In this Quick Takes episodes' bonus content, Dr. David Gratzer and Dr. Leslie Buckley engage in some role-play. Listen to hear how Dr. Buckley uses motivational interviewing techniques as she interacts with a cannabis user suffering from anxiety.
In this episode’s Double Take, Drs. Gratzer and Buckley enjoy the opportunity to engage in some role-play as they run through a scenario in which Dr. Gratzer plays a young adult who is using cannabis to relieve his anxiety. Listen as Dr. Buckley demonstrates some MI techniques while she interviews him.
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November 28, 2019
Double Take: Motivational interviewing for anxiety-related cannabis use (A role-play)
[Musical intro]
David Gratzer: Welcome to Double Take where we’re going to talk further with Dr. Buckley about cannabis, cannabis legalization and the implications for your clinical work.
Dr. Buckley, let's talk about motivational interviewing and, maybe for a few moments, let's do some role-play. I can play the role of a patient. Perhaps you can walk us through some things you might do in terms of incorporating motivational interviewing principles into practice. Fair?
Leslie Buckley: Sounds great.
David Gratzer: Sure. So, let's talk about a 25-year-old gentleman seen, again, in the emergency department. History of panic disorder. Presents, maybe, a little bit unsure if this is the best treatment, but also unsure that he wants to go off of cannabis because it's proven helpful.
Leslie Buckley: Right. So, it's great that he's already a little bit ambivalent. He may as I said, he may not know all of the harms of use. So, you would want to go over that with him.
David Gratzer: So let's role-play. Why don't you give us some questions?
Leslie Buckley: So, you're him?
David Gratzer: I'm him, for now.
Leslie Buckley: So, David, how long have you been using cannabis?
David Gratzer: Well, you know, probably a few years now. I mean, if I think back, I started smoking a bit behind the arena back in high school and I'm probably using it more now. Well, truthfully, I am using it more now.
Leslie Buckley: And what was your anxiety like when you were in high school before use came in into the picture?
David Gratzer: It was bad. You know, I was the sort of kid who liked to do things with others, but hesitated. I always wanted to go to socials and parties, but it was really anxiety provoking. I remember before I started regularly using pot, I remember sitting in a car, having driven over to a party and just sitting there for two hours working up the courage. It's weird because everyone I knew in the party was my friend and there was no pressure on me. Yet, I just I just felt so judged when I'd walk into those parties and I'd smoke a joint or two and suddenly I could be me.
Leslie Buckley: That sounds so tough. Did anybody ever help you with that? Did you ever reach out to anyone to get some help with the anxiety?
David Gratzer: I was too embarrassed to talk about this. I mean, the one thing I discovered was if I went into a party and had a couple of drinks, I felt better. But then I'd be hung over the next day. And the pot I'd heard was medicinal, and I'd heard was helpful, and I tried it and it was. I never got a hangover and never threw up when I did a lot of pot (sometimes I ate too many Doritos) but that was about it. So, what do you think?
Leslie Buckley: And what about people in your social circle? Do you feel like a lot of other people around you are smoking as well?
David Gratzer: Well, now that I'm in university, I think a lot of people use pot. Not everyone, but certainly around parties. It's not uncommon for me to go.
Leslie Buckley: And are you ever using it when you're alone?
David Gratzer: Sometimes.
Leslie Buckley: And do you ever feel like if you don't use it and you feel badly? Like if you feel withdrawal symptoms or just not yourself?
David Gratzer: I've never gotten any withdrawal symptoms, but I do get some more anxiety. So, again, I feel pretty good when I use the pot. I can go to parties; I can give presentations in class. Maybe I'm not as sharp as I usually am, but boy, if I don't use it, I've got the panic.
Leslie Buckley: And what's the most amount of time you've had away from it? If you think about it from when you've been using regularly? Have you ever had a couple of weeks when you haven't had any pot on board?
David Gratzer: Boy, at this point in time, I think I'm just always using it. I mean, it's part of my life. I use it to help me with sleep – now that you mention it. I use it before class presentations. I use it before parties. At this point, I'm probably using it at least daily.
Leslie Buckley: And what's the downside? Is there anything?
David Gratzer: It's costing me a lot of money. I think sometimes I smell because I'm smoking. It can't possibly be healthy long-term to be smoking something – though it's not cigarettes.
Leslie Buckley: How's your function? Do you feel like you're functioning as highly as you could?
David Gratzer: No. I mean, when I smoke before a presentation I'm not as sharp. I know I messed up recently at an English presentation. I was kind of off. I was kind of, frankly, giggly. People thought I'd done something.
Leslie Buckley: And how about irritability? Do you feel like you are lashing out at people? That you're not yourself?
David Gratzer: I've had friends who've had that problem, but personally, I've not.
Leslie Buckley: That's not you. Ok. And would you ever consider, you know, actually having treatment from a psychiatrist for anxiety and maybe considering a medication or some of our therapeutic tools?
David Gratzer: So, my partner told me I should seek out care. Truthfully, I had briefly seen a family doctor. I tried an antidepressant. I thought it actually made my anxiety worse. And I also thought they'd prescribed a drug real fast. I would have liked to maybe explore other things.
Leslie Buckley: Right, because, you know, things have changed. Years have passed since you first started using. And it would be really interesting to see what your baseline anxiety is now because it could have changed over this time. It could be better. It could be just the same as it was.
David Gratzer: So, I worry about that. Though, like if I go cold turkey or something, am I going to have more panic? And I'm coming up on midterms.
Leslie Buckley: Well, this might not be the best time to do it. What we might want to do is set up a follow-up appointment when your midterms are over, when you feel like it's the right time for you. So, let's say in three weeks or so and maybe talk about making a change at that time. Maybe even trying to try an experiment of two weeks or so without any use at all and see how you are. And maybe try some medications, try to help you sleep better. We could even introduce some medications during your withdrawal if you feel like the anxiety really is creeping up.
David Gratzer: I like this idea of two weeks because I'm pretty hesitant on making a big long-term commitment, especially if I don't know about the anxiety.
Leslie Buckley: Well, I think that's great! There's been a lot of things that you've been able to do. If you look back right, you've been able to push through a lot of anxiety in your life, you've achieved, you're in school, you're doing well. You have supports around you. So, you've been able to accomplish a lot. I think it would be really worthwhile for you to find out whether the cannabis is helping you or hurting you. And if you take these two weeks, and you do feel better, then it's maybe something that you might want to continue.
David Gratzer: Let's pause right here. Let me step out of my role as a 25-year-old cannabis user with a full head of hair. What principles are you using right now in terms of engagement?
Leslie Buckley: So, certainly autonomy. I'm really thinking about you and I'm trying to see everything from your perspective, and I want to know what's important to you, why you want to change. I'm thinking about discrepancy. And, also, your hesitancy. You are not sure how things are going to get better. Sometimes with alcohol or cannabis or, sorry, or cocaine, people really believe that things will be better, and they can imagine that future. But with cannabis, and your character, you weren't sure, so I was trying to create that possibility for you. to think that it could be better. And if it's not, that's okay. At least, you know, there's still a reward, there's still a gain. And you would leave that experiment knowing more than you did before.
David Gratzer: And what's a pitfall here? With clinicians trying to do this motivational interviewing, exploring this discrepancy. What's a rookie error?
Leslie Buckley: Probably the biggest rookie error is feeling too strongly about it. And with all the knowledge someone might have gained about substance use and harms, and maybe even a strong opinion about cannabis, we could come on too strong and push too much and maybe turn somebody off. Maybe he wouldn't come back in three weeks. So, it could've been a mistake that I told you to come back in three weeks. Maybe I should have taken this opportunity while you're motivated and you're here with me to try that experiment.
David Gratzer: And just to jump ahead, if we were to keep going with a role-play, what are some things that you'd want to do before the end of the session?
Leslie Buckley: I would want to talk about withdrawal. I would want to give a lot of information about how someone might feel. So, nausea, vomiting, could have irritability, sleep problems, and maybe talk about sleep meds if needed. And I would want to talk about concerns and triggers that this person is worried about in that two weeks. I'd want to talk about structuring the two weeks and really thinking about things to do and planning events to keep, you know, sort of some distractions there. And I'd want to talk about safe things to do when there might be a craving. So if we had time, we would walk through what it's like to have a craving, how to ride through a craving, an alternative or soothing things that work for that young man, because things that work for me might not work for him.
David Gratzer: So, it's a personalized plan.
Leslie Buckley: Yes.
David Gratzer: Sleep medications. What are some medications you may choose?
Leslie Buckley: So, in addictions, we almost always use Trazodone because it's just the least addictive of the sleep meds.
David Gratzer: That's right. So, that's an old antidepressant. You're using it at a low dosing like 29, (Leslie Buckley: 50 mg) 50. And if the patient suggests that Trazodone isn't hopeful, what might one consider otherwise?
Leslie Buckley: You know, I probably wouldn't use a benzo because I actually never prescribe them unless somebody is already on them and I need to. Maybe I would consider Zopiclone, but I would much prefer Trazodone unless somebody really strongly feels like they don't want to use that.
David Gratzer: Gabapentin if the renal function's good?
Leslie Buckley: Sure.
David Gratzer: And where do you stand on Melatonin?
Leslie Buckley: I don't know enough. I don't really suggest it.
David Gratzer: Fair enough. And then thinking bigger picture for a moment, if you were to talk to a colleague who wasn't so familiar with motivational interviewing. What's a nice workbook or book one could recommend?
Leslie Buckley: Miller and Rollnick have books with new editions coming out, if you wanted to read a lot. But even if you just wanted a brief update, a reminder, you could just Google it, and even on Wikipedia, it will give you the important reminders of the main tenets of motivation interviewing.
David Gratzer: Excellent. Thank you very much Dr. Buckley.
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