2. overview
• Cannabis (also called marijuana) is the most commonly used illegal
psychoactive substance worldwide. Its psychoactive properties are
primarily due to one cannabinoid: delta-9-tetrahydrocannabinol
(THC); THC concentration is commonly used as a measure of
cannabis potency
• Medically, marijuana is used for stress and pain relief and to
increase appetite. Recreationally, marijuana is used for its calming
effects and to achieve the notorious “high.” Street names for
marijuana include: pot, dope, ganja, grass, mary jane, reefer and
weed.
• 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.
3. EPIDEMIOLOGY
Cannabis use — Cannabis was used by an estimated 192 million people
(range 166 to 234 million) worldwide in 2016, approximately 3.9
percent (range 3.4 to 4.8 percent) of the global population age 15 to 64
years .
4. Statistics on Marijuana Addiction and
Abuse
• Marijuana is a psychoactive drug
which comes from the THC-
bearing cannabis plant. It is
becoming increasingly legal
throughout the United States,
both for medicine and for
recreation, but it’s still not
completely safe because it may
be addictive and cause health
problems.
5. • About 30-40 million Americans smoke marijuana every year.
• About 43% of American adults admit to trying marijuana.
• In 2017, 1.2 million Americans between the ages of 12 and 17 and
525,000 Americans over the age of 26 used marijuana for the first
time.
• In 2018, 13% of 8th graders, 27% of 10th graders, and 35% of 12th
graders had used marijuana at least once in the past year. Less than
1% of 8th graders, about 3% of 10th graders, and about 5% of 12th
graders reported using it every day.
• About 30% of people who regularly use marijuana have a marijuana
use disorder.
• The average batch of marijuana in 1990 contained less than 4% THC,
but that percentage has since risen to over 12%. The average batch of
marijuana has become more powerful.
6.
7. Risk and protective factors for cannabis
use include:
age : Cannabis use varies with age. The highest past-year prevalence is
among young adults (18 to 25 years old) (33.0 percent); the lowest
prevalence is among early adolescents (0.5 percent among 12 year olds and
2.8 percent among 13 year olds); past year prevalence is 11.0 percent among
those 26 years or older
Sex: Men are almost twice as likely as women to have used cannabis over the
past month, 11.3 versus 6.7 percent, respectively. Men and women initiate
cannabis use in roughly comparable numbers and at roughly comparable
mean ages.
Race and ethnicity – Cannabis use over the past month is more prevalent
among those of mixed race (17.7 percent), , blacks or African Americans
(11.1 percent), and Native Americans (13.6 percent) compared with the
overall non-Hispanic United States population (9.1 percent), and less
prevalent among Asians (3.3 percent)
8. Cannabis (marijuana): Acute intoxication
• PHARMACOLOGY AND TOXICITY:
• Site of action — The cannabinoid receptor is a G-protein linked
receptor, which inhibits adenylyl cyclase and stimulates potassium
conductance. There are two known cannabinoid receptors: CB1 and
CB2
9. CB1 is found in the central nervous system including the basal
ganglia, substantia nigra, cerebellum, hippocampus, and cerebral
cortex. It acts presynaptically and inhibits release of several
neurotransmitters including acetylcholine, L-glutamate, gamma
amino butyric acid (GABA), norepinephrine, dopamine, and 5-
hydroxytryptamine.
●CB2 is found peripherally in the immune system tissues (eg,
splenic macrophages and B lymphocytes), peripheral nerve
terminals, and vas deferens. It is postulated that it plays a role in
regulation of immune responses and inflammatory reactions.
Anandamide and palmitoylethanolamide are known endogenous
cannabinoid receptor ligands.
10. • Pharmacokinetics — The pharmacokinetics and pharmacodynamics of
delta-9 tetrahydrocannabinol (THC) vary by route of exposure as follows
• ●Inhaled marijuana – After inhalation of marijuana smoke, onset of
psychoactive effects occurs rapidly with peak effects felt at 15 to 30
minutes and lasting up to four hours. These effects mirror plasma delta-9
tetrahydrocannabinol (THC) concentrations. Approximately 2 to 3 mg of
inhaled THC is sufficient to produce drug effects in a naïve user. Pulmonary
bioavailability varies from 10 to 35 percent of an inhaled dose and is
determined by the depth of inhalation along with the duration of puffing
and breathholding.
• ●Ingested marijuana – When compared to inhalation, cannabis ingestion
has a delayed onset of psychoactive effects that ranges from 30 minutes to
three hours. Clinical effects may last up to 12 hours. Orally administered
cannabis has low bioavailability (5 to 20 percent) because of chemical
degradation in gastric acid and substantial first-pass metabolism in the
liver. In naïve users, psychotropic effects occur with 5 to 20 mg of ingested
THC.
11. THC is lipid soluble, highly protein bound
(95 to 99 percent),
and has a volume of distribution of
2.5 to 3.5 L/kg.
12. • Cannabis formulations — There are a variety of subspecies and strains
of cannabis (marijuana); Cannabis sativa is one of the most commonly
used for recreational purposes. Cannabis sativa contains over 500
different clinical compounds, and over 60 known cannabinoids; of
these, delta-9 tetrahydrocannabinol (THC) is the most psychoactive
and is responsible for most symptoms of intoxication .
• The dried flower of the marijuana plant has a large range of THC
content, ranging from 1 to 20 percent of the total weight; however,
much variability exists among marijuana samples .
• Chemical analogues of THC, called "synthetic cannabinoids. The
clinical effects can be similar to natural marijuana intoxication, but
may also result in more severe life-threatening symptoms.
13. • Recreational use — Recreational marijuana use often consists
of smoking the dried flower in the form of rolled cigarettes
(joints) and water bongs .THC is also extracted using various
solvents (butane, ethanol, hexane, isopropanol) to create highly
concentrated products (60 to 99 percent of weight) including
oils and tinctures called "wax," "dabs," "budder," and
"shatters". In addition to being smoked, these highly
concentrated products are also vaporized (eg, using electronic
cigarettes) or mixed in food products (such as brownies, cakes,
candies, and beverages) and ingested.
14. • Medicinal use— Medicinal marijuana is supplied as dried flowers of
the Cannabis sativa plant that are smoked as described for
recreational cannabis use. Derivatives of cannabinoids are also
available as pharmaceuticals in some countries including oral
preparations (dronabinol and nabilone(FDA-approved drugs) ).
• the United Kingdom, Canada, and several European countries have
approved nabiximols (Sativex®), a mouth spray containing THC and
CBD. It treats muscle control problems caused by MS, but it isn't FDA-
approved.
• Marijuana and its components have been proposed for various
medicinal purposes, such as chronic severe pain (eg, due to cancer),
refractory nausea and vomiting, anorexia and cachexia, glaucoma,
and seizures . However, none have been proven to have greater
efficacy than other currently available medications.
• In addition, cannabinoids, specifically CBD, have been studied for the
treatment of refractory epilepsy in children .
15. • Side effect 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
16. • Withdrawal symptoms can occur upon abrupt cessation of the drug,
including:
• anxiety
• agitation
• tremulousness
• elevation of vital signs
• insomnia
• irritability
17. • Toxic effects — Recreational cannabis intake to achieve psychoactive
effects can often result in adverse effects because there is no clear
demarcation between doses that achieve symptoms desired by a marijuana
user and noxious effects.
• In adolescents and adults, inhaled doses of 2 to 3 mg of delta-9
tetrahydrocannabinol (THC) and ingested doses of 5 to 20 mg THC impair
attention, concentration, short-term memory and executive functioning .
More severe adverse effects may occur at doses >7.5 mg/m2 THC,
including nausea, postural hypotension, delirium, panic attacks, anxiety,
and myoclonic jerking . Psychosis has also been associated with use of
higher potency/concentrated marijuana products
• Toxicity in children is most often reported after ingestion of a highly
concentrated food product or hashish resin . Estimated oral doses from 5
to 300 mg in pediatrics have caused a range of symptoms such as mild
sleepiness, ataxia, behavior changes, excessive and purposeless motor
activity of the extremities (hyperkinesis), coma, and respiratory depression
with more severe intoxication correlated with higher estimated doses.
18. In children, acute marijuana intoxication typically occurs after exploratory
ingestion of marijuana intended for adult use . Less commonly, intentional
exposure of children by caretakers, including encouragement of cannabis
inhalation to promote sleepiness and to decrease activity, has been reported
• After limited exposures, children may display sleepiness, euphoria,
irritability, and other changes in behavior. Vital signs may show
sympathomimetic effects (eg, tachycardia and hypertension) or, in patients
with depressed mental status, bradycardia. Nausea, vomiting, conjunctival
injection, nystagmus, ataxia, and, in verbal children, slurred speech may
also be present..
• In large overdoses (eg, ingestion of edible products, concentrated oils, or
hashish), coma with apnea or depressed respirations can occur.
Sign and symptoms of acute intoxication
19. Adolescents and adults — The physiologic signs of cannabis
intoxication in adolescents and adults can include:
●Tachycardia
●Increased blood pressure or, especially in the elderly, orthostatic
hypotension
●Increased respiratory rate
●Conjunctival injection (red eye)
●Dry mouth
●Increased appetite
●Nystagmus
●Ataxia
●Slurred speech
20. Complications associated with inhalation use include:
●Acute exacerbations and poor symptom control in patients with
asthma
●Pneumomediastinum and pneumothorax suggested by tachypnea,
chest pain, and subcutaneous emphysemas caused by deep inhalation
with breathholding
●Rarely, angina and myocardial infarction
The risk for myocardial infarction among regular cannabis users has
been found to be as high as 4.8 times baseline.
21.
22. Cannabis is the most widely used illicit drug, but use of
stimulants (ATS and Captagon) in the South of Iraq is present.
23.
24.
25. Can you possess and use cannabis in Iraq?
• It’s illegal to use or possess cannabis in Iraq, and the laws are harsh
for even those caught with relatively small amounts. The 2014
International Drugs Strategy Report found that the country’s drug
laws were not in-line with international advances in treatment or law
enforcement, with harsh prison sentences in place for relatively minor
offences. Personal use of cannabis can be punished by three to 15
years in prison.
26. Can you grow cannabis in Iraq?
• It’s illegal to cultivate cannabis in Iraq, even limited amounts for
personal use. It’s not that commonly grown in the country, as the
environmental conditions aren’t ideal. The US Department of
Agriculture’s analysts reported that most of the territory is too arid,
and that even attempts to grow cannabis in the south of the country
(where there’s more water) have been somewhat unsuccessful.
• One such raid happened in 2006, when authorities arrested a farmer
in northern Iraq and destroyed his cannabis crop, estimated to be
worth $2million.
27. • Incidences of drug arrests have risen most steeply in Basra, with
arrests nearly doubling since late 2014. From October 2015 to
December 2017, 4,035 arrests were made in this city alone.
• Drug use is most common in Basra, followed by the regions of
Baghdad and Maysan. It’s believed that usage has grown in Basra due
to its border with Iran and Kuwait (where drug use is common). This
makes the area particularly vulnerable to trafficking.
• Iraqi authorities are more concerned with the rise of opiate and
amphetamine addiction, rather than cannabis.
28. in previous reports about drug use in Iraq, licit drugs has were the most
extensively misused category of drugs (WHO, 2010). In the present survey,
the rates of current misuse are reported to be very low; consequently, we
will examine lifetime rates of misuse. Among these medications, which can
be prescribed and may be acquired via the pharmacy system in Iraq, anabolic
steroids and benzodiazepines (anabolic steroids, 1.1%;
benzodiazepines 1%) are the most widely misused, with benzehexol and
“other pills” (mostly allermine)
next in order of reported lifetime misuse; reported at 0.5% each. Somadril,
Tramadol and cough syrup were misused the least; reported at 0.3%, 0.2%
and 0.2%, respectively. The misuse of these medications, while low overall,
has tremendous geographical variation, which is noteworthy. In the South
region, specifically the Maysan and governorates,
29. lifetime misuse of benzodiazepines was reported in 17.7% of females
and 11.5% of males,
and lifetime anabolic steroid misuse was reported at 20% among males
in Thi Qar governorate. In general, the data from this item reflect a
parallel picture of the geography of licit drug misuse; rates are lower in
the Baghdad, Middle, and North regions, with several exceptions, while
they are
much higher in the South region.
30. Illicit Drugs
Similar to the licit drug category, self-reported rates of
current use of illicit drugs is very low, so lifetime rates
will be discussed. Lifetime cannabis use was reported
by 0.2%, while the use of inhalant, ATS/Captagon and
opium/heroin was reported at 0.1% each. Of interest is
the fact that although the mean age at first use of those
who reported lifetime use of cannabis, ATS/Captagon and
opium/heroin use was over 20 years old, inhalant users
reported their age at first use as 13.8 years. These data
suggest that prevention efforts with youth should include
information on the dangers of inhalants.
31.
32. Knowing someone who uses inhalants by more than 5% of participants
for each, while knowing someone who uses cannabis was reported by
4.6%. Knowing someone who used ATS/ Captagon was reported by
2.3%. Although opium/heroin self-reported lifetime rates were lowest
of any illicit drug category, over 4% of participants reported knowing
someone who uses this category of drugs. Consistent with self-report
data, in all regions except the South, rates of knowing someone who
used an illicit drug are under 10%, except in Erbil (11.0%). In the South,
in Al-Muthanna governorate the rate of knowing someone who used
an illicit drug was under 10%, however, in Al-Basrah (62.8%) and Thi
Qar (34.9%), the rates of knowing someone were much higher. This
major disparity between the geographical areas as well as between the
self-reported lifetime rates and the “knowing someone” rates call for
further exploration of the extent of drug use in the Southern region.
33. references
• U.S. Department of State/Bureau of International Narcotics and Law Enforcement Affairs. Survey of
Substance Abuse in Iraq Final Report. 2015;(August):1–22
• United Nations Office on Drugs and Crime, World Drug Report 2018, Vienna 2018.
• Grotenhermen F. Pharmacokinetics and pharmacodynamics of cannabinoids. Clin Pharmacokinet 2003;
42:327.
• Adams IB, Martin BR. Cannabis: pharmacology and toxicology in animals and humans. Addiction 1996;
91:1585.
• McGilveray IJ. Pharmacokinetics of cannabinoids. Pain Res Manag 2005; 10 Suppl A:15A.
• Cooper ZD, Haney M. Comparison of subjective, pharmacokinetic, and physiological effects of
marijuana smoked as joints and blunts. Drug Alcohol Depend 2009; 103:107.
• van der Pol P, Liebregts N, Brunt T, et al. Cross-sectional and prospective relation of cannabis potency,
dosing and smoking behaviour with cannabis dependence: an ecological study. Addiction 2014;
109:1101.
• Claudet I, Le Breton M, Bréhin C, Franchitto N. A 10-year review of cannabis exposure in children under
3-years of age: do we need a more global approach? Eur J Pediatr 2017; 176:553.
• Noble MJ, Hedberg K, Hendrickson RG. Acute cannabis toxicity. Clin Toxicol (Phila) 2019; 57:735.
• Richards JR, Smith NE, Moulin AK. Unintentional Cannabis Ingestion in Children: A Systematic Review. J
Pediatr 2017; 190:142.
34. references
• DrugFacts: Marijuana. National Institute on Drug Abuse. January 2014
http://www.drugabuse.gov/publications/drugfacts/marijuana (Accessed on November 03, 2014).
• Loflin M, Earleywine M. A new method of cannabis ingestion: the dangers of dabs? Addict Behav
2014; 39:1430.
• Morean ME, Kong G, Camenga DR, et al. High School Students' Use of Electronic Cigarettes to
Vaporize Cannabis. Pediatrics 2015; 136:611.
• Hartman RL, Brown TL, Milavetz G, et al. Controlled Cannabis Vaporizer Administration: Blood and
Plasma Cannabinoids with and without Alcohol. Clin Chem 2015; 61:850.
• Linszen D, van Amelsvoort T. Cannabis and psychosis: an update on course and biological plausible
mechanisms. Curr Opin Psychiatry 2007; 20:116.
• Barkus E. High-potency cannabis increases the risk of psychosis. Evid Based Ment Health 2016;
19:54.
• Di Forti M, Marconi A, Carra E, et al. Proportion of patients in south London with first-episode
psychosis attributable to use of high potency cannabis: a case-control study. Lancet Psychiatry
2015; 2:233.
• Claudet I, Mouvier S, Labadie M, et al. Unintentional Cannabis Intoxication in Toddlers. Pediatrics
2017; 140.
35. references
• Maurice Veldman,Cannabis in Iraq – Laws, Use, Sensi Seeds
Updated on 04/02/2020
• Caswell A. Marijuana as medicine. Med J Aust. 2019;156(7):497–8.
