Alan Flashman
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Cannabis and autism: An informal update 2019

It's a firstline treatment for all patients on the spectrum, there's no medical justification for starting with psychotropic meds

I have now had the privilege to treat over 500 autistic kids with medical cannabis in Israel. This report is meant to support this treatment by documenting a more extensive experience than the original 100 cases I reported on a year and a half ago.

The results continue to be rather consistent. As I reported earlier, about 60% of children respond well to an oil that is 20:1:: CBD:THC. Another 15-20% need a higher proportion of THC, often more THC than CBD. The last 20% or so remain somewhat enigmatic; at times a change of strains makes a big difference, sometimes we admit have to admit treatment failure.

I try to make the treatment as systematic as possible, despite our ignorance regarding more of the compounds in the cannabis plants we use. I try to get an optimal effect of the appropriate oil (60% of the time the CBD rich oil, 20% of the time the THC rich oil) in the morning dose by increasing by a drop every few days until increase yields no improvement. Then I try to “fine tune” the CBD:THC ration with the other oil in the same way until optimal effect is reached. Then I see how long the dose lasts and add one or more additional doses during the day until a good result over the entire day and good sleep is achieved. This trial and error takes about a month.

My experience suggests that this systematic approach creates the most reliable results. There are others whose experience leads them to “guess” when to add the THC oil to the CBD oil, or when to add additional doses, but I find when I reevaluate the treatments at the annual license renewal that oftentimes a less than optimal result has been achieved. There is no data-based way to study this.

When the first approach is not effective, I then systematically attempt to try other strains and about half the time this yields good results. Therefore at least 10% of the children in my experience require access to a variety of full strains in order to achieve treatment goals. I can state unequivocally that I have personally witness children who respond entirely differently to different strains whose CBD:THC ratio is identical.

Excellent results are attained along the full range of the autistic spectrum. Most studies for some reason favor looking at low-function children with violent outbursts. My experience show that high-functioning children respond extremely well, with an increased sharpness in their listening, presence, precision of language and more appropriate responses to humor. They feel much better as human beings and more secure in social settings. Many of these children are able to recognize the improvement as an improved connectivity between resting and executive brain states that I had suggested in an earlier communication. I have treated several dozen very young children, less than 4 years of age, with results as encouraging as those for the older children.

I have seen almost no side effects to this treatment. Some rare children (about 3-4 out of 500) whose sphincter control was borderline lost control (3 of bladder, one of both bladder and rectum) temporarily. The regression was reversed when the particular oil was discontinued. No one became addicted and there were absolutely no outbreaks of anything like psychosis due to cannabis treatment.

It is very impressive to see just how many children are able to discontinue other psychotropic medication once they stabilize on cannabis. I would estimate about three-quarters of children on medications are able to discontinue and feel better for doing such.

Two areas remain less clear. One is the exacerbation of seemingly obsessional behaviors that comes together with improvement of other areas such as explosive expressions of frustration. My preliminary view is that this is likely to be temporary and be a result of heightened presence and awareness. AT times I have added St. John’s Wort with occasional success. This is an area for more study.

The second area is that of attention. In Israel many overactive autistic children are given the additional diagnosis of ADHD, something I feel to be rather unscientific. In my experience 80-90% of the treatments with stimulants are either unsuccessful or deleterious. However, the results of cannabis ion attention are less reliable than in other areas. I would estimate that perhaps half of the children become more attentive. This issue may involve the way the school setting interacts with the cannabis treatments. It is another are for more systematic study.

This very form of this communication documents the need for differential research in this field. So far published reports do not distinguish characteristics of the children, and correlation with doses and strains. This is an obvious desideratum. I am grateful to TOI for the use of this blog to communicate with the community of families and physicians who are nearly starved for information and can get little guidance from published studies to date.

I would like to propose a series of First Principles for Clinical Practice based on my experience:

  1. Medical Cannabis belongs in the first line of treatment for autistic children. This includes low function, high function and very young children. The treatment is virtually harmless and provides a substantial relief and improvement in quality of life for a large majority of suffering children and families for whom other treatments are substantially less effective and much more toxic.
  2. It is unconscionable for a physician treating autism in 2019 to remain ignorant of the beneficial effects of medical cannabis on autism. Such is the situation in Israel, where the official physician for a school or residence for autistic children takes no interest or responsibility for exploring the place of cannabis in the therapeutic regimen. One such facility even requested that I become the cannabis consultant in parallel to the official physician. My response was to put in writing in Hebrew all that I have learned and offered to train all of the physicians working for the association of parents of autistic children at no cost, but there was no response to my offer. In 2019 I think that a physician who “waits for hard evidence” is delinquent in the oath not to withhold potentially effective agents to patients. Just one doctor’s opinion, to be sure.
  3. There is absolutely no medical justification for withholding cannabis treatment for autistic children and requiring that other agents be used first.
  4. There is no justification for withholding cannabis treatment from young children.
  5. The treatment with cannabis oils is benign enough to not require medical approval or supervision. The experience in Israel suggests that medical supervision creates unnecessary obstacles to optimal treatment. For example, the IMCA will arbitrarily grant or not grant a license for a child who for example has not “completed a course of conventional treatment” (which does not exist), or limits the dose over-ruling the treating physician’s determination, without examining the patient or assuming responsibility for the treatment. These are egregious violations of accepted medical practice in all areas other than cannabis. The simple fact is that parents are more than capable of using medical cannabis, they can consult with physicians or others, they will do no harm, and there is overall much more harm done to patients by arbitrary oversight. In short, medical cannabis for autistic children will be vastly improved by legalization of cannabis.
  6. Despite the legalization of pure CBD oil (practically everywhere except Israel), autistic children require a balance of CBD and THC and pure CBD is unlikely to provide optimal treatment.
  7. It is crucial that autistic children have access to a variety of different whole plant strains. While it is not possible to specify which strains affect which children, I can state as an observed fact that some children respond differentially to different strains despite a similarity in CBD:THC ratios. The proposed “reform” of medical cannabis which proposes to mix strains according to CBD and THC alone will harm autistic children and I suspect will harm a great many other medical cannabis patients. It is hoped that this proposed reform will either be cancelled or deemed illegal. I admit to composing an expert opinion against it.
About the Author
Alan Flashman was born in Foxborough, MA, and gained his BA from Columbia, MD from NYU, Pediatrics, Adult and Child Psychiatry specialties at Albert Einstein College of Medicine, The Bronx, NY. He has practiced in Beer Sheba since 1983, and taught mental health at Hebrew University, Tel Aviv University and Ben Gurion University. Alan has edited readers on Therapeutic Communication with Children (2002) and Adolescents (2005) in Hebrew, translated Buber's I and Thou anew into Hebrew, and authored Losing It, an autobiography, and From Protection to Passover. He recently published two summary works of his clinical experience (both 2022) Family Therapies for the 21st Century and Mental Health in Pediatrics.
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