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Marijuana: The Inevitable Progression from Medical to Recreational Use
Kirk Moberg, MD, PhD, FASAM
Medical Director, Illinois Institute for Addiction Recovery
Clinical Professor, Departments of Internal Medicine and Psychiatry & Behavioral Medicine
University of Illinois College of Medicine
Illinois Alcohol and other Drug Abuse Professional Certification, Inc.
March 17, 2016
Agenda
• Cannabis: the basics
• Our society’s relationship with marijuana
• Cannabis is an addictive drug
• The arguments for and against a medical role
• Unintended outcomes
• The revenues and costs of legalization
Give credit where credit is due
Kevin Sabet, PhD Nora Volkow, MD
CANNABIS: THE BASICS
Cannabis sativa
483 compounds84 cannabinoids
Hemp
Hemp seedsEaten raw, hemp milk, hemp juice,hemp milk ice-cream, waffles, tofu,nut butters
Hemp stalkPaper, construction material,clothing, biofuels
Compressed hemp seeds
The psychoactive parts
Leaves
BudsFLowers
D-9-tetrahydrocannabinolidentified 1964
Flowers and leaves
More potent derivatives
Trichomes
Hashish: pressed kief, detached trichomes, and fine material that falls from leaves or scraped resin
Kief: trichome rich powder
Cannabis orHashish
Hash oil
Organic solvent
Hash Oil
Consequences
Burns in Colorado
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8
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12
14
16
18
2010 2011 2012 2013 2014
Self admitted MJ users treated for burns
Self admitted MJ userstreated for burns
Dabbing
80%
“Another danger of “dabbing” cannabis oils is passing out after a particularly strong dose. At a recent conference, there were at least three different emergency calls due to use of high-potency cannabis extracts. One person fainted and cracked his nose on the sidewalk, in another case of woman broke her teeth on the floor.
Several explosions and fires have been reported due to BHO extractions done indoors with open-air blasting methods. Recently, a 2-year-old child had to be helicoptered from Eureka to Sacramento for medical treatment after a butane explosion in his home caused severe burns on his body.
Is there a reluctance to call that an overdose?
OUR SOCIETY’S RELATIONSHIP WITH MARIJUANA
The pendulum swings the other way
April 28, 2014
Dichotomy
Past month use
Risk: past year
Risk: daily use
“We will use [medical marijuana] as a red-herringto give marijuana a good name.”Keith Stroup, head of NORML, 1979.
“Cannabis is one of the safest drugs ever in the pharmacopeia. Period.”Allen St. Pierre, Director of the National Organization for the Reform ofMarijuana Laws, 1999.
CANNABIS IS AN ADDICTIVE DRUG
Cannabinoid receptorsCB1 and CB2
CB1 receptors—brainCB2 receptors—immune system
suppression; pain
Copyright ©2004 by the National Academy of Sciences Gogtay, Giedd, et al. Proc. Natl. Acad. Sci., 2004
MRI Scans of Healthy Children and Teens Over Time
GM loss = maturation
DSM-5: CANNABIS USE DISORDER
• A. A problematic pattern of use leading to clinically significant impairment or distress, as manifested by at least 2 of the following, occurring within a 12-month period
– Is often taken in larger amounts or over a longer period than was intended
– Persistent desire or unsuccessful efforts to cut down
– Great deal of time spent in activities necessary to obtain, use or recover from effects
– Craving, or strong desire to use
– Failure to fulfill major role obligations at work, school or home
– Continued use despite problems as a result
– Important social, occupational or recreational activities are given up or reduced because of use
– Recurrent use where it is physically hazardous
– Continued use despite knowledge of a physical or psychological problem that is known to be caused or exacerbated by it
– Tolerance
– Withdrawal
45,570 patients followed longitudinally in Sweden—15 year follow up
Lancet, 1987
Dunedin study (IQ)
• 1037 patients
• Followed from birth to age 38
• Cannabis use ascertained at age 18, 21, 26, 32, 38
• Neuropsychological testing at 13, before initiation of cannabis use, at 38, after pattern of use had developed
Meier et al., 2012
Results (additional diagnoses hypothesis)
Hard drugs= amphetamines, cocaine, heroin
Adolescent vs. adultnumber of times meeting diagnostic criteria
Post cessation
Infrequent = weekly or less often
Criticisms
• Socioeconomic factors—IQ correlates with socioeconomic status
• Socioeconomic factors—use of cannabis correlates with socioeconomic status
• Education—lack of education correlates with IQ
Response and re-evaluation
• Original paper did address education
• Authors re-evaluated socioeconomic status, ran the data and there was no difference
National Epidemiologic Survey on Alcohol and Related Conditions
2001-2002; 43,093 respondents, non-institutionalized, 18 years of age and older
Junk on the internet
What is harm anyway?
• Mental illness
• Respiratory illness
– Acute and chronic bronchitis
– COPD
• Cardiovascular illness
– ED visits for tachycardia but studies limited
More
Adverse Effects of Short-Term Use and Long-Term or Heavy Use of Marijuana.
Volkow ND et al. N Engl J Med 2014;370:2219-2227
Level of Confidence in the Evidence for Adverse Effects of Marijuana on Health and Well-Being.
Volkow ND et al. N Engl J Med 2014;370:2219-2227
Ferguson and Boden, 2008
Drugged driving
Mu-Chen Li, 2011
Meta-analysis:Drivers who testedpositive or self-reported weremore than twice as likely to be involved in a crash.
85% of Washington drivers involved infatal crashes are positive for THC.
THE ARGUMENTS FOR AND AGAINST A MEDICINAL ROLE
Increases over Time in the Potency of Tetrahydrocannabinol (THC) in Marijuana and the Number of Emergency Department Visits Involving Marijuana, Cocaine, or Heroin.
Volkow ND et al. N Engl J Med 2014;370:2219-2227
Cannabidiol:THC
Dravet syndrome
Colorado Timeline
• 2001—Medical marijuana in Colorado
• 2005—Denver legalizes possession
• 2007-08—First stores
• 2009—700 stores; 3.5% of adults have MMJ license
• 2012—Legalized
• 2014—Recreational stores open
Doctors supported this
We know how this turned out
Cannabis for medical purposes
• Illinois—45• New Mexico—20• Washington—17• Arizona—16• New York—15• Michigan—14• Maine—12• New Jersey—12• Rhode Island—12• Delaware—11• Montana—11• Connecticut—11• Oregon—10
• Alaska—10• Hawaii—9• Minnesota—9• California—8• Colorado—8• Washington DC—8• Georgia—8• Massachusetts—8• Nevada—8• Vermont—7• New Hampshire—7• Maryland—5• Louisiana—3
Jurisdictions where recreational use is legal
Don’t worry, I won’t read all of these
AIDS, Alzheimer’s Disease, ALS, Arnold-Chiari Malformation and Syringomyelia, Autism, Cachexia/Wasting Syndrome, Cancer, Causalgia, Chronic Inflammatory Demyelinating Polyneuropathy, Chronic Pain due to Trauma, Chronic Pain (post-operative),Chronic Pain Syndrome, Crohn’s disease, Complex Regional Pain Syndrome Types I and II, Dystonia, Fibromyalgia (severe), Fibrous Dysplasia, Glaucoma, Hepatitis C, HIV, Hydrocephalus, Interstitial Cystitis, Intractable Pain, Irritable Bowel Syndrome, SystemicLupus Erythematosis, Multiple Sclerosis, Muscular Dystrophy, Myasthenia Gravis, Myoclonus, Nail-Patella Syndrome, Neurofibromatosis, Osteoarthritis, Parkinson’s Disease, Post-Concussion Syndrome, PTSD, Residual Limb Pain, Rheumatoid Arthritis, Seizures, Sjogren’s Syndrome, Spinal Cord Disease, Spinal Cord Injury, Spinocerebellar Ataxia, Tourette Syndrome, Traumatic Brain Injury
As of October 2015
Louisiana
Symptoms Related to Cancer Chemotherapy, Glaucoma, Spastic Quadriplegia
California
Cancer, Anorexia, AIDS, Chronic Pain, Multiple Sclerosis, Epilepsy, Glaucoma, Arthritis
Not done yet…
“any other chronic or persistent condition which limits a major life activity and is capable of causing serious harm”
Mono-amine oxidase inhibitor
So, we have a patient withParkinson’s disease
Shall we prescribe tobacco?
So, how do we get from…
Point A—no legalization to…
Point B—legalization for medicinal purposes
This doesn’t do it
This does
<5%Less than 5% of card holdersare cancer, HIV/AIDS orglaucoma patients.
Avg patient: 32 year old WM;history of drug abuse; no lifethreatening disease
Compassionate care orIncreased access to marijuana?
Vocabulary
• THC—D-9-tetrahydrocannabinol
• Dronabinol (Marinol®)
• Nabilone
• Cannabidiol (Epidolex®)
• Nabiximols (Sativex®; 1:1 ratio of THC:CBD)
• Levonantradol (not in clinical use)
The data
• 79 trials• 6462 patients
• HIV/AIDS appetite stimulation• Nausea and vomiting due to chemotherapy• Chronic pain• Spasticity due to multiple sclerosis or paraplegia• Depression• Anxiety disorder• Sleep disorder• Psychosis• Glaucoma• Tourette syndrome
Conclusions
• 4 articles judged low risk of bias
Conclusions
• Best evidence is for chronic pain of a variety of sorts
• Suggestion of benefit for spasticity in MS and paraplegia
Whiting et al., 2015, Cannabinoids for Medical Use: A Systematic Review and Meta-analysis, JAMA
More data
• 34 studies
• Class I (8)
• Duration (1948-2013)
Medications used
• Oral cannabis extract
• Nabiximols
• THC
Results
• Spasticity—OCE effective; Nabiximols, THC probably effective• Central pain or painful spasms including spasticity related
pain—OCE effective; Nabiximols, THC probably effective• Urinary dysfunction—Nabiximols probably effective for
decreasing number of voids; THC, OCE probably ineffective• Tremor—THC, OCE probably ineffective, Nabiximols possibly
ineffective• L-dopa induced dyskinesia in Parkinson’s—OCE probably
ineffective• Non-chorea symptoms of Huntington disease, cervical
dystonia, epilepsy, Tourette syndrome—oral cannabinoids unknown efficacy
Koppel et al., 2014, Systematic Review: Efficacy and safety of medical marijuanaIn selected neurologic disorders, American Academy of Neurology
Cannabidiol is in preliminary trials for Dravet syndrome and showing promise
The COMPASS trial; December 2015
Evidence presented that inhaled marijuana is effective at relieving chronicnon-cancer pain
DO EMPLOYERS HAVE ANY RIGHTS?
June 15, 2015
Colorado Supreme Court says companies can fire workers for using medical marijuana in their off-hours
Is marijuana a medicine?
NO: Smoked or inhaled raw marijuanais not a medicine
YES: There are marijuana based pillsavailable and other medicationscoming soon
MAYBE: Research is ongoing
LET’S FOLLOW THE MONEY
Prohibition didn’t work…after all you can’t legislate morality
The face of Prohibition
Prohibition facts
18th ammendment
193321st ammendmentMoore, 1989
An important fact…
An important fact…
These guys didn’t start withProhibition and they didn’tend with Prohibition.
Let’s look at cartels
Most widely smuggled legal product$657 billion/year business in 2009105 organized crime groups in CanadaTaliban and Hezbollah
The idea that taxation and increasedregulation (e.g. lowering potency) wouldresult in less of a black market isnaïve.
Benefits
29.5 per 100,000to 10.7 per 100,000
10.1 per 100,000to less than 5 per 100,000
Disorderly conductDecreased by 50%
The first equity company dedicated to the marijuana industry
“The use of marijuana ... has importantimplications for the tobacco industry in termsof an alternative product line. [We] have theland to grow it, the machines to roll it andpackage it, the distribution to market it. In fact,some firms have registered trademarks, whichare taken directly from marijuana street jargon.These trade names are used currently on littleknownlegal products, but could be switched ifand when marijuana is legalized. Estimatesindicate that the market in legalizedmarijuana might be as high as $10 billion annually
- 1970s report commissioned by cigarettemanufacturer Brown and Williamson (nowmerged with R.J. Reynolds)
“This is what the end of prohibition looks like,” said Brendan Kennedy, the CEO of Privateer Holdings, which owns Marley Natural and plans to run it out of a loft space on Manhattan’s Lower East Side. “Bob Marley started to push for legalization more than 50 years ago. We’re going to help him finish it.”
Big Marijuana
Big Tobacco and medical cigarettes
We know that these role models were intended for adults
See?
“[O]ur company welcomes the opportunity to make it clear that we do not promote thesale of tobacco products to children.” (American Tobacco Company)
“We are not for getting youth to smoke, I want to make that plain right now.” (Congressional Testimony of Bowman Gray, Chairman of RJ Reynolds on behalf of theentire industry.)
[W]e segment the market, and the segmentation we use in our marketing to developmarketing strategies, I will make the point very clearly here that not one of those segments, and there are many, is the youth segment.” (Congressional testimony ofEd Horrigan, RJ Reynolds)
“In our view, smoking is an adult custom and the decision to smoke should be based onmature and informed individual freedom of choice.” (1993 Tobacco Institute pressrelease)
But sometimes there really are secret files
“The 14-18 year old group is an increasing segment…RJR must soon establish asuccessful new brand in this market if our position in the industry is to be maintainedover the long term.” (Secret Documents obtained from RJ Reynolds after the Tobacco Master Settlement Agreement of 1998)
“[Young people are] the only source of replacement smokers…” (Secret Documentsobtained from RJ Reynolds after the Tobacco Master Settlement Agreement of 1998)
“[T]he base of our business is the high school student.” (Secret Documents obtainedfrom Lorillard after the Tobacco Master Settlement Agreement of 1998)
2016 Republican primary
Follow the money
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1970 1980 1990 2000 2010 2013
$ million
% approval
NORML established
G. Soros recruits Ethan Nadelmanstarts Lindesmith Center.Focus on winnable issues likeMedical marijuana.
Progressive Ins. and U of Phoenix foundersFundlegalization
Lobbyist contributions for AK and ORapproximately $9.2M
0%
20%
40%
60%
80%
100%
120%
Pro-marijuana Anti-marijuana
2014 mid terms
2014 mid terms
UNINTENDED OUTCOMES
April 9, 2015
Marijuana Taxes Won’t Save State Budgets
Colorado’s marijuana tax collections are not as high as expected. In February 2014,
Gov. John Hickenlooper’s office projected Colorado would take in $118 million in
taxes on recreational marijuana in its first full year after legalization. With seven
months of revenue data in, his office has cut that projection and believes it will
collect just $69 million through the end of the fiscal year in June, a miss of 42 percent.
That figure is consequential in two ways. First, it’s a wide miss. Second, compared
with Colorado’s all-funds budget of $27 billion, neither $69 million nor $118 million
is a large number.
Drug dealer says legal pot helps his business
One of the great mysteries of Colorado’s legal pot experiment
remains: Will legalization take down the black market?
It’s too early to say definitively, but one Colorado drug dealer is saying the high
prices of legal recreational weed in its first two months — including a
$24.50 gram of Super Lemon Haze at Medicinal Wellness Center recently
documented in The Cannabist’s strain reviews — hasn’t hurt his business.
In fact, his business is actually better because of the high legal recreational
prices.
“If anything (legalization) has helped (my business),” the unidentified dealer
tells CNBC’s Harry Smith in the network’s “Marijuana in America: Colorado
Pot Rush” documentary, which premiers on Feb. 26. “It’s overpriced.
It’s being taxed way too high, and I feel like the prices should definitely
come down lower.”Cannabist, February 26, 2014
Alcohol and Tobacco:Money Makers or Dollar Drainers?
Tobacco costs$200 billion
Alcohol costs$185 billion
Revenues: $14 billion Revenues: $25 billion
NY Times 8/31/2008; tobacco free kids; policy archive/bitstream/handle
Colorado marijuana interdiction seizures
0
50
100
150
200
250
300
350
2005 2006 2007 2008 2009 2010 2011 2012
Seizures
Seizures
22
11
1
2
182
12
12
8
1
1
6
6
41
4
22
7
4
415 3
1
5
4
4
22
1
1
2
14
8
6
Total Reported Seizures per State from Colorado: 2013
3
The answer is…
What you tell people when they say there has never been marijuana overdose in recorded history?
WHAT ARE EDIBLES?
Snacks Laced With Marijuana Raise Concerns
By JACK HEALYJAN. 31, 2014
ED visits to Colorado Children’s Hospital for MJ overdose
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2008-2011 2013 2014 1st 6 months
Children 3-7
Children 3-7
OhioMedical and Recreational
Responsible Ohio PAC: $11,973,695
BuddieOscar
Nonna MarijuanaBong Appetite
Aurora Leveroni
Outcome
36% yes64% no
Why?
