Medical Marijuana in Colorado: Voices from the Field

Transcription

1 Medical Marijuana in Colorado: Voices from the Field Robert E. Booth, Ph.D. Division of Substance Dependence, University of Colorado School of Medicine, Denver, CO Supported by the National Institute on Drug Abuse RO1 DA031816

2 The author declares no financial or other conflict of interest

3 Marijuana Key Events 2000 Colorado voters approve legal use of marijuana for medical purposes To obtain registry card: patients must be diagnosed with debilitating condition in the context of a bona fide relationship with a physician Debilitating conditions include: Cancer, Glaucoma, HIV/AIDS, Cachexia, Severe pain, Severe nausea, Seizures, Muscle spasms and any other condition approved by the Colorado Department of Public Health and Environment (CDPHE) Patients and recommending physicians complete an application; if the application is not denied within 35 days, the patient is assumed to have a valid registration

4 Marijuana Key Events 2009 January: 495 applications February: Obama administration declares that federal resources will not be used to circumvent state laws concerning MMJ October: 4,751 applications/month and CDPHE can no longer process them within 35 days December: 10,585 applications/month and explosion in the number of MMCs 2013 November: Colorado voters pass Amendment 64 legalizing recreational use of marijuana

5 Medical Marijuana Regulations Patients: need physician recommendation and complete application must agree to grow their own, designate caregiver to grow for them or designate a MMC may possess 2 ounces (or more if medically necessary) must renew annually Physicians: need to have unrestricted medical license need to have current Drug Enforcement Administration (DEA) registration may not have conflict of interest with a MMC must have a bona fide relationship with the patient

6 Medical Marijuana Regulations Medical Marijuana Centers (MMCs): may sell marijuana to registered patients must grow at least 70% of their own marijuana through their Optional Premises Cultivation (OPC) license Medical Marijuana Infused Product Manufacturer (MMIP): may produce edibles, tinctures or beverages for wholesale to MMCs cannot call their product food as it would need to be regulated by the Food & Drug Administration (FDA) cannot cultivate medical marijuana

7 Marijuana Epidemiology in the Denver-Metro Area and Colorado

8 Past Month Marijuana Use: Comparison of , & NSDUH: Denver Metro, Colorado & US

9 Perception of Great Risk of Smoking Marijuana Once a Month: Comparison of , & NSDUH: Denver Metro, Colorado & US

10 Past 30-Day Marijuana Use by Grade: School Survey 50% 40% % 20% 18% 23% 18% 28% 21% 22% 30% 24% 26% 32% 31% 28% 28% 23% 22% 10% 9% 13% 4% 0% 6th 7th 8th 9th 10th 11th 12th HS Avg Denver Colorado U.S. Source: Healthy Kids Colorado School Survey 9-12

11 Number Colorado School Drug Related Suspensions and Expulsions: K-12: through School Years Source: Colorado Dept. of Education

12 Denver Metro Area DAWN Emergency Dept. Visits-- Unweighted Data: CY 2010 Amphet & Other Stim 5,1% Methamphetamine 11,0% MDMA 2,7% Hallucinogens 2,1% Other 1,6% Other Club 0,4% Synth. Cannabinoids 0,6% Marijuana 33,4% Heroin 13,1% Cocaine 29,9% Source: Drug Abuse Warning Network

13 Number of physicians by number of medical marijuana registrants by time period Source: Medical Marijuana Registry, Colorado Department of Public Health and Environment, May /09 6/10 12/10 6/11 12/11 6/12 12/12 >1, , ,007 1, Total Physicians

14 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Number Colorado Medical Marijuana Registry: Applications vs. Patients with a Valid ID --Revised September Medical Marijuana Patients with a Valid Registry ID New MMR Patient Applications Source: Colorado Department of Public Health and Environment

15 Colorado Medical Marijuana Patients with a Valid Registry ID by Age Group and Time Period Age Group Under 18% 18-25% 26-35% 36-45% 46-55% 12/09 6/10 12/10 6/11 12/11 6/12 12/ and Over% Total N 41,039 95, , ,698 82,089 99, ,526 Source: Colorado Dept. of Public Health and Environment, Medical Marijuana Program

16 Colorado Medical Marijuana Patients with a Valid Registry ID by Debilitating Medical Condition and Time Period Condition 12/09 6/10 12/10 6/11 6/12 7/13 N % N % N % N % N % N % Cachexia , , , , ,170 1 Cancer , , , , ,929 3 Glaucoma , , , ,104 1 HIV/AIDS Muscle Spasms 12, , , , , , Seizures , , , , ,861 2 Severe Pain Severe Nausea 37, , , , , , , , , , , Does not add to 100% as some patients report using medical marijuana for more than one debilitating medical condition

17 Number Blood Tests for Driving Under the Influence of Drugs in Colorado from 2009 to Colorado Dept of Health, Lab Services

18 Note : These crashes may include other drugs and alcohol, therefore Cannabis itself may not have been the main contributing factor of the fatal crash. Source: Colorado Department of Transportation:Data Analysis Unit from Fatal Accident Reporting System Year Cannabis Related Motor Vehicle Fatalities among Total Motor Vehicle Fatalities in Colorado by Year: 2008 through 2011 Cannabis Related Crashes Fatalities among Cannabis Related Crashes Total Motor Vehicle Fatalities Percent Fatalities Cannabis Related % % % %

19

20

21

22

23

24

25

26 Qualitative Findings from Semi-Structured Interviews (N = 35) physicians, MMC owners, growers; law enforcement, lawyers & a member of the Colorado legislature Focus Groups (N = 32) 4 focus groups with medical marijuana patients

27 Prescribing Physicians: Somebody can take it during the day and be completely focused and not stoned and be therapeutic. And they ll be anti-seizure, anti-pain, anti-whatever they want it to be. When asked about the benefits of marijuana, That s a hard question to answer. I mean they re using it so my sense is that they feel like they re getting benefit. I know a couple of patients that have been very open with me and say it helps them, so you try to assess if they re getting relief with the therapies they re trying, but whether that s from medical marijuana or from the other medications they re using or physical therapy or counseling I don t know.

28 Non-prescribing physicians Honestly, when people tell me they re on medical marijuana they re telling me they just want to get high. That s basically what I hear. I think it s a mockery of responsible medicine and it s embarrassing to the profession of medicine. I don t think there s great science to support it, although too I suppose I have concerns that it s probably not necessarily worse than some of the stuff we prescribe although that s not an endorsement. I m sure it makes people feel better; I don t question that for a moment, but I think it has clearly addictive properties. It doesn t necessarily constitute a good long-term solution to what are usually long-term problems that people are taking it for. They re not meditating, they re not doing yoga, they re not getting exercise, and they re not necessarily following a good diet. They re still eating junk food and sitting and being very sedentary and watching television and smoking cigarettes. I think they think maybe they re being healthy by using medical marijuana but they don t really exhibit a lot of other behaviors that are what we would consider healthy behaviors.

29 Medical marijuana patients on health benefits: I have Lupus. They give me the medication that they give people for malaria, which really upsets my stomach. I feel nauseous all day. I take it twice, but medical marijuana makes it so I can eat, which I have to do with that medication and it makes the nausea not so bad. I have a social anxiety disorder. It really helps with that. I have my card for post-op pain in my shoulder; I really just use that as an excuse to get it. Anxiety is unaccepted as a reason. It really helps me function in social settings. It helps me be myself, be more confident I have such high anxiety that it will actually manifest into feeling physical pain. So I get a lot of muscle pains as well as mental stress and anxiety from the whole situation. One hit of cannabis and your exhaling all those worries away, it s incredible, it really is. When my wife came down with ALS (Lou Gehrig s disease) I was buying it on the street because it would do two things for her - one, most important, it helped her sleep; two, it lightened her mood. It enabled her to shift her focus and just relax more. However, at that time I didn t know squat about cannabis, neither did she - we just knew that marijuana is marijuana like 90% of the people out there. And so sometimes I would get something and bring it home, and I didn t know what I was getting - it was just marijuana. And she would turn into what I called the chatty Cathy, and now I know that that was Sativa and so she d be up and active and wanting to do things and engage. Other times it would just put her to sleep - she d get what we call the couch look.

30 Pain management: marijuana vs. opiates: I know we ve got a former soldier who was taking like 30 oxycodone a week to control the pain and now has gotten down to where he s doing maybe three a week or something like that - I can t remember the exact numbers. But all kinds of stories like that, and if you talk to any center they will have stories like that as well of people who have been able to get off the opiate-based drugs by using cannabis. But at the same time it really changed our lives because it allowed my husband to go from 180mg of oxycodone a day to none two years later. We were at a point in our life where I hated him. He was always sick and on so much narcotic that he was not the person who I married at all. So I watched this evolution in my life and became very passionate about medical marijuana. My dealings with cannabis was pretty limited to minimal recreational use, but in 2005 no medicine worked for my bipolar and my back was bothering me so I went to the doctor and they gave me opiates. I had an allergic reaction to opiates and my mood got worse. So with that in mind, I started using medical cannabis to help. I used it for my pain and it also helped my bipolar like none of the other medicines that I d had, and I tried everything.

31 Dispensary owners on mental health benefits: Yeah, I think it helps with paranoia, anxiety, depression. We do monitor all of our patients for those things anyway but there are also people who use medical marijuana, really, to self-medicate psychiatric disease. I think for some people, in addition to maybe depression and anxiety, is PTSD, which is a huge problem in our patient population. Many, many of our patients have PTSD and I think several of them use marijuana as a calming agent for PTSD. Dispensary owners regarding types of marijuana to recommend: The big thing I want to know is why are they here? What do they have? Is it cancer? Is it just normal pain? Is it an accident? One guy came in with a battery in his hip and wires going up and down his spine. He had a car accident. I don t know what kind of pain he deals with so I recommended edibles. The tough part there is when someone has never eaten edibles before, it s a different experience. Sometimes it takes an hour to two hour before it kicks in. That s the hard part for people to understand because smoking is immediate. Less than five minutes to get to your full peak; so for cancer patients dealing with nausea, smoking is a little bit better. But edibles can help you better because they are longer lasting. So maybe you smoke right when you take the edible to affect you until the edible kicks in, and then you can go through it the rest of the day.

32 Medical marijuana consumers regarding strains of marijuana: Male 1: I ve found Indicas taste better and Sativas are stronger. What they did is they had Sativa-based schwag and they mixed it with Indica because people wanted better taste and better flavor, better smell and all that. That s when the Indica started mixing with the Sativa. Male 8: A true Sativa is just unreal. A real, true Sativa will make your ears buzz like a bee is in there. You ll be so alert. Male 7: Male 4: A true Sativa will make you paranoid. It can. It can almost be a little speedy. Yeah, it ll make your heart pump, it ll make you nervous. Male 8: I ve had 140 pulse from Sativa. We were sitting at this grill and I took my pulse. It was 140, but yet I was not speeding. I was calm. That s the thing about cannabis. It can make you feel alert. Male 6: I found this one called Black Russian and it s totally black and it s like getting a hug. It was like the old man could have smoked that, helped with the pain. I haven t been able to find it since. Male 8: Male 6: Hawaiian is like that to me, soft stone. I ate a cupcake before work one time and I could barely stand up, so that s not good.

33 Dispensary owner about edibles: This gentleman came in and bought two edibles from me, ate half of the bank roll waited 45 minutes and then ate the other half. Right there that s 100 milligrams. Two and half hours later he came back and said he wasn t feeling anything, so he bought a bag of my gummies. Each one is 25 milligrams. He ate two gummies over another hour period, went to dinner, everything was fine at dinner, but at the end he started to feel it, plus he had a glass of wine. They went to the Pepsi Center for a hockey game; he said he spent two periods in the bathroom freaking out. He couldn t sit with his girlfriend and her friend. Freaking out in the bathroom, like wanting to leave, but didn t want to leave because he didn t want to ruin their night. He couldn t be around the public, and I m like, Oh my God dude, like that s what I was trying to tell you. Sometimes you just have to take and let it kick in, but everybody s body is a little different. From a consumer about edibles: Particularly with edibles - people can have what we call the Oh my God experience because you simply cannot un-eat. It sneaks up on you, people sometimes eat too much; I mean it s happened to everybody. I had an edible, I thought I had a smaller amount but I woke up and my eyes were wide open, they were dilated fully. I had a hard time seeing. I had to actually crawl to the bathroom and, but you know, it wore off after about an hour. So it was fine, I just had to lie in bed and wait for it to pass.

34 Medical marijuana consumers on driving: Male 5: There s a study that was just released about that. A guy did a test and found out that actually, individuals who consume marijuana medically on the medical level, because they have to keep it there at this point, are safer than drivers who do not use marijuana. Male 8: Male 5: Male 8: That s a fact. A fact, a proven fact. I know of a study that Car and Driver did. Male 5: You re trying to convince the insurance agency to put marijuana users on their policies because they re bound not to have accidents. Male 4: Male 8: When I get the right dose of the highest quality meds, I m the last guy you want on the road. I know these people that drive after they smoke it, but I ve had no problems doing it. Male 8: The thing is when people get high and they get so high they can t drive they know they shouldn t be driving. It does not remove judgment. Male 3: I smoke a lot and I like to eat lollipops and hard candies. I smoke during the day because I do a lot of driving and I hate driving in the city. I am pretty sure you guys are all aware that happens in Denver, it s terrible. Smoking just helps me take deep breaths and not get road rage. So I usually smoke Sativas during the day and then at night I smoke Indicas because that will help my shoulder and help me go to sleep.

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49 0

50

51 Survey Findings with Medical Marijuana Patients (N= 81) and Illicit Marijuana Users (N=127)

52 Registered vs. Non-registered User Comparison Note: There were no significant differences between registered and unregistered users on these marijuana use behaviors.

53 Marijuana and Other Drug Use (N = 208) Self Report UAs

54 Marijuana as aid to quit other drug use (N = 208)

55 Reasons for Marijuana Use (Total users: N = 208) (Users reporting medical uses: N = 136)

56 Marijuana and Behavior (Total users: N = 208) Of registered users (N = 81):

57 Summary Background: Beginning in 2009, the number of applications for medical marijuana and the number of registered patients began to rise exponentially, reaching more than a quarter million by July 2013 Epidemiological data: From , past month marijuana use increased steadily; Colorado, especially the Denver-metro area, far exceeded the U.S.; in Denver had twice the nation s percent of users In , past month marijuana use among high school students increased continuously from the 6th through the 12th grades, reaching 32% by the 12 th grade, more so in Denver and Colorado than the U.S. Beginning in 2009, drug-related school suspensions/expulsions increased sharply From , blood tests for driving under the influence of THC far exceeded any other drug, reaching an all-time high in 2012 From cannabis-related motor vehicle fatalities progressively increased, while total motor vehicle fatalities decreased

58 Summary Continued Qualitative data: Most physicians interviewed were opposed to medical marijuana but some felt it was beneficial Medical marijuana patients felt strongly that it helped with a variety of conditions, including: nausea, anxiety, bipolar disorder, PTSD, loss of appetite, sleep deprivation, pain management and to get off prescription opiates Survey data: Medical users were more likely to have used marijuana to reduce prescription opiates (60% vs. 27%), while illicit users were more likely to report using marijuana to reduce use of other illicit drugs (44% vs. 31%) 56% of medical users reported using marijuana because of anxiety, as did 41% for depression; neither condition is an accepted debilitating condition according to the CDPHE 85% of medical users reported driving while high on marijuana in their lifetime, as did 71% of illicit users; 68% and 45%, respectively, drove within 3 hours of using marijuana in the past year 91% and 95% of medical and illicit users, respectively, reported having sex while high on marijuana Among registered medical marijuana users, 81% had shared marijuana with others and 23% sold marijuana to others

59 Epidemiology Data Study Limitations Reflect trends, not cause and effect Qualitative Data Based solely on opinion Sample could have been biased (e.g., medical marijuana users included only current patients) Survey Data Social desirability (yet self-reported drug use and UAs highly consistent) Recall (although most variables asked about ever or last 30 days ) A portion of illicit marijuana users were former Project Safe clients and thus may not generalize to the larger population of non-registered users

60 Conclusions Epidemiological data show increasing adverse trends regarding the use of marijuana beginning in 2009, coinciding with the rapid rise in medical marijuana applications and registered patients Qualitative and quantitative findings indicated that many marijuana users felt it helped them with a variety of debilitating conditions, not all of which were approved for registration Both medical marijuana patients and illicit users reported that marijuana helped them reduce the use of other drugs, particularly prescription opiates Driving a car while high on marijuana, having sex while high, as well as sharing marijuana, were so common they could be considered normative behaviors

61

62 Contributors: Ingrid A. Binswanger, M.D, M.P.H. Karen F. Corsi, ScD, M.P.H. Christine Garver-Apgar, Ph.D. Bruce D. Mendelson, M.P.A. Deborah J. Rinehart, Ph.D. Christian C. Thurstone, M.D. Project Safe staff Special thanks to Wilson Compton, M.D. & Elizabeth Lambert Supported by the National Institute on Drug Abuse R01 DA031816