Marijuana - IAODAPCA

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
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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 compounds
84 cannabinoids
Hemp
Compressed hemp seeds
Hemp seeds
Eaten raw, hemp milk, hemp juice,
hemp milk ice-cream, waffles, tofu,
nut butters
Hemp stalk
Paper, construction material,
clothing, biofuels
The psychoactive parts
Leaves
Buds
FLowers
D-9-tetrahydrocannabinol
identified 1964
Flowers and leaves
More potent derivatives
Kief: trichome rich powder
Hashish: pressed kief, detached trichomes,
and fine material that falls from leaves or scraped resin
Trichomes
Hash Oil
Organic solvent
Cannabis or
Hashish
Hash oil
Consequences
Burns in Colorado
Self admitted MJ users treated for burns
18
16
14
12
10
Self admitted MJ users
treated for burns
8
6
4
2
0
2010
2011
2012
2013
2014
Dabbing
80%
Several explosions and fires have been
reported due to BHO extractions done indoors
with open-air blasting methods. Recently, a 2year-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.
“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 highpotency cannabis extracts. One person fainted
and cracked his nose on the sidewalk, in
another case of woman broke her teeth on the
floor.
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-herring
to 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 of
Marijuana Laws, 1999.
CANNABIS IS AN ADDICTIVE DRUG
Cannabinoid receptors
CB1 and CB2
CB1 receptors—brain
CB2 receptors—immune system
suppression; pain
MRI Scans of Healthy
Children and Teens Over Time
GM loss = maturation
Copyright ©2004 by the National Academy of Sciences
Gogtay, Giedd, et al. Proc. Natl. Acad. Sci., 2004
DSM-5: CANNABIS USE DISORDER
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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. adult
number 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 WellBeing.
Volkow ND et al. N Engl J Med 2014;370:2219-2227
Ferguson and Boden, 2008
Drugged driving
Meta-analysis:
Drivers who tested
positive or selfreported were
more than twice
as likely to be
involved in a crash.
85% of Washington drivers involved in
fatal crashes are positive for THC.
Mu-Chen Li, 2011
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
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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
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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
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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, Systemic
Lupus 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”
So, we have a patient with
Parkinson’s disease
Mono-amine oxidase inhibitor
Shall we prescribe tobacco?
So, how do we get from…
Point A—no legalization to…
Point B—legalization for medicinal purp
This doesn’t do it
This does
Compassionate care or
Increased access to marijuana?
<5%
Less than 5% of card holders
are cancer, HIV/AIDS or
glaucoma patients.
Avg patient: 32 year old WM;
history of drug abuse; no life
threatening disease
Vocabulary
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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
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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 marijuana
In 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 chronic
non-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 marijuana
is not a medicine
YES: There are marijuana based pills
available and other medications
coming 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
Moore, 1989
1933
21st ammendment
An important fact…
An important fact…
These guys didn’t start with
Prohibition and they didn’t
end with Prohibition.
Let’s look at cartels
The idea that taxation and increased
regulation (e.g. lowering potency) would
result in less of a black market is
naïve.
Most widely smuggled legal product
$657 billion/year business in 2009
105 organized crime groups in Canada
Taliban and Hezbollah
Benefits
29.5 per 100,000
to 10.7 per 100,000
10.1 per 100,000
to less than 5 per 100,000
Disorderly conduct
Decreased by 50%
The first equity company dedicated to
the marijuana industry
“The use of marijuana ... has important
implications for the tobacco industry in terms
of an alternative product line. [We] have the
land to grow it, the machines to roll it and
package it, the distribution to market it. In fact,
some firms have registered trademarks, which
are taken directly from marijuana street
jargon.
These trade names are used currently on
littleknown
legal products, but could be switched if
and when marijuana is legalized. Estimates
indicate that the market in legalized
marijuana might be as high as $10 billion
annually
- 1970s report commissioned by cigarette
manufacturer Brown and Williamson (now
merged 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 the
sale 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 the
entire industry.)
[W]e segment the market, and the segmentation we use in our marketing to develop
marketing 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 of
Ed Horrigan, RJ Reynolds)
“In our view, smoking is an adult custom and the decision to smoke should be based on
mature and informed individual freedom of choice.” (1993 Tobacco Institute press
release)
But sometimes there really are secret files
“The 14-18 year old group is an increasing segment…RJR must soon establish a
successful new brand in this market if our position in the industry is to be maintained
over 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 Documents
obtained from RJ Reynolds after the Tobacco Master Settlement Agreement of 1998)
“[T]he base of our business is the high school student.” (Secret Documents obtained
from Lorillard after the Tobacco Master Settlement Agreement of 1998)
2016 Republican primary
Follow the money
180
160
140
120
100
G. Soros recruits Ethan Nadelman
starts Lindesmith Center.
Focus on winnable issues like
Medical marijuana.
NORML
established
Progressive Ins. and
U of Phoenix founders
Fund
legalization
$ million
80
% approval
60
40
20
0
1970
1980
1990
2000
2010
2013
Lobbyist contributions for AK and OR
approximately $9.2M
2014 mid terms
120%
100%
80%
60%
2014 mid terms
40%
20%
0%
Pro-marijuana
Anti-marijuana
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?
Alcohol costs
$185 billion
Revenues: $14 billion
Tobacco costs
$200 billion
Revenues: $25 billion
NY Times 8/31/2008; tobacco free kids; policy archive/bitstream/handle
Colorado marijuana interdiction
seizures
Seizures
350
300
250
200
Seizures
150
100
50
0
2005
2006
2007
2008
2009
2010
2011
2012
1
1
1
1
2
1
1
8
1
2
6
6
6
8
12
12
2
1
15
41
3
5
1
2
4
2
4
4
3
4
4
2
18
2
4
2
7
2
Total Reported Seizures per State from Colorado: 2013
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 HEALY
JAN. 31, 2014
ED visits to Colorado Children’s
Hospital for MJ overdose
Children 3-7
16
14
12
10
8
Children 3-7
6
4
2
0
2008-2011
2013
2014 1st 6 months
Ohio
Medical and Recreational
Oscar
Buddie
Responsible Ohio PAC: $11,973,695
Nonna Marijuana
Bong Appetite
Aurora Leveroni
Outcome
36% yes
64% no
Why?
Questions?
kirk.moberg@unitypoint.org