’ll be you don’t have to stay, but he can stay to answer some of these questions. So just wanted to reiterate that this one says cannabis. Do people youth who use cannabis have higher rate of developing multiple sclerosis since myelin is being targeted? I don’t know the answer to that. It’s a really interesting question. I don’t know. I just don’t happen to know. Yeah, yeah. In theory, sure, but know theory doesn’t always bear out in science, so I wouldn’t want to speculate, right? Do you know of a relationship between faith or lack of faith in a higher power in the use of cannabis? I feel like the questioner has something in mind asking that, and it’s I don’t want to try to guess so I don’t have a simple answer to that question. And I, you know, if I just look at it concretely, the answer would be, No, I don’t. But I think that probably doesn’t do the question justice to answer it that way. Yeah. And I would welcome if, you know, if that person wants to email me or help me understand the question better, I’d be happy to respond. Perfect. Is the idea of weak character still used as practitioners shift to addiction as mental illness, rather than the more critical view of addiction? Well, I’m going to respond to that question, I don’t know if it’ll be exactly an answer to what you had in mind, but I think I have a better sense of what this question means than I did of the last one, at least in a more detailed sense.
So what it makes me think of is when I started in practice, I started in Boston. My residency in Boston has a very well established and this was, you know, in the mid-1980s at a very well-established 12-Step community, and it was a very traditional 12 step community. And I was working in a psychiatry residency residency, so we we would interface with the 12-Step community. We got invited to go to meetings to learn more about it, to open meetings. But we did bump in. We bumped heads sometimes about it’s it’s one thing or the other. Now in the big book, it says If you have psychiatric, I’m paraphrasing, of course I have it memorized, but it says if you have psychiatric problems, you should seek psychiatric help for your psychiatric problems. This is for alcoholism. Which I really appreciate about the book, I hate that about the the founders of AA, but they understood what this program was for and what it wasn’t for. And they didn’t they were not dismissive of other problems or how to approach them. But the. What what can come, it can come across as very judgmental, if particularly from the outside of 12-Step, you hear something like character defect. And it seems judgmental. And from what I know, I’m not a member, but from what I know of 12-Step, from having worked with hundreds and hundreds of people who were members, family members who are members is that that’s not what it means at all. It’s saying, you know, take a critical look at yourself and something’s not right here. You’ve got to do something about it. Yeah. It’s a defect. You know, the language may be, you know, maybe people get a little fussy about the language and then. Here it as being judgmental. Put people in the world judgmental about addiction, of course, and they still are. Has it improved over time? I think so, but it’s still a problem. Just like people stigmatize mental illness. You know, I won’t. Since I’m going to tell you this story, I won’t tell you who it’s about. But we tried to refer someone with a psychotic illness to a substance abuse treatment center not long ago.
And the first question I got was, Well, is he violent? And this is from a well-established, well-known place that I have respect for. I didn’t have a lot of respect for that question, but you know, the attitudes are still out there. People hear certain key words and they get scared and they have reactions. And that’s true about addictions, too. Yeah. One thing that changes, though, I think the legalization of cannabis has had an effect with a lot of people in the general population of just kind of normalizing it. Oh, it’s no different from alcohol. Well, that’s not reassuring. We have plenty of people are trouble alcohol causes. I mean, lots of people can drink and never have trouble in their lives, and that’s true. But, you know, for 10 or 15 percent of the population, a very large number. That’s not true. And I think the same is going to turn out to be true with cannabis as it becomes more available. Yeah, it’s harder to what makes me nervous, I made a little note I put, I wrote driving because what makes me nervous is like the DUI stuff, dwi stuff. Alcohol is so much easier to track. Now we have all these places where cannabis use is legal. But then as far as I mean, studies have shown like impairs you behind the wheel. So but then you can’t really. There’s I mean, there’s some sobriety tests, actually, but there’s some study. There’s a study I didn’t include because it seemed a little more complicated than I would have time to go into. But I’ll give you the bottom line of it. There are people who are looking at trying to figure out now that it’s legal. How might the cops test you to know if you’re legally quote, legally intoxicated? Of course, it’s much bigger than that because it involves changing the laws. Not to say there has to be a legal standard to then, right? Ultimately, it’s the police officer’s judgment. You know, even if you blow 0.07 and you’re acting like you’re drunk, he can still arrest you. Yeah, but we don’t have levels for THC and even if we did. The level of alcohol correlates much more tightly with impairment.
And there’s a lot of science and research behind it, then does the level of THC, the level of THC that impairs is much more variable from individual to individual. So just getting a THC level, even if we had a quick way to do it on the road wouldn’t be good enough. It’s probably not where we’re headed. I think they’re going to eventually come up with something else or some kind of, you know, like the sobriety test, no matter what your level is, probably is still listening. I think that’s why they use the sobriety field test and things like, you know, officer judgment, that kind of stuff. Exactly. This is a quick question at what age does, is the frontal cortex fully developed? Well, I mean, the most concrete answer is never because we’re always growing and changing. We don’t actually grow new nerve cells either much or at all past late adolescence, early adulthood. But we are rewiring our nerve cells all the time. The average neuron has 10000 connections with other neurons. That’s why you hear the statement, sometimes there are more synapses that is connections between neurons in a human brain than there are stars in the universe. Wow. It’s a it’s a big, big, big number. So that’s why brain mapping is so difficult because it’s such a detailed map, but the fact is we’re changing that everyone is changing that all the time until you die, you know? And you know, for people over the age of late 20s to 30, it slows down. We don’t do it as much for people between about 17, 18 and late 20s. It’s going on much more rapidly, much more actively. It’s much more robust. But I think what the question is really about is, you know, when do you have all of the neurons in your frontal lobe and that’s, you know, by early to mid-20s, late 20s at the latest? I don’t know what the latest science lands exactly, but it’s, you know, early to late 20s somewhere. That’s the reason why our yellow brick is organized around emerging adulthood is to take advantage of that neuroplasticity. Exactly. Um, what’s the difference between THC and CBD? Yeah, the chemicals are just slightly different.
The the functional differences as relevant to this talk I talked about earlier, THC is clearly an intoxicant can impair cognition, has all the other effects. I’ve talked about CBD. The research so far is that it is not as much of an intoxicant. Maybe not at all for many people probably has some anti-anxiety properties. It doesn’t mean it can’t be addictive because we certainly have seen people here who are very dependent on it. But it may not be as addictive, meaning may not have as much of a withdrawal syndrome. I think the jury’s out on that, but I think it’s possible that we have as much of a withdrawal syndrome and there probably are some safe uses for it, just like there are some safe uses for THC, but I don’t think they’re fully established yet. We’ve had a couple of people here with very refractory psychotic conditions who asked about about CBD, and there are some researchers who have done some small studies that showed some promise that adding CBD to an antipsychotic drug may actually help some people get to a more stable and less symptomatic state with their psychosis. We haven’t seen any really convincing success with that, but that’s only a few people, and it’s hard to conclude anything. Yeah, we just keep having more and more questions come in here, so we might not get through all of these, so guys wouldn’t if we don’t again, Dr. Baron’s information will go out in the email, so you’ll be able to to email him this person. I’m just kind of going down the list. And so says this person says, How often do you hear people buying pot from their dealer illegally finding out that there was a secret ingredient in it, like opioid fentanyl, et cetera, and then accidentally becoming addicted to that substance, too? That’s a loaded question. Yeah. Personally, I haven’t that doesn’t mean it’s impossible. You know, there are very few people, but there are people who have a single exposure to a particular drug and then from that moment forward can’t get enough of it. So in theory, could that happen? I guess you’d have to know what it was, though. I was going to say, I don’t know that you could know what it was, right?
So I mean, I guess you could just go shopping around until you find the same effect, which plenty of people do. Yeah, yeah. Yeah. Um, let me see. I can see these now Krystle. So. Oh OK. Thc, oil and wax. Is it just THC or are there other cannabinoids? I don’t actually know. I think if it’s produced, you know, let’s say casually, it’s less likely to be pure anything if it’s produced by a lab, maybe more likely. But I don’t know of any labs that are producing that. No, I mean, like a legitimate laugh. Are Ambien, Rembrandt or Trazamine, I think he meant trazamin. Are they safer than the indica strain canabanoids? Yes. I’m sure people some people get great success with cannabis for sleep versus oral meds. You know, cannabis for anything, even for glaucoma and nausea from chemotherapy has potential complications. And in my view, it’s not worth those complications, and there are a lot of other ways. They’re not all medications. A lot of ways to promote sleep. Know some of them are supplements. Some of them are techniques that alpha stem device helps depending on what’s causing the insomnia. Treating the underlying condition can help. So. And Sleep Pharmaceuticals for sleep are kind of limited, too. There are some work better than others. Some people do great with trazodone over many, many years. Not everyone responds to it. No, I’m not a big fan of Ambien because it’s very benzodiazepine, like even though technically it isn’t a benzodiazepine. It also has that fugue state associated with it. My residency director took a similar drug many years ago when she was on a redeye flight from California back to Boston. So she took it before she got on the flight around nine, 10 p.m. Pacific time, she flew back to Boston, she got off the plane, took a cab to the office, you know, was by that time, it’s eight a.m. When saw five or six patients went to a couple of meetings, went home, went to sleep, woke up the next morning and the last thing she could remember was driving to LAX. I, yeah, I had a family member that took it for a while and the the reaction.
I mean, it was bad when she was up in the middle of the night, like talking to people that weren’t there. I mean, it was it’s relatively rare, but but it’s it’s a thing that’s unpredictable. Mm hmm. Yeah. Uh, let’s see, work with teens, it looks more like a common. I’m not sure what is common, but I assume you mean cannabis, and yes, it’s very common in high schools. Is this a true statement, the less the perception of a reward for an activity? Uh, yes, it’s not. Well, if by perception you mean the experience of reward, yes, that’s how dopamine works, basically. You know, the less rewarding it is, the less attractive now. You know, there’s this thing called masochism. It’s a real thing. There are people who deliberately seek out. A painful, self-defeating, humiliating, demeaning. Situations, substances. Circumstances, relationships. So what’s happening there probably is that. There’s a there’s a distortion of self experience that makes those things feel rewarding. Even though they also have all those other feelings associated, but generally speaking, yes. Can you address any concerns of the impact for use by folks more in the geriatric range? Oh, I’m glad you reminded me of something. So I was I met someone not long ago in a circumstance I can’t. I’m not at liberty to talk about for privacy reasons, but who has? That’s a very. Profound and legal. Financial interest in the cannabis industry. In the legal cannabis industry, and that person said to me, nobody under 25 should use this ever. Now he just cut out like 40 percent of his market. They said that so there’s that says several things to me. One, this is a better informed person than I expected the person to be about the actual, you know, thing that’s being sold because I agree I would set the age a little higher. But you know, in principle, we agree to. Not just interested in the money, which was kind of reassuring if if you were, you wouldn’t say something like that, right? And three thinks that there’s plenty of market for everyone older than that, and there probably is. Mm hmm.
So I don’t have as much experience lately with older people using, but it probably isn’t as dangerous because the, you know, especially with the psychosis, which to me is one of the most dangerous things because there are people who have this vulnerability but may never develop the illness unless they’re exposed to this drug. This is not something inevitable in cannabis just makes it happen sooner. That may be true for some people. This is something that’s a potential. And because of that epigenetics we’re talking about, it may never get activated if you never smoke weed. Right? And the difference between living a life with psychosis and living one without it is huge. People with psychosis die 15 to 20 years earlier than people without their quality of life is much less. They have a harder time maintaining relationships, jobs, et cetera, et cetera. Many of you already know this. There’s a window of vulnerability that more or less ends by 30 or early 30s and past that you may not be taking quite the same risk if you if you want to get high occasionally. I’m not particularly endorsing it. I just think that the numbers change. So, yeah, it may be somewhat safer. It doesn’t mean it’s risk free. The experience of acute and longer term withdrawal syndrome, fatigue, lethargy, low motivation, post-acute withdrawal, I think, is what you’re referring to. It can involve cravings, although they tend to get less intense with time like most cravings. Their cognitive impairments that can take a long time to recover and they’re less likely to recover. The younger you start, so they may not entirely. So let’s just some some examples. Hey, I’m going to one was a nice there was one question. Yeah, and there was a question in the comment section, it says. For patients with Parkinson, cannabis seems to help with the decrease in tremors is their medication without much side effects that can help these cases. It’s an alternative to cannabis. I’m not a Parkinson’s expert. I know there are some new medications for Parkinson’s. I know some people with Parkinson’s if their symptoms are mild and stable. I’m not making a recommendation here, I’m not a neurologist, but I’m aware of people who’ve been advised not to take medication.
Because the the from what I understand, if the symptoms are not progressing quickly, they often don’t at all. There are people who go 20 years with the same level of symptoms and going on medication, they cause more trouble than it helps. So that’s one one partial answer. But there is a technology called transcranial magnetic stimulation, which we use here for depression and for OCD that’s been researched for PTSD. But and it probably can be used to help it. But the most recent protocol they research actually didn’t work out so well. But there also is a TMS machine that’s targeting the basal ganglia, which is the affected part of the brain in Parkinson’s, and that does show effects. It is not like depression. A lot of people get treated for depression with TMS. They have a great reduction of symptoms or remission, and it is sustained. And there’s recent research to show that it can be sustained for quite a long time. With Parkinson’s, you probably have to keep doing it. You may not have to do it as often after the initial trial, but because it’s a degenerative disease. It may require ongoing treatment at some frequency in order to sustain the effects, but it has definitely shown some beneficial effects. And there are no side effects, right? That was a good, a good alternative, and I think that’s what they were asking. Some things that possibly may work. Yeah, if I got Parkinson’s, I’d be running to the TMS machine. Thank you. That’s that’s the best thing I can say about it. And it’s an off label use of the TMS. It’s available, but it would almost certainly not be covered by insurance at this point because the FDA has not approved the. Epilepsy. Hospice and hospice treatment is a whole different ballgame. You know, I there’s nothing I would deny someone in hospice, although personally I wouldn’t endorse euthanasia. That’s the only thing I would deny. Somebody in hospice if I were running the hospice, but anything that helps somebody be more comfortable as they’re dying. I don’t. Now, you know, the 16 year old is dying in hospice, and once we. And it makes him psychotic, you’re probably not helping them, right?
But but in general, yeah, in that population, it’s just a different the whole, the whole way of thinking about risks and benefits. It’s different. It’s a different goal. The whole goal is comfort. A desire for STEM help with sleep, yes. But if you. Get your hands on one, don’t use it too close to bedtime because it is more likely to paradoxically keep you up. Then help you sleep, you have to use it a couple of hours beforehand. And 20 to 30 minutes at a time is usually best, not i personally use that, and that’s really that does a really good job. You do it. I tried it. I tried it out. You know, you can feel something a little weird feeling with your head. Get filled. Yeah, but I didn’t get that. So some people get a little like lightheaded, dizzy or something usually goes away after a few minutes or if you turn the power down, right? But the other thing that you have kind of have to get this to know what’s working, or at least many people do. There’s a little tingling in your ear lobe, and some people just don’t like that. Not really pain. It’s just odd. So. It’s on the controlled substance report in Ohio. I’m not sure I understand this question about. I mean, I actually went to med school in Ohio, but. I wasn’t really exposed to that very much at the time. Yeah, sorry, I can’t meaningfully respond to that one. Um. Oh, the name of the device that Tonda and I were just talking about is alpha stim. It’s also called direct current transcranial stimulation. That’s the type of device it is. The brand is Alpha Alpe, a stem stim. It was actually invented in the 1960s, and it kind of looks like it’s a retro looking cell phone sized box with a wire plugged in and two leads that clip on like a clip on earrings due to your ear plugs with some little, some conductor gel. And they they designed it in the Soviet Union to help their cosmonauts sleep in space. Because they had a very short day night cycle, it’s 90 minutes long when you’re orbiting the Earth and it screws up your sleep.
Uh, yeah, I think we talked about the office then copy the slides, yes, ADHD and cannabis use. Well, not not globally. I can’t speak to an association between ADHD and cannabis use. I mean, people with ADHD are just more likely to have trouble with drugs of all kinds. I don’t think, you know, of course, they sometimes they’re drawn to stimulants and things like cocaine and overusing caffeine and that sort of thing. But, you know, I’ve had friends with ADHD or their kids tell me, you know, the worst thing about it is you’re always letting people down. And that can cause anxiety and shame, and cannabis just makes you feel less so temporarily, they may turn to it. Yeah. Kind of see why we can. It’s it’s 12, 20. So yeah, OK. Yeah, I would love to answer all of these, and I probably won’t have time. But coming in to see please email me, please email me. I’m open to that time out and I’ll make sure the doctor, Baron and Tracey’s information is on the email that goes out. I promise. So if we didn’t get to your question, please take no offense to it. But we are 20 minutes over time. I know a lot of you hung out and some of you had to go. So, Dr. Baron, this has been amazing. We’ve received a ton of good feedback. I hope you’ve seen some of that coming up in the chat. I know some of i appreciate the kind words. Thank you. Yeah, yeah, yeah. We’ve had one that I did see multiple time was, can we have a part two to this, Dr. Baron, that we would love to have you back sometime? Tell me what you want me to talk about and I’ll try to. As I told Krystle and Tracy earlier, I’ll try to overcome my shyness and do it again. You did an absolutely amazing job. Thank you so much. Thank you all so much. Really appreciate it, Tracy. Hi, everybody. And thank you, Dr. Baron and Yellow Brick for this amazing continuing education presentation. If you would like to be added to our CEU mailing list, please email CEU at Kemah Palms dot com.
Thanks for joining us. See you soon.