21 century marijuana -...
TRANSCRIPT
21st century marijuana Meeting of the Minds April 5-6, 2018 LaTisha Bader, PhD, LP, LAC, CMPC
Learning Objectives
� Identify new trends in use, potency, products, and marketing practices that make young adults vulnerable
� Describe how legalization of recreational cannabis has influenced public health, perception and consumption
� Review current research and present
effective ways to communicate use deterrence
3
Special Thanks
• Ben Cort • Laura Martin, MD • Bari Platter, MS, RN,
PMHCNS-BC
Know your intensions
Rules of Attraction The rule of thirds is applied by aligning a subject with the guide lines and their intersection points, placing the horizon on the top or bottom line, or allowing linear features in the image to flow from section to section.
Where have we been
Genesis 1:12 vs. 21st Century � “I have given you all the seed bearing
herbs and plants to use.”
Timeline of Marijuana
2900 BC Chinese
Emperor Fu Marijuana is
popular medicine
1450 BC Anointing Oil
1213 BC Egyptians Used for
glaucoma, inflammation and
enemas
100 BC India
Cannabis and milk used as anesthetic, prolong life, improve
judgment, lower fevers, induce sleep
200 BC Medical
Cannabis used in Greece
70 AD Roman text claims cannabis treats ear
infections and suppresses sexual
longing
1 AD Chinese Text
Recommends Marijuana for 100 ailments
1500 Muslim doctor uses marijuana to reduce
sexuality
9
1611 Jamestown
settlers bring marijuana to
North America
1621 Anatomy of Melancholy
Treats depression
1850 Added to US
Pharmacopeia
1906 Pure Food and
Drug Act Required labeling
of cannabis in OTC remedies
1619 Virginia Assembly
passed law to grow hemp
Late 19th Century Sold in public Rx
Presidents grow crop
1889 Used for opium
withdrawal
10
"As demand for marijuana-based medications accelerated, pharmaceutical firms attempted to produce consistently potent and reliable drugs from hemp. By the 1930s at least two American companies – Parke-Davis and Eli Lily – were selling standardized extracts of marijuana for use as an analgesic, an antispasmodic and sedative. Another manufacturer, Grimault & Company, marketed marijuana cigarettes as a remedy for asthma."
11
1900-1920’s Mexican
Revolution Recreational
use; “Marijuana Menace”
1917 Colorado was
8th state to outlaw
1931 29 states had
outlawed marijuana
1911 Massachusetts 1st state
to outlaw cannabis
1930 Fear of Marijuana
1936 “Reefer Madness”
12
https://www.youtube.com/watch?v=sbjHOBJzhb0
13
1937 Marijuana
Tax Act
1937 Samuel R. Caldwell4
1942 Removed from
US Pharmacopeia
1944 La Guardia Report
1940’s “Hemp for Victory”
1960 Marijuana Popular in Counterculture
1951 Stricter
Sentencing Laws
1964 THC first identified and synthesized
1968 University of Mississippi
becomes official grower of US government
1970 Controlled Substance
Act Schedule of
Drugs No
acceptable medical use
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1970 Mandatory minimum
sentencing repealed
1971 NORML formed
1971 Nixon will not
legalize
1972 Shafer Commission
1973 DEA formed
1976 Parents movement begins
1974 High Times
1980’s War on Drugs
15
1980 Marinol tested
on cancer patients
1985 FDA approves Marinol
1988 Scientists Discover
Cannabinoid Receptor in the Brain
1992 Scientists Discover Endocannabinoid
1996 Medical Use Legalized
in California
1999 Institute of
Medicine (IOM) conducts
comprehensive study on medical
marijuana
1998 Alaska, Oregon and Washington legalize medical marijuana
1999 Marinol moved to Schedule II
16
2000 Colorado allows
medical marijuana (7th
state)
2006 Presbyterian Church
approves resolution to support medical marijuana
2011 DEA places 5 synthetics into
Schedule I “Imminent Hazard”
2014 Federal Banks can cooperate
with marijuana sellers
2003 US government
receives cannabinoid patent
2010 Washington expands list of medical
professionals authorized to recommend marijuana
2013 Another denial to move Schedule
17
May 2015 Gov of Puerto Rico legalizes medical
marijuana
June 2015 Federal government removes obstacle to
marijuana research
2016 California, Nevada, Maine and
Massachusetts legalized recreational marijuana
2016 DEA considers schedule
change Declines, but open doors to
research
Who is using
National Trends
National Trends
Research
22
The human body produces its own cannabis-like compounds, called endocannabinoids, that react with the body’s cannabinoid receptors.
Cannabinoid receptors in the brain stem and spinal cord play a role in pain control, vomiting reflex, appetite, emotional responses, motor skills, and memory formation.
THC and the Developing Body
24
"Twenty-eight years after discovering THC, in 1992, Dr. Mechoulam, along with Dr. William Devane and Dr. Lumir Hanus, identified the brain's first endogenous cannabinoid (or endocannabinoid) - the brain's natural version of THC -which they called 'anandamide,' from the Sanskrit word 'ananda,' which means 'eternal bliss' or 'supreme joy.' Vigorous exercise stimulates the release of anandamide, and the sense of euphoric well-being that comes with a healthy workout - what jogging enthusiasts refer to as a 'runner's high' - is due to elevated levels of endocannabinoids. The endocannabinoid system in the brain is also believed to help mediate emotions, consolidate memory, and coordinate movement."
Controlled Substances Act
� Controlled Substances Act as having a “currently accepted medical use in treatment in the United States,” must meet a five-part test:
(1) The drug’s chemistry must be known and reproducible, (2) there must be adequate safety studies, (3) there must be adequate and well-controlled studies proving efficacy, (4) the drug must be accepted by qualified experts, and (5) the scientific evidence must be widely available.
� According to the DEA, botanical marijuana meets none of these
requirements. First, marijuana’s chemistry is neither fully known nor reproducible. Second, adequate safety studies have not been done. Third, there are no adequate, well-controlled scientific studies proving marijuana is effective for any medical condition. Fourth, marijuana is not accepted by even a significant minority of experts qualified to evaluate drugs. Fifth, published scientific evidence concluding that marijuana is safe and effective for use in humans does not exist
Who’s selling
27
State Laws 2017
29 states with medical marijuana: Alaska Arizona Arkansas California Colorado Connecticut
Delaware Florida Hawaii Illinois Maine Maryland Massachusetts Michigan Minnesota Montana Nevada New
Hampshire New Jersey New Mexico New York North Dakota Ohio Oregon Pennsylvania Rhode Island Vermont
Washington District of Columbia West Virginia
9 states with legalization: Alaska Colorado California Maine Massachusetts
Nevada Oregon Vermont Washington
Why are we using
Medicinal
� Therapeutic values: � relieving nausea � increasing appetite � reducing muscle
spasms and spasticity � chronic pain* � reducing intraocular
pressure � relieving anxiety
� Marijuana has been used to treat the symptoms of cancer and chemotherapy, chronic wasting disease associated with AIDS/HIV, spasticity of multiple sclerosis, epilepsy, and Dravet syndrome (CBD)
Recreational
What are we using Marijuana 101: Flower, Oil, Concentrates, Edibles, Vape, Topicals
1960 1965 1970 1974 1978 1980 1983 1984 1985 1986 1990 1992 1993 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 THC 0.2 0.24 0.39 0.47 1 1 1.5 3.3 3.3 3.5 3.5 3.1 3.1 4 4.54 5.16 4.96 4.67 5.4 6.18 7.26 7.18 8.33 8.09 9.08 10.27 10.25 9.91 10.96 11.42
CBD 0.28 0.31 0.38 0.36 0.33 0.31 0.42 0.4 0.41 0.43 0.45 0.47 0.42 0.46 0.46 0.46 0.53 0.48 0.41
0
2
4
6
8
10
12
14
MA
RIJ
UA
NA
POTE
NC
Y
CBD: NON-
Psychoactive Ingredient
Average THC and CBD Levels in the US: 1960 -
2011
Mehmedic et al., 2010
THC: Psychoactive
Ingredient
34
Plant
05
1015202530354045
2010 2011 2012 2013 2014 2015 2016
THCinCO
THCinCO
Plant - CO
The percent of THC, also known as potency, has been steadily increasing in plants over the last 55 years, while CBD stayed the same.
Dab From Farming to Chemistry
Potency
� Concentrates : 710 is the new 420 � Butane-extracted hash oil (BHO)
A chunk of the stuff the size of a Tic Tac can be the equivalent of hoovering up an entire joint in one
massive toke. Even for hardcore smokers, the experience – which fans call dabbing – can be like getting high for the very first time. Your head spins,
your eyes get fluttery, a few beads of sweat surface on your forehead and, suddenly, you're cosmically
baked.” (Rolling Stone Magazine, 6/20/2013)
Not your granddad’s weed Not your dad’s weed
Not even my weed
Concentrates
“But it’s just a plant…” (80-99% THC) Concentrates
“Budder”
“Shatter”
“Ear Wax”
“Green Crack” wax
Hash Oil Capsules
Butane Hash Oil (BHO)
Concentrates
Concentrates
Concentrates
Concentrates
Concentrates
Concentrates
� Marijuana or “Marihuana” means all the parts of the plant of the genus cannabis whether growing or not, the seeds thereof, the resin extracted from any part of the plant, and every compound, manufacture, salt, derivative, mixture, or preparation of the plant, its seeds, or its resin, including marihuana concentrate.
Concentrates
Vape What’s undetectable, odorless, and immediate…
Oil
49
Increasingly popular and accessible Oil
Oil
Oil
Eat Trending cannabis
Edibles
� 10 mg is a legal dose
How many servings?
Edibles
Edible marijuana was sited as the culprit behind the most troubling cases arriving at the UCH and Children’s Hospital Colorado emergency departments, including severe burns and cycling vomiting syndrome.
Edibles
I can put it where?! Topical
Hearts and
Minds
Hearts and Minds
Clinical Information
67
Intoxication
A. Recent use of cannabis B. Clinically significant problematic behavioral or psychological
changes (e.g., impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgment, social withdrawal) that developed during, or shortly after, cannabis use
C. At least 2 of the following signs, developing within 2 hours of cannabis use: • Conjunctival injection • Increased appetite • Dry mouth • Tachycardia
D. Symptoms not due to a general medical condition and not better accounted for by another mental disorder, including intoxication with another substance
68
Withdrawal A. Cessation of cannabis use that has been heavy and prolonged (ie, usually
daily or almost daily use over a period of at least a few months). B. Three or more of the following signs and symptoms develop within
approximately 1 week after cessation of heavy, prolonged use: • Irritability, anger or aggression • Nervousness or anxiety • Sleep difficulty (ie, insomnia, disturbing dreams) • Decreased appetite or weight loss • Restlessness • Depressed mood • At least one of the following physical symptoms causing significant discomfort:
abdominal pain, shakiness/tremors, sweating, fever, chills, or headache
C. The signs or symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.
It’s addictive
Adults users are more anxious,
more psychotic, less alert, more
disorganized, have dry mouth,
and are more hypertensive and
want to use more.
1 in 10 adults…
1 in 6 adolescents…who try marijuana
will become addicted More adolescents are using
marijuana than smoking
tobacco
70
Toxiology
absorbed into body tissues (including the brain, heart, and fat) or transformed by the liver
Because THC is stored in fatty tissues, it accumulates faster than it can be eliminated in chronic repetitive smokers. Leads to extended retention of THC which is then eliminated from the body at a relatively constant rate with an average elimination half-life being estimated at 18-30 hours.
Urinary results difficult to interpret due to variables such as dosage of THC ingested, frequency of use, timing of urine collection relative to last exposure to marijuana, rate of release of stored cannabinoids in adipose tissue, and an individual's hydration state.
Substance Use Disorder (Addiction) 1. Taking the substance in larger amounts or for longer than the you
meant to 2. Wanting to cut down or stop using the substance but not
managing to 3. Spending a lot of time getting, using, or recovering from use of the
substance 4. Cravings and urges to use the substance 5. Not managing to do what you should at work, home or school,
because of substance use 6. Continuing to use, even when it causes problems in relationships 7. Giving up important social, occupational or recreational activities
because of substance use 8. Using substances again and again, even when it puts the you in
danger 9. Continuing to use, even when the you know you have a physical or
psychological problem that could have been caused or made worse by the substance
10. Needing more of the substance to get the effect you want (tolerance)
11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.
DSM 5
Criteria
2–3: mild 4–5: moderate 6 +: severe
Withdrawal
� Withdrawal symptoms peak at 4 days � Acute withdrawal period lasts 16 days � Most severe symptoms include craving,
restlessness, nervousness and sleeplessness � Marijuana Withdrawal checklist also includes
irritability, depression, anger, strange dreams, loss of appetite and headache
� On the Clinical Global Impression Scale, patients were rated as markedly ill when they go through withdrawal
� Withdrawal symptoms more severe in women � Withdrawal symptoms are a negative
reinforcement for continued use and are associated with less treatment adherence
Bonnet et al 2014
� 12% of those 12 and older have used cannabis in the last year
� 1 in 2 daily users develop cannabis dependence
� More adolescents are using marijuana than smoking tobacco
� Cannabis users have increased risk for use of other substances and development of other alcohol and drug use disorders (access, personality traits, change in reward system)
� Cannabis users have worsened prognosis for a co-occurring alcohol use disorder
Reviewed in Hall, 2014; reviewed in Volkow et al; Schuermeyer et al 2014; Richmond et al 2013; Wall et al 2011; Cerda et al 2012, Weinberger et al 2016, Hassin et al 2016
Cannabis Use Disorder
What we actually know Science and stuff
Acute � Motor
� Diminished reaction time, motor coordination, and perceptual accuracy
� Distorted perception (sights, sounds, time, touch)
� Cardiovascular � Greater difficulty for individuals to intake sufficient oxygen � Increase heart rate (20-100 % faster, for up to 3 hours) � Increased risk of bronchitis, changes consistent with chronic
obstructive pulmonary disease � Increase risk of angina, heart attack in those with previous
heart attack (blood pressure increases) � Increased risk of heart attacks and strokes in those without a
previous history
� Autonomic nervous system � Inhibits sweating and temperature control
Reviewed in Hall, 2014 and Volkow et al 2014; Hodcroft et al 2014; Asbridge et al 2014; Monte et al 2014
Effects on the Body
Acute � Electrolyte imbalances � Respiratory system complications � Second hand smoke exposure causes cardiovascular
effects (animal study) � ED visits: 1-2 are for intoxication…10-15 for associated
illnesses (anxiety, cyclical vomiting, unintentional ingestions, burns)
Chronic � Increased risk of chronic bronchitis � Changes in physical structure of the brain � Immune system � Cannabinoid Hyperemesis Syndrome � Reproductive systems
� Increased risk of testicular cancer (dose response related) � Data on lung, head, and beck cancers associated with
marijuana use is unclear
Reviewed in Hall, 2014 and Volkow et al 2014; Hodcroft et al 2014; Asbridge et al 2014; Monte et al 2014
Effects on the Body
Acute � Impaired memory, judgment � Risk of depression 1.4 x higher � Acute anxiety � Increased risk of anxiety disorders � Worsened outcomes in bipolar disorder � Risk of suicide attempt requiring hospitalizations 2 x higher
Chronic � Increased risk of:
� Impaired cognitive functioning, memory and decision making � Depression, anxiety, and panic attacks � Suicidal ideation and suicide attempts
� Reduced verbal learning, memory, attention � Loss of up to 8 IQ points at adulthood � Neonatal use: Altered brain development (change in sensitivity of
the reward system, impaired neuronal connectivity)
Reviewed in Hall, 2014; Di Forti et al 2014, Giordano et al 2014
Effects on Mental Health
� Use of cannabis associated with 1.4x increased risk of psychosis and regular users with a 2x risk of psychosis
� High potency cannabis, more frequent use, and
genetic susceptibility can increase this risk up to 8x risk
� Use before age 18 has 2.4 times risk of dx of
schizophrenia (dose response) � Risk is 3.3x higher if cannabis use within 3 years
of diagnosis, 1.6x higher if 7 years
Reviewed in Hall, 2014; Di Forti et al 2014, Giordano et al 2014 Also, see Radhakrishnan et al Gone to Pot – A review of the Association between Cannabis and Psychosis
Psychosis
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Marijuana Use and associated behaviors(Table 5.1)
Behavioral Health Problems Strength of association
Alcohol Use +++ Tobacco Use +++ Use of other Illicit Drugs + Bipolar Disorder ++ Unipolar Depression + Social Anxiety +++ Generalized Anxiety + Panic Disorder +++ Posttraumatic Stress Disorder + Attention-deficit / Hyperactivity Disorder +++ Sleep Disturbances + Suicidality and violence +
� May cause excessive sedation when combined with perioperative medications. Avoid marijuana if scheduled for surgery in the next 2 weeks.
� May increase the risk of bleeding when used with aspirin, anticoagulants, antiplatelet drugs, nonsteroidal anti-inflammatory drugs, and ginko biloba
� May affect blood sugar; medications for diabetes many need to be adjusted (e.g. metformin or insulin). Use caution if taking herbs and supplements that affect blood sugar.
� May lower blood pressure. Use caution with medications, herbs or supplements that lower blood pressure,
� May increase drowsiness when used with benzodiazepines, barbiturates, narcotics, some antidepressants, and alcohol.
� Affects the liver’s cytochrome P450 enzyme system (CYP450) and could result in increased blood levels of medications metabolized by CP450 leading to adverse reactions.
http://mayoclinic.org/drugs-supplements/marijuana/interactions/hrb-20059701
Medical Interactions
� No lethal overdoses (due to THC in humans) � Behaviorally mediated deaths through
accidents, suicide, homicide
� Double the risk of motor vehicle accident � Increased likelihood of non-fatal bicycle
accident (9x risk) Reviewed in Hall, 2014; Reviewed in Volkow et al 2014; Hodcroft et al 2014; Asbridge et al 2014;
Monte et al 2014
Effects on Behavior
Use of Cannabis Associated with Worse Social Outcomes at Age 25 (New Zealand Study)
Source:FergussonandBoden.Addiction,103,pp.969-976,2008.
NumberofoccasionsusingCannabisbetweenages14-21
%welfaredependent(ages21-25)
%Unemployed
(ages21-25)
meanpersonalincome
atage25
%gaineduniversity
degreebyage25
400+300to399200to299100to1991to99Never
#ofoccasionsusing
Cannabisages14-21
Know your “CANNABIS Conversation” Finding your voice in the wellness movement…
Give me your Instagram speech!
Harm reduction � SBIRT � Screeners
� Severity of Dependence Scale SDS � Cannabis Abuse Screening Test
CAST � Cannabis Use Disorders Test –
Revised CUDIT-R � Problematic Use of Marijuana � Cannabis Use Problems
Identification Test CUPIT � Marijuana Screening Inventory
� Abstinence challenge, decrease potency or frequency
� Participate in IOP treatment � CANDIS � Discuss legal risks � Support medical interventions and
education � Teach refusal skills
Abstinence
� Know DSM5 criteria for accurate diagnosing � Risks for co-occurring problems � Medication interactions � Risks for youth use versus adult use � Exacerbating of cravings � Legal consequences � Challenge “Reservations”
… and the wellness movement begins
� No current FDA approved medications
Reviewed in Kelly and Levin “Treatment of Cannabis Use Disorder,” in 2015 Textbook of Substance Abuse Treatment; Allsop et al 2014
Treatment
