Week 3 ForumThe forum question for your consideration thi

Week 3 Forum
:
The forum question for your consideration this week focuses on
the legalization and decriminalization of drugs, including
marijuana, in our society. Based on the readings from this week,
and your reflections on your own beliefs, what is your
perspective on the question of legalization of drugs, including
marijuana?
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One “Initial Post” in response to your instructor’s instructions .
This post must be a minimum of 300 words in length. Point
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it, including forum posts, will result in a zero score without an

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Legally Restricted Drugs in Our Society - Part II
Hallucinogens
This week, we turn to the very fascinating topics of
hallucinogenic drugs and marijuana. Like some of the previous
drugs we have studied, these drugs have existed in various
natural forms for many thousands of years and, at various times
in societies, have been held in high regard and, at other times,
viewed with contempt and derision. It is interesting to note how
societal norms, the practices of various religions, political and
social movements, medical treatments, and expectations with
regard to behavior all influence whether the manufacture,
distribution, and use of these classes of drugs are deemed
appropriate or not across societies. In fact, you can see the
varying opinions that institutions and groups of individuals
have held regarding this class of substances as they have been
described as “mind expanding” to those who are accepting and
“mind disrupting” by those who are alarmed by their use over
the years. It is interesting to note that there has only been one
documented fatality that can be ascribed to LSD ingestion since
1960.

Take a look at this 11-minute CrashCourse.com video on altered
states as they relate to substance use and addiction. Discussion
of hallucinogens begins about three-fourths through the
presentation:
https://www.youtube.com/watch?v=9PW1fwKjo-Y
While there are thousands of naturally-occurring plants and
fungi which can produce some perception-altering or
hallucinogenic effects for those that consume them, this lesson
will focus on the most prolific, widely know, and artificially
manufactured of this class of drugs: lysergic acid diethylamide
(LSD). In terms of effect per dose size, it is one of the most
powerful psychoactive drugs known. Paradoxically, the toxicity
(or degree to which it can be poisonous or directly harmful to
the body) of this odorless, tasteless and colorless drug is
relatively low. Its manufacture, distribution and use was made
illegal in the United States in 1966. Hallucinogens, including
LSD, are one of the eleven classes of substances covered by
specific substance-related disorders in the Diagnostic and
Statistical Manual of Mental Disorders.
How does a hallucinogen like LSD affect the brain and body?
Most hallucinogens are classified by the resemblance their
molecules have to particular neurotransmitters in the brain. LSD
is chemically similar to serotonin and affects receptors that are
sensitive to this neurotransmitter. When taken orally, it is
quickly absorbed into the bloodstream and begins to take effect
in 30-60 minutes and reaches a peak potency in two to four
hours. LSD is essentially eliminated from the system and the
effect are gone within four to twelve hours of administration.
Given its high degree of potency and low degree of toxicity,
LSD has a fairly comfortable margin of safety. Recall that this
margin is very different than that of heroin, where the range
between an effective and a lethal dose can be quite narrow.

What are the behavioral patterns of hallucinogen, including
LSD, use?
At the outset of use, LSD arouses the sympathetic nervous
system. This results in an increase in heart rate and blood
pressure, a dilation of the pupils, and a slightly raised body
temperature. Individuals may report feelings of euphoria,
restlessness, or tension release. Laughing or crying may be
present, depending on the individual’s state of mind and the
context in which the drug was administered. After 30 to 120
minutes, the user experiences the resultant “trip” of LSD. The
typical symptoms of hallucinogen use include a wide variety of
perceptual distortions, including visual images, altered body
sense, the intermingling of auditory and visual sensations
(called synthesia), and an altered sense of reality.
Individuals may report seeing vivid images while their eyes are
closed, perception of a multi-level reality, a feeling of
timelessness and separation of one’s mind from one’s body.
Whether all of these phenomenon are characterized as “good” or
“bad” by the user depends in large part of the individual’s
expectations when taking LSD, the psychological health and
well-being of the person, and the environmental setting in
which it occurs. Fortunately, long-term psychiatric problems
associated with LSD use are relatively uncommon.
What are the recommendations for individuals who come across
someone having a “bad trip?” You are advised to remain calm
and to encourage the affected individual to do the same. Any
sudden movements or sense of panic on your part can unduly
influence the individual into feeling the same way and
incorporating that experience into their “trip.” You should
provide reassurance that the situation is temporary and that you
will remain with them until it is over and liken the experience
to watching a TV program or movie. That is, it is outside them

and not real. Finally, make sure the individual is in a quite
environment that is not brightly lit. However, also make sure
that they are not in total darkness, as the absence of visual
stimuli tends to be associated with an increase in hallucinations.
Interestingly, compared to other illicit drugs that you have
studies in this course, the threat of substance dependence with
LSD use is comparatively low. Because of its highly level of
potency, the body builds up a tolerance to the psychoactive
effects of the drug faster than any other class of illicit drug. As
such, one cannot remain in a hallucinogenic state for an
extended period of time with successive dosing, unlike one can
when using heroin, for example. In addition, while the
hallucinogenic state can be quite pleasurable, individuals often
characterize a six- to eight-hour sensory bombardment as quite
exhausting and, oftentimes, unpredictable and nearly impossible
to stop prematurely once it has begun. As such, there are some
unique aspects of this experience that counter-condition the user
to increase the frequency or amount of use over time.
Certainly an additional, negative aspect related to LSD use is
the possibility of a flashback. The phenomenon of flashbacks is
a relatively unique and typically unwanted byproduct of LSD
abuse. This involves the transient recurrence of disturbances in
an individual’s perception that previously occurred when an
individual was intoxicated. In fact, the Diagnostic and Statistic
Manual of Mental Disorders has a diagnosis for this condition:
Hallucinogen Persisting Perception Disorder. The occurrence of
flashbacks in individuals is estimated to be at five to thirty-five
percent of users and can occur with not only habitual users but
also individuals who have used LSD once. The exact mechanism
by which this phenomenon occurs is not fully understood.
What challenges to “club drugs” like MDMA pose to
individuals?

Another generation of synthetically produced hallucinogens
have been produced which, unlike LSD, which works with
serotonin receptors, work with the neurotransmitter
norepinephrine. MDMA (3, 4-
methylenedioxymethamphetamine), also known by its common
street name Ecstasy, is technically a stimulant that also
produces hallucinogenic effects on its user. It is used to elevate
the mood of partygoers, create a feeling of connectedness to
others, and provides a boost in energy that allows individuals to
dance and stay awake through the night. Problems associated
with the drug include impairment of memory, confusion, muscle
tension, nausea, risk for liver damage, symptoms of anxiety and
depression, insomnia, and paranoid thinking. Reduced sweating
is one symptom that, in a hot club environment followed by
hours of dancing, can create the risk for heat stroke or
exhaustion.
Interested in learning more? Here’s a quick 2-minute video from
ASAPScience.com on MDMA and its effects:
https://www.youtube.com/watch?v=jEAr7ThsYew
Substance Dependence
What does it mean to be substance dependent?
For the last few weeks, we have discussed a variety of illicit
drugs that have the threat, when abused regularly, of leading to
dependence. What does it mean to have cocaine dependence or
hallucinogen dependence? Typically, dependence is formally
diagnosed when a person’s symptoms indicate that he or she is
persisting in their use of a drug despite significant problems in
their life that are related to the use of the drug. Conducting a
clinical interview with the individual where their drug use,
work history, family life, social relationships, and other
important life occurrences are reviewed will reveal a

problematic pattern.
Over the course of a year, when at least three of the following
symptoms are found, a consideration should be made as to
whether the individual is drug dependent: (1) tolerance of the
drug; (2) withdrawal symptoms and active attempts to avoid
them; (3) a history of the drug being taken in increasingly larger
doses and over long periods of time than would be intended; (4)
attempts to cut down or stop using by the individual have been
unsuccessful; (5) the individual spends a large portion of their
waking hours in activities whose goal is obtaining, using, or
recovering from the drug; (6) the drug use is to the extent that it
has impaired the individual’s occupation, familial and social
functioning in meaningful ways; and (7) despite the presence of
physical and/or psychological problems stemming from its use,
the individual continues to abuse the drug.
Certainly, some drugs are more prone to tolerance and/or
withdrawal than others. For example, many people continue to
smoke cigarettes or use other forms of nicotine as a way to
avoid the negative withdrawal symptoms they might otherwise
experience. By contrast, pronounced withdrawal symptoms are
not as common with repeated use of hallucinogens. It is
interesting to note that all classes of classically abused drugs
that you will review in this course can result in a clinical
diagnosis of dependence, except for the licit drug caffeine.
Marijuana
Moving now to your study of marijuana, one of the most
politicized drugs of the twentieth (and twenty-first) centuries.
As a nice overview, review this quick four-minute SciShow.com
video on the substance:
https://www.youtube.com/watch?v=FsJzCdFlpyQ

Marijuana is another example of a drug that has been similarly
praised and demonized by different groups of people at different
periods of time throughout our country’s history. Present across
cultures for thousands of years, it is arguably the world’s oldest
cultivated plant not used as a food source. The hardy plant from
which this drug is derived is a bit of an anomaly; it produces
symptoms akin to many other classes of drugs, but is unique
unto itself. It produces some excitatory effects, but is not
thought to be a stimulant; it produces some sedative effect, but
is does not induce a stupor as could be seen with depressants; it
produces some mild analgesic effects, but is not chemically
related to opioids; it can produce mild hallucinations at high
doses, but it not a hallucinogen like LSD. It should be noted
that cannabis is one of the eleven classes of substances covered
by specific substance-related disorders in the Diagnostic and
Statistical Manual of Mental Disorders.
How does marijuana affect the brain?
The active ingredient of marijuana is the chemical
compound delta-9-tetrahydrocannabinol (THC). When ingested,
often through smoking, the THC stimulates specific neuronal
receptors in areas of the brain that are associated with short-
term memory and motor control. The degree to which THC
affects the brain and produces the symptoms of intoxication
depend heavily on the individual ingesting the drug and the
experience they have in doing so. Regular marijuana smokers,
when compared to novice users, inhale more deeply and hold
the smoke in their lungs for a longer period of time, thereby
allowing more of the THC to enter their bloodstream more
quickly and with less consumption of marijuana than cigarettes,
or “joints.” Further, chronic users will have residual THC in
their system that elevates the total quantity of THC consumed
with every new dose. When dosage levels are controlled, the
phenomenon of tolerance is demonstrated with marijuana use,

just like other illicit drugs you have studied in this course. More
systematically, THC acts as an immune suppressant within the
body, making a marijuana user more susceptible to infection and
disease.
What are the behavioral symptoms of marijuana use?
Cannabis intoxication can involve feelings of grandiosity,
euphoria, and inappropriate laughter, followed by sedation,
lethargy and altered sensory perceptions. Short-term memory
and judgment can be impaired as well as motor skills. At times,
individuals using cannabis have reported the sensation that time
is moving slowly. While some individuals believe that
marijuana use is relatively harmless, a clinical level of
psychological dependence can, in fact, develop. Habitual users
commonly report cravings.
Whether with short-term or habitual use, withdrawal symptoms
present themselves with the cessation of marijuana use.
Symptoms include stomach discomfort, feelings of irritability,
loss of appetite, and symptoms of anxiety. These symptoms can
last for up to two days in duration. For those who use marijuana
in a chronic fashion, withdrawal symptoms that mimic those of
tobacco cessation are common as well. Nevertheless, all of
these symptoms are certainly less pronounced or dangerous than
the withdrawal symptoms one would experience from cessation
of chronic heroin or alcohol abuse.
What are some of the factors behind the decriminalization and
legalization of marijuana and its use as a medical treatment?
Marijuana regulated as medicine has been shown to be
effective in the treatment of glaucoma and asthma, but it’s most
efficacious use is in the treatment of nausea and weight loss
secondary to the treatment of cancer. A growing number of
states have legislatively approved marijuana for such uses under

medical supervision, and the federal government has stopped
using its resources to prosecute or restrict individuals’ use of
marijuana for such purposes.
Current public policy in the United States has shifted
dramatically from prior decades such that the possession of
marijuana in small amounts in essentially decriminalized. That
is, possession would be subject to a small fine but not otherwise
viewed as a criminal offense requiring prosecution. A small
number of states have legalized possession and a growing
number of states have legislative bills forwarded for
consideration each year. As you recall, history has shown that
use of certain substances have been in and out in favor of
society. Additionally, doctors for pain management commonly
prescribe hydrocodone, codeine, and oxycodone while the
opioid heroin is illegal to possess or use.
Botanical name:
Cannabis sativa
Other common names: weed, pot, herb, bud, dope, spliff,
reefer, grass, ganja, 420, chronic, Mary Jane, gangster, boom,
skunk. There are over 200 street names for marijuana.
What is Marijuana?
Marijuana (cannabis) is a green, brown or gray mixture of dried,
shredded leaves, stems, seeds and flowers of the hemp plant
Cannabis sativa
. Marijuana is used as a psychoactive (i.e. mind altering)
recreational drug, for certain medical ailments and for religious
and spiritual purposes. Sinsemilla, hash/hashish (resinous form)
and hash oil (sticky black liquid) are stronger forms of
marijuana.
According to the National Institute on Drug Abuse (NIDA),

marijuana is the most abused drug in the US. Many states in the
US have now legalized marijuana for medical or recreational
use. However, according to federal law, the possession of
marijuana (cannabis) is still illegal in the US, except within
approved research settings.
How Does Marijuana Work?
The main active chemical in marijuana is THC (delta-9-
tetrahydrocannabinol), the psychoactive ingredient. The highest
concentrations of THC are found in the dried flowers, or buds.
When marijuana smoke is inhaled, THC rapidly passes from the
lungs into the bloodstream and is carried to the brain and other
organs throughout the body. THC from the marijuana acts on
specific receptors in the brain, called cannabinoid receptors,
starting off a chain of cellular reactions that finally lead to the
euphoria, or "high" that users experience. Feeling of a relaxed
state, euphoria, and an enhanced sensory perception may occur.
With higher THC levels in those who are not used to the effects,
some people may feel anxious, paranoid, or have a panic
attack.
Certain areas in the brain, such as the hippocampus, the
cerebellum, the basal ganglia and the cerebral cortex, have a
higher concentration of cannabinoid receptors. These areas
influence memory, concentration, pleasure, coordination,
sensory and time perception.1
Marijuana's strength is correlated to the amount of THC it
contains and the effects on the user depend on the strength or
potency of the THC. Different strains will contain different
levels of THC. In general, the THC content in marijuana has
been increasing since the 1970s, when it contained roughly 10%
THC. In 2015, as reported by Live Science, researchers from the
American Chemical Society found levels of THC at roughly
30%.

There are many other chemicals found in marijuana, many of
which may adversely affect health. Marijuana contains over 60
different cannabinoid compounds, and overall 400 different
compounds have been identified in marijuana, including THC,
cannabidiol (CBD), cannabinol, and β-caryophyllene, as noted
by the National Institute of Drug Abuse (NIDA).
How is Marijuana Used?
Marijuana may be smoked as a cigarette (called a joint or a nail)
or in a pipe or bong. It may be smoked in "blunts", which are
cigars that have been emptied of tobacco and refilled with
marijuana, often in combination with another drug, such as
crack. The “blunts” retain tobacco leaf used to wrap the cigar
and therefore it combines marijuana's active ingredients with
nicotine and other harmful chemicals.
Some users also mix marijuana into food or use it to brew tea.
In states that have now legalized sale of marijuana for
recreational use, the marketing of edible products, such as
cookies, brownies, and chocolates, are popular for those who
prefer not to smoke the product.
Vaporizers are also popular for those who prefer not to inhale
smoke. The devices concentrate the THC from the marijuana
into a storage unit and the person then inhales the vapor, not the
smoke. Some vaporizers use a liquid marijuana extract that can
be extremely high in THC content, and can be
dangerous to novice users
, resulting in emergency room admissions.
Approved and Investigational Products
In the United States, the
Controlled Substances Act

(CSA) of 1990 classifies marijuana as a Schedule I substance,
which states it has no approved medical use and a high potential
for abuse. This Federal definition is highly controversial, and
can limit marijuana's availability for clinical research studies.
However, many US states have legalized the use of marijuana
for medical and/or recreational use. Prescription medicines
containing synthetic cannabinoids (THC) are also available.
Dronabinol, a pharmaceutical form of THC, and nabilone, a
synthetic cannabinoid, are approved by the FDA to treat certain
conditions.
Marinol
, generics (dronabinol capsules) - Classified as Schedule III
Syndros
(dronabinol liquid) - Classified as Schedule II
Cesamet
(nabilone capsules) - Classified as Schedule II
Syndros is a liquid form of dronabinol. Both dronabinol and
nabilone are approved to treat patients receiving anti-cancer
medicine (chemotherapy) who have nausea and vomiting,
particularly patients who do not respond to other treatments.
Dronabinol (Marinol and Syndros) is also approved to treat
anorexia (loss of appetite) associated with weight loss in
patients with AIDS (Acquired Immune Deficiency Syndrome).
Sativex
(nabiximols)

Sativex (nabiximols) is not currently approved for use in the
US, but is available in 30 countries outside the US, including
Canada, the UK, Spain, Germany, Denmark, the Czech
Republic, Sweden, and New Zealand. Sativex, an oral
sublingual spray, is approved for use in multiple sclerosis (MS)
spasticity. In Israel, Sativex is approved for the indications of
MS spasticity and for chronic cancer pain. Sativex is composed
of standardized extracts of THC and cannabidiol and is
available as an oral mucosal spray formulation. Studies from
Lakhan, et al report that THC and cannabidiol (CBD) provide
therapeutic benefit for Multiple Sclerosis (MS) spasticity
(muscle stiffness/spasm) symptoms.
GW Pharmaceuticals and Otsuka Pharmaceuticals announced
results of three US Phase 3 trials in 2015 for the use of Sativex
for the treatment of pain in patients with advanced cancer who
experience inadequate analgesia during optimized chronic
opioid therapy. According to the study results, Sativex did not
meet the primary endpoint of demonstrating a statistically
significant difference from placebo for pain control.
Epidiolex
(cannabidiol or CBD), also from GW Pharmaceuticals, is a
cannabinoid product FDA approved in June 2018 for the
treatment of patients two years and older with
seizures
associated with Lennox-Gastaut syndrome (LGS) and Dravet
syndrome. Epidiolex comes as an oral solution.
These forms of epilepsy -- Lennox-Gastaut syndrome and
Dravet syndrome -- are severe, rare, and begin in childhood.
Epidiolex is the first FDA-approved drug that contains a
purified drug substance derived from marijuana -- CBD -- and
the first treatment for Dravet syndrome.
In

pivotal Phase III studies
with 516 patients with either seizure type, Epidiolex, as an
adjunct with other seizure drugs, was shown to be effective in
reducing the frequency of seizures when compared with
placebo.
Common side effects with Epidiolex included sleepiness,
diarrhea, sedation and lethargy, signs of possible liver damage,
and decreased appetite, among others. It was rescheduled from a
Schedule I controlled substance to a Schedule V controlled
substance in September 2018 by the DEA. Medications listed in
Schedule V have a proven medical use but a low potential for
abuse.
Extent of Marijuana Use
Marijuana is reported as the most widely used illicit drug in the
US, according to the 2016
National Survey on Drug Use and Health
. In the past survey year (2016), 37.6 million people, or 13.9%
of US adults reported using marijuana. In the same survey, past
year marijuana use among adolescents aged 12 to 16 years
dropped from 12.9% to 11.7% in males, but remained steady at
12.3% females. Overall, marijuana use was highest amongst the
age group 18 to 25 years of age at 33%.
In the 2016
Monitoring the Future Survey
, 22.5%, 14% and 5.4% of 12th, 10th, and 8th graders,
respectively, reported marijuana use in the past year.
Interestingly, 68.9% of high school seniors do not view regular
marijuana smoking as harmful, but 68.5% say they disapprove
of regular marijuana smoking.
Marijuana Side Effects

Side effects of marijuana use will be variable from person to
person, depending upon strength and amount of marijuana used
and if the user is occasionally or chronically exposed to THC.
Side effects can be magnified in older people.
The short-term effects of marijuana or cannabinoid use include:
increased heart rate
low blood pressure, orthostatic hypotension
muscle relaxation
slowed digestion
dizziness
distorted perception (sights, sounds, time, touch)
difficulty in thinking, memory, and problem solving
loss of coordination and motor skills
agitation, anxiety, confusion, panic, paranoia
increased appetite
dry mouth, dry eyes
Reaction time may be impaired while driving. NIDA research
shows that drivers have slower reaction times, impaired
judgment, and problems responding to signals and sounds if
driving while under the influence of THC.

Panic attacks, paranoia and psychosis may occur acutely and be
more common in psychiatric patients, a reported by Heller. For
chronic users, the impact on memory and learning can last for
days or weeks after its acute effects wear off, as noted by the
NIDA. Marijuana, if purchased on the street, may be cut (or
substituted) with substances that can lead to unknown,
dangerous side effects.
THC in marijuana is strongly absorbed by fatty tissues in
various organs. Generally, traces of THC can be detected by
standard urine testing methods several days or more after a
smoking session. In heavy chronic users, traces can sometimes
be detected for weeks after they have stopped using marijuana.
Long-term abuse of marijuana may lead to dependence in some
people. McKenna, et al have reported on the addicting potential
of marijuana, noting that "it is an erroneous belief widely held
by the general public, and among many physicians, that
marijuana is not addicting." However, not all people will
become addicted to marijuana and the effects can be
psychological in some patients. Withdrawal symptoms can occur
upon abrupt cessation of the drug, including:
anxiety
agitation
tremulousness
elevation of vital signs
insomnia
irritability

Marijuana also may affect mental health. Studies show that use
may increase the risk of developing psychosis (a severe mental
disorder in which there is a loss of contact with reality)
including false ideas about what is happening (delusions) and
seeing or hearing things that aren’t there (hallucinations),
particularly if you carry a genetic vulnerability to the disease.
Also, rates of marijuana use are often higher in people with
symptoms of depression or anxiety, as reported by the NIDA.
There have been no reports of THC overdose leading to death.
Marijuana Effects on the Heart
Shortly after smoking marijuana the heart rate increases
drastically and may remain elevated for up to 3 hours. This
effect may be enhanced if other drugs are taken with marijuana.
One study from Mittleman, et al has suggested that the risk of
heart attack may increase by up to 4.8-fold in the first hour
after smoking marijuana. The effect may be due to the increased
heart rate, as well as altered heart rhythms. The risk of heart
attack may be greater in those with specific risk factors such as
patients with high blood pressure, heart arrhythmia, or other
cardiac disease.
Harvard Health also reports that the risk of a heart attack is
several times higher in the hour after smoking marijuana than it
would be normally, and this should be a red flag for anyone
with a history of heart disease. The risk of stroke may be
increased, as well.
Marijuana Effects on the Lungs
After smoking marijuana, the bronchial passage relaxes and
becomes enlarged. Marijuana smoke contains many of the same
cancer-causing chemicals found in cigarette smoke, often in
greater quantities, as reported by Mehmedic and colleagues.

Both types of smoke contain cancer-causing nitrosamines,
polycyclic aromatic hydrocarbons, vinyl chlorides, and phenol
per research reported by Martinasek. Studies have shown that
marijuana smoke contains 50 to 70 percent more carcinogenic
hydrocarbons than tobacco smoke, and is an irritant to the
lungs. Marijuana users tend to inhale more deeply and hold their
breath longer than tobacco smokers do, which further increases
lung exposure to carcinogenic smoke.
People who smoke marijuana often have the same respiratory
problems as cigarette smokers. These individuals may have
daily cough and phlegm, symptoms of chronic bronchitis,
shortness of breath, chest tightness, wheezing and more
frequent chest colds. They are also at greater risk of getting
lung infections like pneumonia, as reported by the NIDA.
A 2016 systematic review of the respiratory effects of
inhalational marijuana from Martinasek, et al indicates that
there is a risk of lung cancer from inhalational marijuana as
well as an association between inhalational marijuana and
spontaneous pneumothorax, emphysema, or COPD. In the
review, eight of the 12 studies indicated an increased risk of
lung cancer from cannabis use or cases indicating lung cancer
occurrence.
Drug Interactions With Marijuana
Combining marijuana with other CNS depressant drugs that
also cause drowsiness or sedation (such as alcohol,
barbiturates, sedating antihistamines, anti-anxiety medications,
opiate pain killers, etc) can magnify the drowsiness. DO
NOT drive if you are under the influence of marijuana,
alcohol or any sedating drug.
A study from Hartman, et al shows that low doses of alcohol

can significantly elevate the concentrations of THC in the
blood.
Marijuana use can raise the heart rate (tachycardia) and may
be dangerous if used with other drugs that may also increase
the heart rate. People with cardiovascular disease should
avoid marijuana use.
The cannabinoids in marijuana (THC, cannabidiol) can
affect liver enzymes and may alter the blood levels and
effects of medications.
Drug interactions are often unpredictable or undocumented
with marijuana and extreme caution should be exercised.
Effects During Pregnancy and Breastfeeding
Marijuana is also the most common illicit drug used during
pregnancy, in roughly 2% to 5% of women. According to a 2017
updated report published by the American College of
Obstetricians and Gynecologists (ACOG) entitled
Marijuana Use During Pregnancy and Lactation
, 34% to 60% of marijuana users continue use during pregnancy,
with many women believing that use is relatively safe. These
numbers could rise as more states continue to legalize marijuana
for medicinal or recreational purposes. Due to possible adverse
effects of marijuana on the fetus, ACOG recommends that
marijuana should be avoided during pregnancy.
Any drug of abuse can affect a mother's health. It can be
difficult to determine the effects of marijuana on a baby’s
health because women who use marijuana often use other
substances, such as alcohol, nicotine, or drugs of abuse. THC
appears to cross the placenta, according to Davies et al.

Human fetuses exhibit the cannabinoid receptor type 1 in the
nervous system as early as 14 weeks of gestation, and animal
studies suggest cannabinoid exposure may lead to abnormal
brain development. As reported by de Moraes Barro and
colleagues, babies born to adolescents who used marijuana
during pregnancy have shown adverse neurological behavior
effects of the newborns in the first 24 to 78 hours after delivery.
Most reports do not show an association between marijuana use
and preterm birth. However, as noted by ACOG, studies have
suggested the use of marijuana with tobacco may increase the
risk for preterm delivery. In addition, research demonstrates
that babies born to mothers who used marijuana during
pregnancy at least once per week (or more) were smaller than
those born to mothers who used the drug less frequently.
Studies on school performance have shown differing results: in
middle class children age 5 to 12 years, no specific cognitive
effects were seen; however, in lower socioeconomic, primarily
urban groups, poorer reading and spelling scores and lower
teacher-perceived school performance was observed, per ACOG.
THC is excreted in breast milk, according to Davies, et al.
ACOG recommends that marijuana use be discontinued during
breastfeeding. The scientific data are not strong enough to
determine the risk to the nursing infant.
Addictive Potential of Marijuana
A drug is addicting if it causes compulsive, uncontrollable drug
craving, seeking, and use, even in the face of negative health
and social consequences.
Research suggests that roughly 9 percent of users become
addicted to marijuana, with higher rates if the user starts at a
young age (17 percent) and in those who use marijuana daily

(25-50 percent). While not everyone who uses marijuana
becomes addicted, when a user begins to seek out and take the
drug compulsively, that person is said to be dependent or
addicted to the drug. Some heavy users develop a tolerance to
marijuana; meaning that the user needs larger amounts to get
the same desired results that he or she used to get from smaller
amounts, as noted by the NIDA.
Long-term users who try to quit could experience withdrawal
symptoms such as sleeplessness, irritability, anxiety, decreased
appetite and drug craving. Withdrawal symptoms usually begin
about a day after the person stops using marijuana, peaks in 2 to
3 days and may take about 1 to 2 weeks to subside. McKenna
reports that marijuana addiction is difficult to treat in the clinic.
Patients can have a lengthy withdrawal and symptoms that can
continue for months after stopping marijuana use.
Medical Marijuana
Marijuana has been used as a therapeutic and medicinal agent
for centuries, dating back to the 27th century BC. Today, it is
still used for medicinal purposes, although restrictive laws
surrounding its use now exist. Medical marijuana is available in
many different forms from dispensaries: as an oil, pill,
vaporized liquid, nasal spray, and as the dried plant product.
As of November 26, 2018, 33 US states, the District of
Columbia, Puerto Rico and Guam now legally allow marijuana
for personal medical use. Rules surrounding the use of medical
marijuana
vary by state
.
The first state in the union to legalize the medical use of
marijuana was California in 1996 with Proposition 215. States
that allow medical marijuana include: Alaska, Arizona,

Arkansas, California, Colorado, Connecticut, Delaware, Florida,
Hawaii, Illinois, Louisiana, Maine, Maryland, Massachusetts,
Michigan, Minnesota, Missouri, Montana, Nevada, New
Hampshire, New Jersey, New Mexico, North Dakota, New York,
Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, Utah,
Vermont, Washington, West Virginia, and the District of
Columbia, plus Puerto Rico and Guam.
Legal Status of Marijuana
It is important to recognize that these state medical and
recreational marijuana laws do not change the fact that using
marijuana continues to be an offense under Federal law.
Medical marijuana in the US is controlled at the state level. Per
federal law, cannabis, a schedule I drug, is illegal as noted in
the Controlled Substances Act, but the federal government,
under the previous Obama administration, had stated they would
not actively prosecute patients and caregivers complying with
state medical marijuana laws. However, use of medical
marijuana outside of the state laws for illegal use or trafficking
would not be tolerated by state or federal government. These
rules may be changing under Attorney General Jeff Sessions.
Political leaders, US government officials, health care providers
and medical organizations take differing views of the benefits
and risks of medical marijuana. Proponents state that marijuana
has valid medical uses and further research should be pursued,
while opponents list concerns about health risks, and the
"gateway" effect of marijuana that can lead to more dangerous
drug abuse, among other issues. Nonetheless, legalization of
medical marijuana continues to be pursued at the state level,
with California being the most recent state to legalize recreation
use in January 2018.
An August 2017 Quinipiac University Poll found that 75% of

US respondents oppose the federal government enforcing
federal laws against marijuana in states that have already
legalized medical or recreational marijuana. Nonetheless, state
and federal laws are at odds in the US, currently. Attorney
General Jeff Sessions is a known critic of the cannabis industry
and federal oversight of marijuana legalization has now become
more strict.
In January 2018, the Obama-era Cole Memo, a guidance
document that blocked the Department of Justice (DOJ) from
using federal money to prosecute medical marijuana in states
where it's legal, was set to expire. On January 4, 2018, the DOJ
rescinded this document. As noted in the press release,
"Attorney General Jeff Sessions directed all U.S. Attorneys to
enforce the laws enacted by Congress and to follow well-
established principles when pursuing prosecutions related to
marijuana activities." Basically, Sessions directed federal
prosecutors go after legal marijuana as they choose, without a
set of rules. Whether the feds will go after the large state-run,
legalized recreational or medical marijuana industry, the over
5,500 mom and pop marijuana shops in the U.S., those who
divert legal marijuana across state lines, or some other
combination, remains to be seen.
In order to qualify for legal medical marijuana, patients must
have a diagnosed condition that is on their state’s list of
qualifying medical marijuana conditions, and receive a
recommendation from their doctor. The patient can then obtain a
medical marijuana card, or qualification, to purchase medical
marijuana and associated products from dispensaries.
Although the conditions vary from state-to-state, top medical
conditions for which patients might use medical marijuana
include:

Cancer
Glaucoma
HIV/AIDS
Persistent
muscle spasms
, including those that are characteristic of
multiple sclerosis
Seizures
Severe pain
Severe nausea
Cachexia or dramatic weight loss and muscle atrophy
(wasting syndrome)
According to various state laws, medical marijuana can be used
for treatment of other debilitating medical conditions, such as
decompensated cirrhosis, amyotrophic lateral sclerosis,
Alzheimer's disease, and post-traumatic stress disorder. Not all
states that approve of medical marijuana have enacted laws to
allow its use for all of these conditions. Another difference
between states - the amount of marijuana for medical use that
can be possessed by the individual patient or primary caregiver
varies, but may include dried marijuana and live plants.
In addition, the quality of research studies, or the availability of
research, is often limited for some of these conditions.
Cancer

According to 2017 data published by the National Cancer
Institute, a number of
in vitro
(laboratory), animal, and human studies have looked at the use
of cannabinoids (delta-9-THC, CBD) in various cancer uses;
however, it's important to remember many studies were small
and more research may be needed.
No cannabis (marijuana) or cannabinoid agent is approved by
the FDA for the treatment of cancer. Cannabis is not approved
for treatment of any related symptom of side effect of cancer
therapy. Two cannabinoids (dronabinol and nabilone) are FDA-
approved for the treatment of chemotherapy-related nausea and
vomiting in patients who have not responded to standard
therapy.
Antitumor Activity
: Studies in rodents have shown that cannabinoids may be
able to kill cancer cells while protecting normal cells. These
agents may be able to inhibit tumor growth by causing cell
death and blood blood vessels growth. Animal or lab studies
have shown positive results in colon cancer, liver cancer,
breast cancer, brain cancer, and lung cancer, although many
more studies are needed. Animal studies are often not
reproducible in humans.
Oral cannabidiol (CBD) has been looked at to treat recurrent
solid tumors in humans.
An oral spray combining 2 cannabinoids (delta-9-THC and
CBD) given with temozolomide to treat recurrent
glioblastoma multiforme (brain cancer).
Cannabidiol (CBD) to treat acute graft-versus-host disease
in patients who have had an allogeneic hematopoietic stem

cell transplantation (stem cell transplant from a donor).
Stimulating Appetite
Animal and human studies have shown that delta-9-THC
(dronabinol) taken by mouth can stimulate appetite, although in
cancer patients the use of megestrol may be more effective.
However, in patients with AIDS, a clinical trial showed that
delta-9-THC incerased appetite and reduced weight loss
compared to those taking a placebo.
In the US, dronabinol (brand names Marinol and Syndros) are
FDA-approved to treat anorexia (loss of appetite) associated
with weight loss in patients with AIDS (Acquired Immune
Deficiency Syndrome).
According to the NCI
, there are no published studies of the effect of inhaled cannabis
on cancer patients.
Nausea and Vomiting
According to NCI
, cannabinoid receptors found in brain cells may have a role in
controlling nausea and vomiting. Animal studies have shown
that delta-9-THC and other cannabinoids may act on
cannabinoid receptors to prevent vomiting caused by certain
types of chemotherapy. Two cannabinoid drugs are approved in
the US for the treatment of anti-cancer treatment
(chemotherapy) nausea and vomiting in patients who have not
responded to standard therapy:
dronabinol (Marinol, generics)
nabilone (Cesamet)

Several studies have evaluated the use of inhaled cannabis for
chemotherapy-related nausea and vomiting, although results
were mixed and a there is not enough information to interpret
the results.
Nabiximols (Sativex) is an oral spray of standardized extracts of
THC and cannabidiol not available in the US. It is approved
outside the US to treat spasticity linked with multiple sclerosis.
Nabiximols was shown in a small randomized trial in Spain to
treat chemotherapy-related nausea and vomiting.
Severe Pain and Neuropathy (Nerve Pain)
The use of cannabinoids or cannabis
has been evaluated
in the treatment of cancer and nerve pain.
One small study showed that vaporized cannabis combined
with oxycodone did not lead to better pain relief than using
oxycodone alone. However, when vaporized cannabis was
combined with morphine, pain relief was significantly great
than morphine used alone; however, larger studies are
needed.
The use of oral delta-9-THC has been shown to provide good
pain relief as well as provide relief from nausea and
vomiting in cancer patients. In one study, it's pain relief was
comparable to codeine. Cannabinoids have also been shown
to prevent chemotherapy-induced neuropathy in animal
models exposed to various cancer drugs (paclitaxel,
vincristine, cisplatin).
Marijuana may be effective for

neuropathic (nerve) pain
in HIV and other patients. A
review
from the
Annals of Internal Medicine
in August 2017 noted that marijuana is associated with low
strength evidence of effectiveness at reducing chronic nerve
pain known as neuropathy.
A cannabinoid spray used under the tongue was effective for
advanced cancer pain in patients whose pain was not
relieved by strong opioids alone. Sleep was also improved.
In several Phase 3 US trials of Sativex (nabiximols) spray
(not currently approved in the US) for the treatment of
severe cancer pain in patients with inadequate analgesia
using chronic opioid therapy, Sativex did not meet the
primary endpoint of demonstrating a statistically significant
difference from placebo for pain control. Sativex is a
standardized extracts of THC and cannabidiol.
Other Uses
Glaucoma
Marijuana has also been used for glaucoma to lower intraocular
pressure (IOP), but research does not show that marijuana has a
better effect than currently approved glaucoma medications.
Studies have shown that smoked, oral or IV use may have an
effect on lowering IOP, but the effect is short-lived, possibly
only a few hours, which is a major drawback for a condition
that requires around-the-clock effect. Topically applied
marijuana derivatives to the eye have not been shown to have an
effect. Marijuana in any form is not FDA approved for use in
glaucoma.

Research suggests it is not only elevated IOP that may lead to a
damaged optic nerve causing glaucoma, but also reduced blood
flow to the optic nerve. Marijuana use has the potential to lower
optic nerve blood flow, effectively canceling out the benefit of
a lowered IOP, according to the American Academy of
Ophthalmologists (AAO). The AAO does not recommend
marijuana or other cannabis products for the treatment of
glaucoma.4 However, in some US states, marijuana is used for
glaucoma under medical marijuana programs.
Seizures
In June 2018 the
FDA approved Epidiolex
(cannabidiol), from GW Pharmaceuticals, for severe seizures in
patients 2 years and older with Dravet Syndrome or Lennox-
Gastaut Syndrome. The medication comes as a liquid oral
solution to be taken by mouth.
Epidiolex contains cannabidiol, which is a purified drug
substance derived from marijuana, but does not lead to a high as
might be seen with ingestion of tetrahydrocannabinol (THC).
Epidiolex is a Schedule V controlled substance.
Epidiolex’s effectiveness was shown in
three pivotal, Phase III studies
involving 516 patients with either Lennox-Gastaut syndrome or
Dravet syndrome. Epidiolex, taken along with other
medications, was shown to be effective in reducing the
frequency of seizures when compared with placebo.
The most common side effects with
Epidiolex
shown in the clinical trials were:

sleepiness
sedation and lethargy
elevated liver enzymes
decreased appetite
diarrhea
rash
fatigue
malaise and weakness
insomnia
sleep disorder and poor quality sleep
infections.
Multiple Sclerosis
As reported by Hill, there are several studies that have noted
cannabinoids are effective in the treatment of symptoms of
multiple sclerosis, including painful spasms.
In addition, evidence-based guidelines for complementary and
alternative medicine (CAM) in multiple sclerosis (MS) from the
American Academy of Neurology recommend oral cannabis
extract (OCE) or tetrahydrocannabinol (THC) for spasticity
symptoms and pain (excluding central neuropathic pain), and
that the subjective benefit is possibly maintained for 1 year. For

Sativex oromucosal spray (a mix of THC and CBD, not
approved in the US), AAN states that Sativex is probably
effective for improving subjective spasticity symptoms, pain,
and urinary symptoms. Data are inadequate to support or refute
use of smoked cannabis for improvement of spasticity, pain,
balance/posture, or cognition in MS.
The AMA Stance on Medical Marijuana
As outlined in the AMA Policy Statement on Cannabis for
Medicinal Use (H-95.952):
The American Medical Association (AMA) encourages
continued research of marijuana and related cannabinoids in
patients who have serious conditions where marijuana may
have efficacy.
AMA also states that marijuana’s status as a federal
schedule I controlled substance should be reviewed "with the
goal of facilitating the conduct of clinical research and
development of cannabinoid-based medicines, and alternate
delivery methods. This should not be viewed as an
endorsement of state-based medical cannabis programs, the
legalization of marijuana, or that scientific evidence on the
therapeutic use of cannabis meets the current standards for a
prescription drug product."
The AMA urges the National Institutes of Health (NIH),
Drug Enforcement Agency (DEA), and Food and Drug
Administration (FDA) to implement procedures to facilitate
grant applications and the conduct of well-designed clinical
research into the medical utility of marijuana.
The AMA believes that effective patient care requires the
free and unfettered exchange of information on treatment

alternatives and that discussion of these alternatives between
physicians and patients should not subject either party to
criminal sanctions.
Recreational Use of Marijuana
A majority of Americans support legalization of marijuana -- 61
percent pro versus 33 percent against -- according to findings
from a Quinnipiac University National Poll in August 2017.
As of November 2018, the states or districts where recreational
use of marijuana is legal are:
Alaska
California
Colorado
Maine
Massachusetts
Michigan
Nevada
Oregon
Vermont
Washington
Washington, D.C.

In 2012, voters in Colorado and Washington state passed
initiatives legalizing marijuana for adults 21 and older under
state law. The states of Oregon and Alaska, as well as
Washington, D.C also voted to approve recreational use of
marijuana in November 2014. In November 2016, four more
states - California, Massachusetts, Maine, and Nevada - voted in
recreational marijuana. On July 1, 2018 Vermont's recreational
use law came into effect. In 2018, Michigan became the 10th
US state to legalize recreational use, but a legalization vote
failed in North Dakota. Laws surrounding recreational use
varies by state.
It is important to note that the federal government still
considers marijuana a dangerous drug and that the illegal
distribution and sale of marijuana is a federal crime. Under the
Controlled Substances Act (CSA), marijuana is still considered
a
Schedule 1 drug
. The current Trump administration, and in particular the
Attorney General Jeff Sessions, is not in favor of marijuana
legalization, but so far has not reversed any state's legalization
measures.
Recreational marijuana is lucrative. According to New Frontier
Data, a research company that analyzes legal marijuana revenue,
in 2016 sales reached $6.6 billion. These numbers include $4.7
billion for medical marijuana and $1.9 billion for recreational
use. If current trends continue, the marijuana industry overall
may exceed $24 billion by 2025.
Marijuana Dangers: Driving, Use in Children
Smoking marijuana can make driving dangerous; do not mix the
two. The cerebellum is the section of the brain that controls

balance and coordination. When THC affects the cerebellum’s
function, drivers may have slower reaction times, impaired
judgment, and problems responding to signals and sounds if
driving while under the influence (DUI) of THC.
In all states, including states that allow recreational marijuana,
driving under the influence of marijuana is illegal. However,
because THC metabolites can remain in the blood for up to one
month (or possibly longer), the DUI charge is usually based
subjective measures. The evaluation will take into account
driving patterns, one’s physical symptoms and appearance, a
field sobriety test, and possibly a blood test for THC. States
differ on the penalties, although an arrest and court date will
most likely be involved if the officer deems the person
impaired.. First offenses rarely involve long jail time, but may
involve probation, community service, a suspended license,
fines and fees, and DUI school.
The American Academy of Pediatrics (AAP) released a
report in February 2017
urging doctors to protect children from the harms of marijuana
as the US becomes increasingly tolerant to the drug. The brain
is not fully developed until around 25 years of age. Experts note
that marijuana use in the young can lead to abnormal brain
development. Frequent use of high-potency THC over extended
periods of time suggests that there can be negative effects on
learning, memory, attention and problem-solving ability,
as reported
in
Pediatrics
in October 2017. The AAP suggests that doctors urge parents
not to use marijuana around children. Other concerns with
children include the potential of exposing them to secondhand
smoke and accidental poisoning with edibles such as brownies
or candy.

Related:
Drug Testing FAQs
See Also
Bath Salts
Cannabis
Cocaine
Devil's Breath
Ecstasy
Fentanyl (Abuse)
GHB
Gray Death
Hashish
Heroin
Ketamine
Kratom
Krokodil
LSD

MDMA
Mescaline
Opium
PCP (Phencyclidine)
Psilocybin (Magic Mushrooms)
Quaaludes
Rohypnol
Speed (methamphetamine)
Synthetic Marijuana (Spice or K2)
TCP (Tenocyclidine)
U-47700 (Pink)
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