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  1. 1. Marijuana Jeopardizing Youth Eric A. Voth, M.D., F.A.C.P-Eric A. Voth, M.D., F.A.C.P- ChairmanChairman The Institute onThe Institute on Global Drug PolicyGlobal Drug Policy
  2. 2. Brain Development Motivation Emotion Judgment Cerebellu m Amygdala Nucleus Accumbens Prefrontal Cortex Judgement is last to develop! Physical coordination Sensory processing Maturation starts at the back of the brain and moves to the front
  3. 3. 30-day Marijuana Use
  4. 4. Friends Who Use
  5. 5. Perception of Harm – % reporting NO RISK with regular use
  6. 6. CESAR FAX U n i v e r s i t y o f M a r y l a n d , C o l l e g e P a r k A Weekly FAX from the Center for Substance Abuse Research January 18, 2010 Vol. 19, Issue 2 U.S. High School Seniors’ Perception of Harm from Regular Marijuana Use Decreasing 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 0% 10% 20% 30% 40% 50% 60% 70% 80% Perceived Risk of Harm from Regular Use Used in Past Month Percentage of U.S. Twelfth Grade Students Reporting Past Month Marijuana Use and Perceived Risk of Harm from Regular Marijuana Use, 1975-2009 SOURCE: Adapted by CESAR from University of Michigan, “Teen Marijuana Use Tilts Up, While Some Drugs Decline in Use,” Press Release, 12/14/09. Available online at http://www.monitoringthefuture.org/data/09data.html#2009data-drugs.
  7. 7. Marijuana  Impurity-488 substances, 66 cannabinoidsImpurity-488 substances, 66 cannabinoids  Resembles tobacco in constituents.Resembles tobacco in constituents.  High THC concentrations 2-30%High THC concentrations 2-30%  1/2 life 5-7 days1/2 life 5-7 days
  8. 8. Ave %THC potency (seizures)  19751975 0.74%0.74%  19771977 0.900.90  19801980 2.062.06  19831983 3.233.23  19851985 2.822.82  19901990 3.353.35  19921992 3.103.10  19951995 3.753.75  19961996 4.074.07  19971997 4.534.53  19981998 4.434.43  19991999 4.554.55  20002000 4.874.87  20012001 5.325.32  20022002 6.346.34  20032003 6.126.12  20062006 8.758.75  20072007 9.69.6  20082008 8.88.8 University of MississippiUniversity of Mississippi Potency monitoring reportPotency monitoring report
  9. 9. Neuro-Behavioral Effects
  10. 10. Cognitive Changes  AttentionAttention  ConcentrationConcentration  Decision-makingDecision-making  InhibitionInhibition  ImpulsivityImpulsivity  Working memoryWorking memory  Verbal fluencyVerbal fluency  Concept formation and planningConcept formation and planning J Addict Med 2011;5:1-8J Addict Med 2011;5:1-8
  11. 11. Memory Difficulty sorting information andDifficulty sorting information and inhibition of memory even after ainhibition of memory even after a mean two year abstinence.mean two year abstinence. SOLOWIJ- LIFE SCIENCESSOLOWIJ- LIFE SCIENCES 1995;5:2119-261995;5:2119-26
  12. 12. Structural Damage to Brain  59 users 33 controls59 users 33 controls  Ave age 33, Ave use 15 yrs, started 16.7 yoAve age 33, Ave use 15 yrs, started 16.7 yo  Ave joints /mo=147Ave joints /mo=147  Ave life joints 25922Ave life joints 25922  Demonstrated axonal connectivityDemonstrated axonal connectivity impairment in hippocampus, splenium ofimpairment in hippocampus, splenium of corpus callosum, commissural fiberscorpus callosum, commissural fibers Brain 2012:135;2245-2255Brain 2012:135;2245-2255
  13. 13. Neuropsychological Decline  1037 individuals1037 individuals  Pot use at 18,21,26,32,38 y/oPot use at 18,21,26,32,38 y/o  Neuropsych testing at 13 before pot and 38Neuropsych testing at 13 before pot and 38  Broad Neuropsychological decline acrossBroad Neuropsychological decline across all domains even controlling for educationall domains even controlling for education  Greatest decline was adolescent andGreatest decline was adolescent and persistent use.persistent use. Proc Natl Acad Sci U S A. 2012 Aug 27Proc Natl Acad Sci U S A. 2012 Aug 27
  14. 14. From the horse’s mouth  ““I used to smoke this stuff regulerly I quit because II used to smoke this stuff regulerly I quit because I needed to pass a test to get a job. The reason I am writingneeded to pass a test to get a job. The reason I am writing is because I never had any of thougs side effects you talkis because I never had any of thougs side effects you talk about don’t get me wrong its not for every body. But youabout don’t get me wrong its not for every body. But you don’t need to say untrue things about it coordinationdon’t need to say untrue things about it coordination imparment that’s bs it allows you to focus better on singleimparment that’s bs it allows you to focus better on single things its perfect for kids like I was that cant concetrate onthings its perfect for kids like I was that cant concetrate on ting well you don’t have to reply to this email I am justting well you don’t have to reply to this email I am just bored and looking at stuff on the net and emailing peoplebored and looking at stuff on the net and emailing people and going on and on cause I cant sleep well you have aand going on and on cause I cant sleep well you have a nice day.nice day.
  15. 15. Driving effects
  16. 16. Driving Effects  Combining EtOH and Marijuana in FirstCombining EtOH and Marijuana in First Study Reduced Driving SkillsStudy Reduced Driving Skills  .07 + 100ug = Plain EtOH of 0.09.07 + 100ug = Plain EtOH of 0.09  .07 + 200 ug = Plain EtOH of .14 g/dl.07 + 200 ug = Plain EtOH of .14 g/dl  NHTSA Notes Annals of Emergency MedicineNHTSA Notes Annals of Emergency Medicine  2000;35:3992000;35:399
  17. 17. Colorado Pot
  18. 18. Marijuana & Pilots
  19. 19. Psychiatric and Behavioral Disorders
  20. 20. Marijuana and depression  1920 subjects1920 subjects  15 year follow up15 year follow up  Likelyhood of major depression 4 timesLikelyhood of major depression 4 times greater among users.greater among users. Am J. Psychiatry 2001;158:2033-2037
  21. 21. Depression  Depressive responses measuredDepressive responses measured  Lower doses= Serotonin agonistLower doses= Serotonin agonist  Higher doses= Serotonin suppressantHigher doses= Serotonin suppressant  Effect was the Medial Prefrontal CortexEffect was the Medial Prefrontal Cortex J Neuroscience 2007;27:11700-11711J Neuroscience 2007;27:11700-11711
  22. 22. Marijuana and Psychosis  40454045 psychosis-freepsychosis-free and 59 individualsand 59 individuals exhibiting psychosis at baseline assessment.exhibiting psychosis at baseline assessment.  Marijuana predictedMarijuana predicted 2.762.76 times greatertimes greater likelihood oflikelihood of any psychotic symptomsany psychotic symptoms,, predictedpredicted 24.1724.17 times higher incidence oftimes higher incidence of severe psychotic symptomssevere psychotic symptoms, and predicted, and predicted 12 times higher need for clinical assessment12 times higher need for clinical assessment and care for psychotic symptoms.and care for psychotic symptoms. American Journal of EpidemiologyAmerican Journal of Epidemiology 2002;156:319-272002;156:319-27
  23. 23. Persistence of Psychosis  Risk of psychosis -no prior psychosis whoRisk of psychosis -no prior psychosis who used pot, 1.9 times greater that non-users inused pot, 1.9 times greater that non-users in ave 3.5 years.ave 3.5 years.  Continued pot use risk of future psychosisContinued pot use risk of future psychosis was 31% vs 20% in those who did not usewas 31% vs 20% in those who did not use out to approx 8.5 years.out to approx 8.5 years.  BMJ 2011;342: d738BMJ 2011;342: d738
  24. 24. Marijuana and Bipolar Illness  166 first-episode bipolar I disorder patients.166 first-episode bipolar I disorder patients.  Cannabis and alcohol associated with theCannabis and alcohol associated with the first episode of maniafirst episode of mania Bipolar Disorder 2008;10:738-741Bipolar Disorder 2008;10:738-741
  25. 25. Marijuana and Behavior  Marijuana had a greater effect on degree ofMarijuana had a greater effect on degree of violent behavior in non-delinquentviolent behavior in non-delinquent individuals than in delinquent individuals.individuals than in delinquent individuals. This effect is even more prominent than theThis effect is even more prominent than the effect of cocaine, amphetamine, oreffect of cocaine, amphetamine, or tranquilizer/sedative use.tranquilizer/sedative use. Friedman AS, J Addict Dis. 2003;22:63-78Friedman AS, J Addict Dis. 2003;22:63-78
  26. 26. Gateway Effects &Addiction
  27. 27. Gateway Effect  Risk spans entire course of adolescent development.  Young people exposed to other users are at higher risk for early initiation.  Clear family standards and proactive family management are important in delaying alcohol and marijuana use.  Kosterman R, Hawkins JD, Guo J, Catalano RF, Abbott RD.  . American Journal of Public Health 2000;90:360-366.
  28. 28. Gateway effects  Risk of other drug use with weekly marijuana vs nonusers: 14-15 y/o 66.7% 17-18y/o 28.5% 20-21y/o 12.2% 24-25y/o 3.9% Fergusson DM, et al. Addiction 2006;101:556-569
  29. 29. Marijuana Dependence  Most patients claimed serious problems withMost patients claimed serious problems with cannabis, and 78.6% met criteria for cannabiscannabis, and 78.6% met criteria for cannabis dependence.dependence.  Two thirds reported withdrawal. Cannabis is aTwo thirds reported withdrawal. Cannabis is a reinforcer. produces both dependence andreinforcer. produces both dependence and withdrawal and reinforces cannabis use.withdrawal and reinforces cannabis use.  Regular cannabis use rapid as tobaccoRegular cannabis use rapid as tobacco progression, and more rapid than alcoholprogression, and more rapid than alcohol CrowleyDrug and Alcohol Dependence 1998;50:27-37CrowleyDrug and Alcohol Dependence 1998;50:27-37
  30. 30. Marijuana Dependence  20% used before age 16 (20% used before age 16 (New Zealand)New Zealand)  21.7% demonstrated dependence by age 2121.7% demonstrated dependence by age 21  If 5 positive experiences with pot, 28 xIf 5 positive experiences with pot, 28 x increase risk of dependence.increase risk of dependence. Fergusson DM, Horwood LJ, Lynskey MT, Madden PAF. Early reactions to cannabis predict later dependence. Arch Gen Psychiatry 2003;60:1033-1039
  31. 31. Fetal/Newborn Effects
  32. 32. Effect on Conception  Women smoking> 90 times in their lifetimeWomen smoking> 90 times in their lifetime had 27% fewer oocytes retrieved (P=.03)had 27% fewer oocytes retrieved (P=.03) and 1 fewer embryo transferred (P!.05).and 1 fewer embryo transferred (P!.05). Women smoking marijuana >10 times inWomen smoking marijuana >10 times in lifetime infants 17% (P=.01) smallerlifetime infants 17% (P=.01) smaller Women smoking marijuana 1 year beforeWomen smoking marijuana 1 year before IVF/ GIFT had25% fewer oocytes retrievedIVF/ GIFT had25% fewer oocytes retrieved (P=.03)(P=.03)  Am J Ob-Gyn (2006) 194, 369–76Am J Ob-Gyn (2006) 194, 369–76..
  33. 33. Effect on Conception (cont)  If men smoked marijuana 11 to 90 times inIf men smoked marijuana 11 to 90 times in their lifetime, there was a 15% decrease intheir lifetime, there was a 15% decrease in infant birth weight (P = .03)infant birth weight (P = .03)  more than 90 times, there was a 23%more than 90 times, there was a 23% decrease (P=.01).decrease (P=.01).  Women and men who smoked in the past 15Women and men who smoked in the past 15 years, had 12%(P=.04) and 16% (P=.03)years, had 12%(P=.04) and 16% (P=.03) smaller infants, respectively.smaller infants, respectively.
  34. 34. Pre-Term Birth  3234 births from healthy women3234 births from healthy women  Use of marijuana (particularly pre-Use of marijuana (particularly pre- pregnancy) is a strong environment risk forpregnancy) is a strong environment risk for pre-term birth.pre-term birth. Dekker GA, Lee SY, North RA, McCowan LM, Simpson NAB, et al.Dekker GA, Lee SY, North RA, McCowan LM, Simpson NAB, et al. (2012PLoS ONE 7(7): e39154. doi:10.1371/journal.pone.0039154)(2012PLoS ONE 7(7): e39154. doi:10.1371/journal.pone.0039154)
  35. 35. Newborn Effects BirthweightBirthweight LengthLength Head CircumferenceHead Circumference Abnormal DevelopmentAbnormal Development Neurological IrritabilityNeurological Irritability
  36. 36. Fetal/Infant Effects Prenatal exposure to marijuana is associated withPrenatal exposure to marijuana is associated with reduction in birth weight, length, and headreduction in birth weight, length, and head circumference even when tobacco use factoredcircumference even when tobacco use factored out.out. Clinical Chemisty 2010;56:1442-1450Clinical Chemisty 2010;56:1442-1450
  37. 37. Fetal Effects: 14 y/o  524 subjects524 subjects  Confounding variables controlledConfounding variables controlled  Greatest effect first Trimester >1joint /dayGreatest effect first Trimester >1joint /day  Fetal exposure= 14 y/o Wechsler compositeFetal exposure= 14 y/o Wechsler composite  Poor Intelligence age 6Poor Intelligence age 6  Attention and Depression age 10Attention and Depression age 10 Neurotoxicology and TeratologyNeurotoxicology and Teratology Goldschmidt and DayGoldschmidt and Day 34 (2012) 161–16734 (2012) 161–167
  38. 38. Respiratory Effects  CoHb 5x TOBACCOCoHb 5x TOBACCO  TAR 3x TOBACCOTAR 3x TOBACCO  Decreased DiffusionDecreased Diffusion  Cellular InflammationCellular Inflammation  Precancerous ChangesPrecancerous Changes  Diminished Lung ImmunityDiminished Lung Immunity
  39. 39. Respiratory Effects  Cannabis associated with dose-relatedCannabis associated with dose-related impairment of large airways resulting inimpairment of large airways resulting in obstruction, wheezing, mucous, andobstruction, wheezing, mucous, and hyperinflation.hyperinflation.  Dose equivalence 1: 2.5-5 vs tobaccoDose equivalence 1: 2.5-5 vs tobacco Thorax 2007;0: 1-7Thorax 2007;0: 1-7
  40. 40. Lung Damage  Marijuana smoking leads to bullous lungMarijuana smoking leads to bullous lung disease in normal CXR and lung functiondisease in normal CXR and lung function 20 years earlier than seen with tobacco20 years earlier than seen with tobacco Respirology 2008;13:122-127Respirology 2008;13:122-127
  41. 41. Marijuana and Lung Cancer  The risk of lung cancer increased 8% (95%The risk of lung cancer increased 8% (95% confidence interval (CI) 2–15) for eachconfidence interval (CI) 2–15) for each joint-yr of cannabis smoking, 7% (95% CIjoint-yr of cannabis smoking, 7% (95% CI 5–9) for each pack-yr of cigarette smoking,5–9) for each pack-yr of cigarette smoking,  The highest tertile of cannabis use wasThe highest tertile of cannabis use was associated with an increased risk of lungassociated with an increased risk of lung cancer relative risk 5.7 (95% CI 1.5–21.6)),cancer relative risk 5.7 (95% CI 1.5–21.6)), Eur Respir J 2008; 31: 280–286Eur Respir J 2008; 31: 280–286
  42. 42. Marijuana Lobby & “Medical” Pot
  43. 43. Medical Excuse Marijuana No compelling evidence that there is a significant group of untreated or inadequately treated patients. Pro-marijuana lobby getting its “nose under the tent”
  44. 44. Marijuana Policy Project  "This is the next step in the evolution of medical marijuana as a political issue," "We have informed elected officials about the widespread public support for the issue, we have lobbied members of Congress and their staffs directly, and we have activated our grassroots. Now it is time to provide financial support to those who are willing to support medical marijuana.” Steve Fox Marijuana Policy Project (MPP) Washington, D.C.
  45. 45. Important points to remember  Safe, effective reliable medicines are bestSafe, effective reliable medicines are best for patients, and they are availablefor patients, and they are available  Marijuana is impure, unreliable, full ofMarijuana is impure, unreliable, full of contaminants, high side effect rate.contaminants, high side effect rate.  Defense to possession bypasses FDA andDefense to possession bypasses FDA and jeopardizes consumer protectionjeopardizes consumer protection  Medical excuse marijuana createsMedical excuse marijuana creates “medicine by popular vote.”“medicine by popular vote.”
  46. 46. Proposed Medicinal Uses of Marijuana Nausea of ChemotherapyNausea of Chemotherapy GlaucomaGlaucoma Appetite StimulationAppetite Stimulation Multiple SclerosisMultiple Sclerosis Pain/ MigrainePain/ Migraine Misc- Cramps, Sleep, DepressionMisc- Cramps, Sleep, Depression
  47. 47. Who is Actually Using Medical Excuse Marijuana?  Under 34 -- 45.4%Under 34 -- 45.4%  Under 54 (most pain age older) 84%Under 54 (most pain age older) 84%  For Pain 82%For Pain 82%  For Anxiety 37%For Anxiety 37%  For Depression 26%For Depression 26%  For Nausea 27%For Nausea 27%  For Appetite 37.7%For Appetite 37.7% Journal of psychoactive drugsJournal of psychoactive drugs 2011;43:128-1352011;43:128-135
  48. 48. Colorado Medical Excuse Pot  Sept 2011 127,444 usersSept 2011 127,444 users  94% pain94% pain  Ave Age 40Ave Age 40  Denver has 400 dispensaries (375 StarbucksDenver has 400 dispensaries (375 Starbucks state-wide)state-wide)  Denver Dispensary crime up 69% with 75%Denver Dispensary crime up 69% with 75% increase in burglaries.increase in burglaries. Denver Police June 4, 2012Denver Police June 4, 2012
  49. 49. MarijuanaMarijuana ForFor PainPain
  50. 50. Pain  Healthy volunteers doses 0,2,4,8% THCHealthy volunteers doses 0,2,4,8% THC  Decrease of pain medium dosesDecrease of pain medium doses  Increase of pain higher dosesIncrease of pain higher doses  ?Specific substance responsible??Specific substance responsible? Anesthesiology. 2007;107:785-96Anesthesiology. 2007;107:785-96
  51. 51. THC as Opioid Adjunct  THC alone ineffective for the most partTHC alone ineffective for the most part  Literature is contradictory. SomeLiterature is contradictory. Some demonstrated higher morphine dosesdemonstrated higher morphine doses  May be useful as an adjunct to opiodsMay be useful as an adjunct to opiods International Review of Psychiatry,International Review of Psychiatry, April 2009; 21(2): 143–151April 2009; 21(2): 143–151
  52. 52. Palliative Care  Studies largely marginalStudies largely marginal  Mostly involve oral or SativexMostly involve oral or Sativex  Not indicated as sole agentNot indicated as sole agent  May be some add-on benefitMay be some add-on benefit International Journal of Palliative NursingInternational Journal of Palliative Nursing 2010, Vol 16, No 102010, Vol 16, No 10
  53. 53. Sativex as add-on for pain  Advanced cancer patients on opioid painAdvanced cancer patients on opioid pain medsmeds  Low, medium, high dose treatementsLow, medium, high dose treatements  Add on to the opioid medicationAdd on to the opioid medication  Low and medium dose had benefit, not highLow and medium dose had benefit, not high dosedose  Adverse events dose related and high doseAdverse events dose related and high dose was unfavorablewas unfavorable
  54. 54. Pain in HIV  Trial in HIV-associated neuropathyTrial in HIV-associated neuropathy  No comparison to other medicines norNo comparison to other medicines nor MarinolMarinol  Benefit in reducing the neuropathic painBenefit in reducing the neuropathic pain comparable to existing medicationscomparable to existing medications  Difficult to discern “high” vs. medicalDifficult to discern “high” vs. medical effecteffect  Abrahms Neurology 2007;68 515-521Abrahms Neurology 2007;68 515-521
  55. 55. Abrahms  Table 2 Mean side effect scores by study groupTable 2 Mean side effect scores by study group  Anxiety* 0.25 (0.14, 0.44) 0.10 (0.05, 0.22)Anxiety* 0.25 (0.14, 0.44) 0.10 (0.05, 0.22)  Sedation† 0.54 (0.36, 0.81) 0.08 (0.04, 0.17)Sedation† 0.54 (0.36, 0.81) 0.08 (0.04, 0.17)  Disorientation† 0.16Disorientation† 0.16(0.07, 0.34)(0.07, 0.34) 0.01 (0.00, 0.04)0.01 (0.00, 0.04)  Paranoia 0.13 (0.03, 0.45) 0.04 (0.01, 0.14)Paranoia 0.13 (0.03, 0.45) 0.04 (0.01, 0.14)  Confusion† 0.17 (Confusion† 0.17 (0.07, 0.390.07, 0.39) 0.01 (0.00, 0.06)) 0.01 (0.00, 0.06)  Dizziness† 0.15Dizziness† 0.15 (0.07, 0.31)(0.07, 0.31) 0.02 (0.01, 0.05)0.02 (0.01, 0.05)  Nausea 0.11 (0.04, 0.30) 0.03 (0.01, 0.14)Nausea 0.11 (0.04, 0.30) 0.03 (0.01, 0.14)  ** p, 0.05; † p 0.001.p, 0.05; † p 0.001.
  56. 56. HIV Cognitive Impairment  HIV patients vs controlsHIV patients vs controls  Significantly more depression and anxietySignificantly more depression and anxiety in marijuana using groupin marijuana using group  More alcohol use if used marijuanaMore alcohol use if used marijuana  Memory impaired even after factoring outMemory impaired even after factoring out depression, anxiety, and alcoholdepression, anxiety, and alcohol The Journal of Neuropsychiatry andThe Journal of Neuropsychiatry and Clinical Neurosciences 2004; 16:330–335Clinical Neurosciences 2004; 16:330–335
  57. 57. Pain Summary  Summary of literature on pain/ quality ofSummary of literature on pain/ quality of studies generally marginalstudies generally marginal  Mostly discussing oral or syntheticMostly discussing oral or synthetic cannabinoidscannabinoids  May be useful as an adjunct particularly forMay be useful as an adjunct particularly for neuropathic painneuropathic pain  As solo agent, high doses needed and moreAs solo agent, high doses needed and more side effectsside effects Current Opinion in Anaesthesiology 2005, 18:424–427Current Opinion in Anaesthesiology 2005, 18:424–427
  58. 58. Cannabinoids in MS meta-analysis  All studied were non-smokedAll studied were non-smoked  Cannabinoids difficult to work withCannabinoids difficult to work with  Adverse effects not related to doseAdverse effects not related to dose  Little benefit for spasticity-poss as add-onLittle benefit for spasticity-poss as add-on  Evidence on tremor weakEvidence on tremor weak  Evidence on pain moderateEvidence on pain moderate  Problems with psychoactivityProblems with psychoactivity CNS Drugs 2011:25 ZajicekCNS Drugs 2011:25 Zajicek
  59. 59. MS- Cognitive Effects  MS patients using smoked or ingested potMS patients using smoked or ingested pot  Impaired processing speed, memory,Impaired processing speed, memory, executive function, spatial perceptionexecutive function, spatial perception  Twice as likely as nonusers to beTwice as likely as nonusers to be classified as globally cognitivelyclassified as globally cognitively impaired.impaired. Neurology 2011;76:1153-1160Neurology 2011;76:1153-1160
  60. 60. As Paul Harvey would say-- ““And now for the rest of the story.”And now for the rest of the story.”
  61. 61. Marijuana and Fatal Crashes California 2008  Five years following medical excuseFive years following medical excuse marijuana dispensaries 1240 fatal crashesmarijuana dispensaries 1240 fatal crashes compared to 631 for the five years priorcompared to 631 for the five years prior  8.3% of fatal single vehicle crashes8.3% of fatal single vehicle crashes  5.5% fatal passenger crashes5.5% fatal passenger crashes  Use rate estimated at 16-20%Use rate estimated at 16-20%  Rivals alcohol as top cause of fatalitiesRivals alcohol as top cause of fatalities Crancer and CrancerCrancer and Crancer Involvement of marijuana inInvolvement of marijuana in California Fatal Vehicle CrashesCalifornia Fatal Vehicle Crashes
  62. 62. Marijuana treatment episodes  National increaseNational increase  1992 92,5001992 92,500  2008 322,0002008 322,000  California increaseCalifornia increase  1992 73001992 7300  2008 350002008 35000 RAND 2010RAND 2010 Altered State?Altered State? Assessing How Marijuana LegalizationAssessing How Marijuana Legalization in California Could Influencein California Could Influence Marijuana ConsumptionMarijuana Consumption
  63. 63. Scientific Status of Medical Excuse Marijuana  Cannabinoids may be useful and worthCannabinoids may be useful and worth studyingstudying  Smoking is problematicSmoking is problematic  Legislative processes bypass the FDA andLegislative processes bypass the FDA and jeopardize the publicjeopardize the public
  64. 64. Organizations Voicing Positions
  65. 65. IOM Recommendations  Rec 5-The goal of clinical trials ofRec 5-The goal of clinical trials of smoked marijuana wouldsmoked marijuana would not be tonot be to develop marijuana as a licensed drugdevelop marijuana as a licensed drug  Rec 6-Rec 6- must meet the followingmust meet the following conditions:conditions: failure of all approvedfailure of all approved medicationsmedications to provide relief has beento provide relief has been documenteddocumented
  66. 66. Practical Issues/Regulation  Has user exhausted all other acceptedHas user exhausted all other accepted medical interventions?medical interventions?  Is the proposed patient a drug abuser?Is the proposed patient a drug abuser?  Does law allow for drug screening to assureDoes law allow for drug screening to assure no use of illegal drugs?no use of illegal drugs?  Will patient have medical oversite andWill patient have medical oversite and monitoring of status and adverse Eventsmonitoring of status and adverse Events  Legal liability and responsibility?Legal liability and responsibility?
  67. 67. Practical Issues/ Regulation  What marijuana will be allowed, whatWhat marijuana will be allowed, what strengths, and who pays for it?strengths, and who pays for it?  Who produces the marijuana?Who produces the marijuana?  Is marijuana purity assured?Is marijuana purity assured?  Is the caregiver licensed and in goodIs the caregiver licensed and in good standing with regulatory agencies?standing with regulatory agencies?  Does the caregiver demonstrate formalDoes the caregiver demonstrate formal training or experience in addiction and intraining or experience in addiction and in the administration of dangerous drugs?the administration of dangerous drugs?
  68. 68. Practical Social Issues  Employment drug testsEmployment drug tests  Health insurance medication ridersHealth insurance medication riders  DUI statutes/ accidentsDUI statutes/ accidents  Student/adult athleticsStudent/adult athletics  Side effectsSide effects  Work productivityWork productivity
  69. 69. Important points to remember  Safe, effective reliable medicines are bestSafe, effective reliable medicines are best for patients, and they are availablefor patients, and they are available  Marijuana is impure, unreliable, full ofMarijuana is impure, unreliable, full of contaminants, high side effect rate.contaminants, high side effect rate.  Defense to possession bypasses FDA andDefense to possession bypasses FDA and jeopardizes consumer protectionjeopardizes consumer protection  Medical excuse marijuana createsMedical excuse marijuana creates “medicine by popular vote.”“medicine by popular vote.”

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