Marijuana Jeopardizing Youth

Eric A. Voth, M.D., F.A.C.P-Eric A. Voth, M.D., F.A.C.P-

Chairman Chairman

The Institute on The Institute on

Global Drug PolicyGlobal Drug Policy

Brain Development

Motivation

Emotion

Judgment

Cerebellum

Amygdala

Nucleus Accumbens

Prefrontal Cortex

Judgement is last to develop!

Physical coordination Sensory processing

Maturation starts at the back of the brain and moves to the front

30-day Marijuana Use

Friends Who Use

Perception of Harm –% reporting NO RISK with regular use

CESAR FAXU n i v e r s i t y o f M a r y l a n d , C o l l e g e P a r k

A Weekly FAX from the Center for Substance Abuse Research

January 18, 2010Vol. 19, Issue 2

U.S. High School Seniors’ Perception of Harm from Regular Marijuana Use Decreasing

0%

10%

20%

30%

40%

50%

60%

70%

80%

Perceived Risk of Harm from Regular Use

Used in Past Month

Percentage of U.S. Twelfth Grade Students Reporting Past Month Marijuana Use and Perceived Risk of Harm from Regular Marijuana Use, 1975-2009

SOURCE: Adapted by CESAR from University of Michigan, “Teen Marijuana Use Tilts Up, While Some Drugs Decline in Use,” Press Release, 12/14/09. Available online at

http://www.monitoringthefuture.org/data/09data.html#2009data-drugs.

Marijuana

Impurity-488 substances, 66 cannabinoidsImpurity-488 substances, 66 cannabinoids Resembles tobacco in constituents. Resembles tobacco in constituents. High THC concentrations 2-30%High THC concentrations 2-30% 1/2 life 5-7 days1/2 life 5-7 days

Ave %THC potency (seizures)

19751975 0.74%0.74% 19771977 0.900.90 19801980 2.062.06 19831983 3.233.23 19851985 2.822.82 19901990 3.353.35 19921992 3.103.10 19951995 3.753.75 19961996 4.074.07 19971997 4.534.53 19981998 4.434.43

19991999 4.554.55 20002000 4.874.87 20012001 5.325.32 20022002 6.346.34 20032003 6.126.12 20062006 8.758.75 20072007 9.69.6 20082008 8.88.8

University of MississippiUniversity of MississippiPotency monitoring reportPotency monitoring report

Neuro-Behavioral Effects

Cognitive Changes

AttentionAttention ConcentrationConcentration Decision-makingDecision-making InhibitionInhibition ImpulsivityImpulsivity Working memoryWorking memory Verbal fluencyVerbal fluency Concept formation and planningConcept formation and planning

J Addict Med 2011;5:1-8 J Addict Med 2011;5:1-8

Memory

Difficulty sorting information and Difficulty sorting information and inhibition of memory even after a inhibition of memory even after a mean two year abstinence.mean two year abstinence.

SOLOWIJ- LIFE SCIENCES SOLOWIJ- LIFE SCIENCES

1995;5:2119-261995;5:2119-26

Structural Damage to Brain

59 users 33 controls59 users 33 controls Ave age 33, Ave use 15 yrs, started 16.7 yoAve age 33, Ave use 15 yrs, started 16.7 yo Ave joints /mo=147 Ave joints /mo=147 Ave life joints 25922Ave life joints 25922 Demonstrated axonal connectivity Demonstrated axonal connectivity

impairment in hippocampus, splenium of impairment in hippocampus, splenium of corpus callosum, commissural fibers corpus callosum, commissural fibers

Brain 2012:135;2245-2255Brain 2012:135;2245-2255

Neuropsychological Decline

1037 individuals1037 individuals Pot use at 18,21,26,32,38 y/oPot use at 18,21,26,32,38 y/o Neuropsych testing at 13 before pot and 38Neuropsych testing at 13 before pot and 38 Broad Neuropsychological decline across Broad Neuropsychological decline across

all domains even controlling for educationall domains even controlling for education Greatest decline was adolescent and Greatest decline was adolescent and

persistent use. persistent use. Proc Natl Acad Sci U S A. 2012 Aug 27 Proc Natl Acad Sci U S A. 2012 Aug 27

From the horse’s mouth

““I used to smoke this stuff regulerly I quit because I I used to smoke this stuff regulerly I quit because I needed to pass a test to get a job. The reason I am writing needed to pass a test to get a job. The reason I am writing is because I never had any of thougs side effects you talk is because I never had any of thougs side effects you talk about don’t get me wrong its not for every body. But you about don’t get me wrong its not for every body. But you don’t need to say untrue things about it coordination don’t need to say untrue things about it coordination imparment that’s bs it allows you to focus better on single imparment that’s bs it allows you to focus better on single things its perfect for kids like I was that cant concetrate on things its perfect for kids like I was that cant concetrate on ting well you don’t have to reply to this email I am just ting well you don’t have to reply to this email I am just bored and looking at stuff on the net and emailing people bored and looking at stuff on the net and emailing people and going on and on cause I cant sleep well you have a and going on and on cause I cant sleep well you have a nice day. nice day.

Driving effects

Driving Effects

Combining EtOH and Marijuana in First Combining EtOH and Marijuana in First Study Reduced Driving SkillsStudy Reduced Driving Skills

.07 + 100ug = Plain EtOH of 0.09.07 + 100ug = Plain EtOH of 0.09 .07 + 200 ug = Plain EtOH of .14 g/dl.07 + 200 ug = Plain EtOH of .14 g/dl

NHTSA Notes Annals of Emergency MedicineNHTSA Notes Annals of Emergency Medicine 2000;35:3992000;35:399

Colorado Pot

Marijuana & Pilots

Psychiatric andBehavioral Disorders

Marijuana and depression

1920 subjects1920 subjects 15 year follow up 15 year follow up Likelyhood of major depression 4 times Likelyhood of major depression 4 times

greater among users. greater among users.

Am J. Psychiatry

2001;158:2033-2037

Depression

Depressive responses measuredDepressive responses measured Lower doses= Serotonin agonistLower doses= Serotonin agonist Higher doses= Serotonin suppressantHigher doses= Serotonin suppressant Effect was the Medial Prefrontal CortexEffect was the Medial Prefrontal Cortex

J Neuroscience 2007;27:11700-11711 J Neuroscience 2007;27:11700-11711

Marijuana and Psychosis

4045 4045 psychosis-free psychosis-free and 59 individuals and 59 individuals exhibiting psychosis at baseline assessment.exhibiting psychosis at baseline assessment.

Marijuana predicted Marijuana predicted 2.762.76 times greater times greater likelihood of likelihood of any psychotic symptomsany psychotic symptoms, , predicted predicted 24.1724.17 times higher incidence of times higher incidence of severe psychotic symptomssevere psychotic symptoms, and predicted , and predicted 12 times higher need for clinical assessment 12 times higher need for clinical assessment and care for psychotic symptoms. and care for psychotic symptoms.

American Journal of EpidemiologyAmerican Journal of Epidemiology

2002;156:319-27 2002;156:319-27

Persistence of Psychosis

Risk of psychosis -no prior psychosis who Risk of psychosis -no prior psychosis who used pot, 1.9 times greater that non-users in used pot, 1.9 times greater that non-users in ave 3.5 years. ave 3.5 years.

Continued pot use risk of future psychosis Continued pot use risk of future psychosis was 31% vs 20% in those who did not use was 31% vs 20% in those who did not use out to approx 8.5 years.out to approx 8.5 years.

BMJ 2011;342: d738 BMJ 2011;342: d738

Marijuana and Bipolar Illness

166 first-episode bipolar I disorder patients. 166 first-episode bipolar I disorder patients. Cannabis and alcohol associated with the Cannabis and alcohol associated with the

first episode of maniafirst episode of mania

Bipolar Disorder 2008;10:738-741 Bipolar Disorder 2008;10:738-741

Marijuana and Behavior

Marijuana had a greater effect on degree of Marijuana had a greater effect on degree of violent behavior in non-delinquent violent behavior in non-delinquent individuals than in delinquent individuals. individuals than in delinquent individuals. This effect is even more prominent than the This effect is even more prominent than the effect of cocaine, amphetamine, or effect of cocaine, amphetamine, or tranquilizer/sedative use. tranquilizer/sedative use.

Friedman AS, J Addict Dis. 2003;22:63-78 Friedman AS, J Addict Dis. 2003;22:63-78

Gateway Effects&Addiction

Gateway Effect

Risk spans entire course of adolescent development.

Young people exposed to other users are at higher risk for early initiation.

Clear family standards and proactive family management are important in delaying alcohol and marijuana use.

Kosterman R, Hawkins JD, Guo J, Catalano RF, Abbott RD. . American Journal of Public Health 2000;90:360-366.

Gateway effects

Risk of other drug use with weekly marijuana vs nonusers:

14-15 y/o 66.7%

17-18y/o 28.5%

20-21y/o 12.2%

24-25y/o 3.9%Fergusson DM, et al.

Addiction 2006;101:556-569

Marijuana Dependence

Most patients claimed serious problems with Most patients claimed serious problems with cannabis, and 78.6% met criteria for cannabis cannabis, and 78.6% met criteria for cannabis dependence. dependence.

Two thirds reported withdrawal. Cannabis is a Two thirds reported withdrawal. Cannabis is a reinforcer. produces both dependence and reinforcer. produces both dependence and withdrawal and reinforces cannabis use. withdrawal and reinforces cannabis use.

Regular cannabis use rapid as tobacco Regular cannabis use rapid as tobacco progression, and more rapid than alcohol progression, and more rapid than alcohol

CrowleyDrug and Alcohol Dependence 1998;50:27-37CrowleyDrug and Alcohol Dependence 1998;50:27-37

Marijuana Dependence

20% used before age 16 (20% used before age 16 (New Zealand)New Zealand)

21.7% demonstrated dependence by age 2121.7% demonstrated dependence by age 21 If 5 positive experiences with pot, 28 x If 5 positive experiences with pot, 28 x

increase risk of dependence. increase risk of dependence. Fergusson DM, Horwood LJ, Lynskey MT, Madden PAF.

Early reactions to cannabis predict later dependence. Arch Gen Psychiatry 2003;60:1033-1039

Fetal/Newborn Effects

Effect on Conception

Women smoking> 90 times in their lifetime Women smoking> 90 times in their lifetime had 27% fewer oocytes retrieved (P=.03) and had 27% fewer oocytes retrieved (P=.03) and 1 fewer embryo transferred (P!.05). 1 fewer embryo transferred (P!.05).

Women smoking marijuana >10 times in Women smoking marijuana >10 times in lifetime infants 17% (P=.01) smallerlifetime infants 17% (P=.01) smaller

Women smoking marijuana 1 year before IVF/ Women smoking marijuana 1 year before IVF/ GIFT had25% fewer oocytes retrieved (P=.03)GIFT had25% fewer oocytes retrieved (P=.03)

Am J Ob-Gyn (2006) 194, 369–76Am J Ob-Gyn (2006) 194, 369–76. .

Effect on Conception (cont)

If men smoked marijuana 11 to 90 times in If men smoked marijuana 11 to 90 times in their lifetime, there was a 15% decrease in their lifetime, there was a 15% decrease in infant birth weight (P = .03)infant birth weight (P = .03)

more than 90 times, there was a 23% more than 90 times, there was a 23% decrease (P=.01). decrease (P=.01).

Women and men who smoked in the past Women and men who smoked in the past 15 years, had 12%(P=.04) and 16% (P=.03) 15 years, had 12%(P=.04) and 16% (P=.03) smaller infants, respectively.smaller infants, respectively.

Pre-Term Birth

3234 births from healthy women3234 births from healthy women Use of marijuana (particularly pre-Use of marijuana (particularly pre-

pregnancy) is a strong environment risk for pregnancy) is a strong environment risk for pre-term birth.pre-term birth.

Dekker GA, Lee SY, North RA, McCowan LM, Simpson NAB, et al. Dekker GA, Lee SY, North RA, McCowan LM, Simpson NAB, et al.

(2012PLoS ONE 7(7): e39154. doi:10.1371/journal.pone.0039154)(2012PLoS ONE 7(7): e39154. doi:10.1371/journal.pone.0039154)

Newborn Effects

BirthweightBirthweightLengthLengthHead CircumferenceHead CircumferenceAbnormal DevelopmentAbnormal DevelopmentNeurological IrritabilityNeurological Irritability

Fetal/Infant Effects

Prenatal exposure to marijuana is associated with Prenatal exposure to marijuana is associated with reduction in birth weight, length, and head reduction in birth weight, length, and head circumference even when tobacco use factored circumference even when tobacco use factored out. out.

Clinical Chemisty 2010;56:1442-1450 Clinical Chemisty 2010;56:1442-1450

Fetal Effects: 14 y/o

524 subjects524 subjects Confounding variables controlledConfounding variables controlled Greatest effect first Trimester >1joint /dayGreatest effect first Trimester >1joint /day Fetal exposure= 14 y/o Wechsler compositeFetal exposure= 14 y/o Wechsler composite Poor Intelligence age 6Poor Intelligence age 6 Attention and Depression age 10 Attention and Depression age 10

Neurotoxicology and TeratologyNeurotoxicology and Teratology

Goldschmidt and Day Goldschmidt and Day

34 (2012) 161–16734 (2012) 161–167

Respiratory Effects

CoHb 5x TOBACCOCoHb 5x TOBACCO TAR 3x TOBACCOTAR 3x TOBACCO Decreased DiffusionDecreased Diffusion Cellular InflammationCellular Inflammation Precancerous ChangesPrecancerous Changes Diminished Lung ImmunityDiminished Lung Immunity

Respiratory Effects

Cannabis associated with dose-related Cannabis associated with dose-related impairment of large airways resulting in impairment of large airways resulting in obstruction, wheezing, mucous, and obstruction, wheezing, mucous, and hyperinflation.hyperinflation.

Dose equivalence 1: 2.5-5 vs tobacco Dose equivalence 1: 2.5-5 vs tobacco

Thorax 2007;0: 1-7 Thorax 2007;0: 1-7

Lung Damage

Marijuana smoking leads to bullous lung Marijuana smoking leads to bullous lung disease in normal CXR and lung function disease in normal CXR and lung function 20 years earlier than seen with tobacco 20 years earlier than seen with tobacco

Respirology 2008;13:122-127 Respirology 2008;13:122-127

Marijuana and Lung Cancer

The risk of lung cancer increased 8% (95% The risk of lung cancer increased 8% (95% confidence interval (CI) 2–15) for each confidence interval (CI) 2–15) for each joint-yr of cannabis smoking, 7% (95% CI joint-yr of cannabis smoking, 7% (95% CI 5–9) for each pack-yr of cigarette smoking, 5–9) for each pack-yr of cigarette smoking,

The highest tertile of cannabis use was The highest tertile of cannabis use was associated with an increased risk of lung associated with an increased risk of lung cancer relative risk 5.7 (95% CI 1.5–21.6)), cancer relative risk 5.7 (95% CI 1.5–21.6)),

Eur Respir J 2008; 31: 280–286 Eur Respir J 2008; 31: 280–286

Marijuana Lobby & “Medical” Pot

Medical Excuse Marijuana

No compelling evidence that there is a significant group of untreatedor inadequately treated patients.

Pro-marijuana lobby getting its “nose under the tent”

Marijuana Policy Project

"This is the next step in the evolution of medical marijuana as a political issue," "We have informed elected officials about the widespread public support for the issue, we have lobbied members of Congress and their staffs directly, and we have activated our grassroots. Now it is time to provide financial support to those who are willing to support medical marijuana.”

Steve Fox Marijuana Policy Project (MPP) Washington, D.C.

Important points to remember

Safe, effective reliable medicines are best Safe, effective reliable medicines are best for patients, and they are availablefor patients, and they are available

Marijuana is impure, unreliable, full of Marijuana is impure, unreliable, full of contaminants, high side effect rate.contaminants, high side effect rate.

Defense to possession bypasses FDA and Defense to possession bypasses FDA and jeopardizes consumer protection jeopardizes consumer protection

Medical excuse marijuana creates Medical excuse marijuana creates “medicine by popular vote.”“medicine by popular vote.”

Proposed Medicinal Uses ofMarijuana

Nausea of ChemotherapyNausea of ChemotherapyGlaucomaGlaucomaAppetite StimulationAppetite StimulationMultiple SclerosisMultiple SclerosisPain/ MigrainePain/ MigraineMisc- Cramps, Sleep, DepressionMisc- Cramps, Sleep, Depression

Who is Actually Using Medical Excuse Marijuana?

Under 34 -- 45.4%Under 34 -- 45.4% Under 54 (most pain age older) 84%Under 54 (most pain age older) 84% For Pain 82%For Pain 82% For Anxiety 37%For Anxiety 37% For Depression 26%For Depression 26% For Nausea 27%For Nausea 27% For Appetite 37.7%For Appetite 37.7%

Journal of psychoactive drugsJournal of psychoactive drugs

2011;43:128-1352011;43:128-135

Colorado Medical Excuse Pot

Sept 2011 127,444 usersSept 2011 127,444 users 94% pain94% pain Ave Age 40Ave Age 40 Denver has 400 dispensaries (375 Starbucks Denver has 400 dispensaries (375 Starbucks

state-wide)state-wide) Denver Dispensary crime up 69% with 75% Denver Dispensary crime up 69% with 75%

increase in burglaries. increase in burglaries. Denver Police June 4, 2012Denver Police June 4, 2012

Marijuana Marijuana

ForFor

PainPain

Pain

Healthy volunteers doses 0,2,4,8% THCHealthy volunteers doses 0,2,4,8% THC Decrease of pain medium dosesDecrease of pain medium doses Increase of pain higher dosesIncrease of pain higher doses ?Specific substance responsible??Specific substance responsible?

Anesthesiology. 2007;107:785-96 Anesthesiology. 2007;107:785-96

THC as Opioid Adjunct

THC alone ineffective for the most partTHC alone ineffective for the most part Literature is contradictory. Some Literature is contradictory. Some

demonstrated higher morphine dosesdemonstrated higher morphine doses May be useful as an adjunct to opiodsMay be useful as an adjunct to opiods

International Review of Psychiatry, International Review of Psychiatry,

April 2009; 21(2): 143–151April 2009; 21(2): 143–151

Palliative Care

Studies largely marginalStudies largely marginal Mostly involve oral or SativexMostly involve oral or Sativex Not indicated as sole agentNot indicated as sole agent May be some add-on benefitMay be some add-on benefit

International Journal of Palliative Nursing International Journal of Palliative Nursing

2010, Vol 16, No 102010, Vol 16, No 10

Sativex as add-on for pain

Advanced cancer patients on opioid pain Advanced cancer patients on opioid pain medsmeds

Low, medium, high dose treatementsLow, medium, high dose treatements Add on to the opioid medicationAdd on to the opioid medication Low and medium dose had benefit, not high Low and medium dose had benefit, not high

dosedose Adverse events dose related and high dose Adverse events dose related and high dose

was unfavorable was unfavorable

Pain in HIV

Trial in HIV-associated neuropathyTrial in HIV-associated neuropathy No comparison to other medicines nor No comparison to other medicines nor

MarinolMarinol Benefit in reducing the neuropathic pain Benefit in reducing the neuropathic pain

comparable to existing medicationscomparable to existing medications Difficult to discern “high” vs. medical Difficult to discern “high” vs. medical

effecteffect Abrahms Neurology 2007;68 515-521Abrahms Neurology 2007;68 515-521

Abrahms

Table 2 Mean side effect scores by study groupTable 2 Mean side effect scores by study group Anxiety* 0.25 (0.14, 0.44) 0.10 (0.05, 0.22)Anxiety* 0.25 (0.14, 0.44) 0.10 (0.05, 0.22) Sedation† 0.54 (0.36, 0.81) 0.08 (0.04, 0.17)Sedation† 0.54 (0.36, 0.81) 0.08 (0.04, 0.17) Disorientation† 0.16Disorientation† 0.16(0.07, 0.34) (0.07, 0.34) 0.01 (0.00, 0.04)0.01 (0.00, 0.04) Paranoia 0.13 (0.03, 0.45) 0.04 (0.01, 0.14)Paranoia 0.13 (0.03, 0.45) 0.04 (0.01, 0.14) Confusion† 0.17 (Confusion† 0.17 (0.07, 0.390.07, 0.39) 0.01 (0.00, 0.06)) 0.01 (0.00, 0.06) Dizziness† 0.15 Dizziness† 0.15 (0.07, 0.31) (0.07, 0.31) 0.02 (0.01, 0.05)0.02 (0.01, 0.05) Nausea 0.11 (0.04, 0.30) 0.03 (0.01, 0.14)Nausea 0.11 (0.04, 0.30) 0.03 (0.01, 0.14) * * p, 0.05; † p 0.001.p, 0.05; † p 0.001.

HIV Cognitive Impairment

HIV patients vs controlsHIV patients vs controls Significantly more depression and anxiety Significantly more depression and anxiety

in marijuana using groupin marijuana using group More alcohol use if used marijuanaMore alcohol use if used marijuana Memory impaired even after factoring out Memory impaired even after factoring out

depression, anxiety, and alcoholdepression, anxiety, and alcohol

The Journal of Neuropsychiatry and The Journal of Neuropsychiatry and

Clinical Neurosciences 2004; 16:330–335Clinical Neurosciences 2004; 16:330–335

Pain Summary

Summary of literature on pain/ quality of Summary of literature on pain/ quality of studies generally marginalstudies generally marginal

Mostly discussing oral or synthetic Mostly discussing oral or synthetic cannabinoidscannabinoids

May be useful as an adjunct particularly for May be useful as an adjunct particularly for neuropathic painneuropathic pain

As solo agent, high doses needed and more As solo agent, high doses needed and more side effectsside effects

Current Opinion in Anaesthesiology 2005, 18:424–427Current Opinion in Anaesthesiology 2005, 18:424–427

Cannabinoids in MS meta-analysis

All studied were non-smokedAll studied were non-smoked Cannabinoids difficult to work withCannabinoids difficult to work with Adverse effects not related to dose Adverse effects not related to dose Little benefit for spasticity-poss as add-onLittle benefit for spasticity-poss as add-on Evidence on tremor weakEvidence on tremor weak Evidence on pain moderateEvidence on pain moderate Problems with psychoactivityProblems with psychoactivity

CNS Drugs 2011:25 ZajicekCNS Drugs 2011:25 Zajicek

MS- Cognitive Effects

MS patients using smoked or ingested potMS patients using smoked or ingested pot Impaired processing speed, memory, Impaired processing speed, memory,

executive function, spatial perceptionexecutive function, spatial perception Twice as likely as nonusers to be Twice as likely as nonusers to be

classified as globally cognitively classified as globally cognitively impaired. impaired.

Neurology 2011;76:1153-1160Neurology 2011;76:1153-1160

As Paul Harvey would say--

““And now for the rest of the story.”And now for the rest of the story.”

Marijuana and Fatal CrashesCalifornia 2008

Five years following medical excuse Five years following medical excuse marijuana dispensaries 1240 fatal crashes marijuana dispensaries 1240 fatal crashes compared to 631 for the five years priorcompared to 631 for the five years prior

8.3% of fatal single vehicle crashes8.3% of fatal single vehicle crashes 5.5% fatal passenger crashes5.5% fatal passenger crashes Use rate estimated at 16-20%Use rate estimated at 16-20% Rivals alcohol as top cause of fatalitiesRivals alcohol as top cause of fatalities

Crancer and CrancerCrancer and Crancer

Involvement of marijuana in Involvement of marijuana in

California Fatal Vehicle CrashesCalifornia Fatal Vehicle Crashes

Marijuana treatment episodes

National increase National increase 1992 92,5001992 92,500 2008 322,0002008 322,000

California increaseCalifornia increase 1992 73001992 7300 2008 350002008 35000

RAND 2010RAND 2010

Altered State?Altered State?

Assessing How Marijuana Legalization Assessing How Marijuana Legalization

in California Could Influencein California Could Influence

Marijuana ConsumptionMarijuana Consumption

Scientific Status of Medical Excuse Marijuana

Cannabinoids may be useful and worth Cannabinoids may be useful and worth studyingstudying

Smoking is problematicSmoking is problematic Legislative processes bypass the FDA and Legislative processes bypass the FDA and

jeopardize the publicjeopardize the public

Organizations Voicing Positions

IOM Recommendations

Rec 5-The goal of clinical trials of Rec 5-The goal of clinical trials of smoked marijuana would smoked marijuana would not be to not be to develop marijuana as a licensed drugdevelop marijuana as a licensed drug

Rec 6- Rec 6- must meet the following must meet the following conditions:conditions: failure of all approved failure of all approved medicationsmedications to provide relief has been to provide relief has been documenteddocumented

Practical Issues/Regulation

Has user exhausted all other accepted Has user exhausted all other accepted medical interventions?medical interventions?

Is the proposed patient a drug abuser?Is the proposed patient a drug abuser? Does law allow for drug screening to assure Does law allow for drug screening to assure

no use of illegal drugs?no use of illegal drugs? Will patient have medical oversite and Will patient have medical oversite and

monitoring of status and adverse Eventsmonitoring of status and adverse Events Legal liability and responsibility? Legal liability and responsibility?

Practical Issues/ Regulation What marijuana will be allowed, what What marijuana will be allowed, what

strengths, and who pays for it?strengths, and who pays for it? Who produces the marijuana?Who produces the marijuana? Is marijuana purity assured?Is marijuana purity assured? Is the caregiver licensed and in good Is the caregiver licensed and in good

standing with regulatory agencies?standing with regulatory agencies? Does the caregiver demonstrate formal Does the caregiver demonstrate formal

training or experience in addiction and in training or experience in addiction and in the administration of dangerous drugs?the administration of dangerous drugs?

Practical Social Issues

Employment drug testsEmployment drug tests Health insurance medication ridersHealth insurance medication riders DUI statutes/ accidentsDUI statutes/ accidents Student/adult athleticsStudent/adult athletics Side effectsSide effects Work productivityWork productivity

Important points to remember

Safe, effective reliable medicines are best Safe, effective reliable medicines are best for patients, and they are availablefor patients, and they are available

Marijuana is impure, unreliable, full of Marijuana is impure, unreliable, full of contaminants, high side effect rate.contaminants, high side effect rate.

Defense to possession bypasses FDA and Defense to possession bypasses FDA and jeopardizes consumer protection jeopardizes consumer protection

Medical excuse marijuana creates Medical excuse marijuana creates “medicine by popular vote.”“medicine by popular vote.”