Minnesota, Marijuana and Myths

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1 3M: Minnesota, Marijuana and Myths Ken Winters, Ph.D. Senior Scientist Oregon Research Institute & Adjunct Faculty, Dept. of Psychology University of Minnesota April 26, 2018 Curious How Marijuana May Impact the Future of Your Community? Hazelden, Plymouth, MN

2 Disclosure I am co-editing a book on marijuana and health with Kevin Sabet, the President and CEO of Smart Approaches to Marijuana, a nonpartisan group that promotes sciencebased policies about marijuana.

3 Self-Disclosure I hope to avoid the following reaction from you after my talk: Before I came here, I was confused about this subject. Having listened to your lecture, I am still confused -- but on a higher level. A concern once voiced by the famous Italian-American lecturer and physicist, Enrico Fermi

4 Web-Based Resources on Marijuana drugfacts/marijuana

5 Recent Resource from SAM

6 1. Marijuana Use in Minnesota 4. Summary 2. Myths 3. Policy Implications

7 Marijuana is Complex to Study Contains hundreds of chemicals Impacts numerous regions of the brain Federal regulations for access by scientists can impede the advancement of research Difficult to administer to animals in standardized ways Difficult to measure intoxication levels in humans Rapid changes in use and perceptions

8 The changing landscape of cannabis (e.g., strains with THC potency; new routes of administration; novel drug combinations), and a culture of rapidly changing norms and perceptions, raise the possibility that our current, limited knowledge may only apply to the ways the drug was used in the past.

9 1. Marijuana Use in Minnesota

10 National Survey on Drug Use and Health (NSDUH) Nationally representative survey conducted periodically by SAMHSA Face-to-face interviews; age 12 and older are eligible in a selected household My focus today: most recent data ( ) and trend report by NSDUH that compared two survey periods ( and )

11 percentages National Survey Data from NSDUH: Marijuana is the Most Frequently Used Illicit Drug (NSDUH, ) Prior Year Use, U.S. Data, Age Marijuana Pain Meds Misuse Cocaine Heroin <

12 percentages Prevalence of Past Year Marijuana Use Among Minnesotans: Several Age Groups (NSDUH, ) age age 26+ age

13 percentages Prevalence of Past Year Marijuana Use Among Minnesotans: Several Age Groups (NSDUH, ) National age age 26+ age

14 percentages 50 Prevalence of Past Year Marijuana Use Among Minnesotans: Several Age Groups (NSDUH, ) Colorado age age 26+ age

15 percentages Minnesota Trends of Past Year Marijuana Use ( and ) (based on NSDUH report) y.o y.o. 26+ y.o.

16 percentages Minnesota Trends of Past Year Marijuana Use ( and ) (based on NSDUH report) National y.o y.o. 26+ y.o.

17 percentages Minnesota Trends of Past Year 48 Marijuana Use ( and ) (based on NSDUH report) 39 Colorado y.o y.o. 26+ y.o.

18 percentages Minnesota Perceptions of Great Harm, Two Age Groups (NSDUH, ) y.o y.o y.o y.o. MJ/Once Mth Drink 5+/1-2 Times Wk

19 percentages Minnesota Perceptions of Great Harm, Two Age Groups (NSDUH, ) Colorado y.o y.o y.o y.o. MJ/Once Mth Drink 5+/1-2 Times Wk

20 To Summarize: Minnesota Marijuana Use Patterns Indicate That.. Recent prevalence rates for all age groups are generally in-line with national averages. Similar to national data, young adults report the highest prevalence rates and the largest up-tick in trend rates compared to other age groups.

21 1. Marijuana Use in Minnesota 2. Myths (or not?)

22 Fact Checking the Marijuana Debate 1. Legalization is wanted by the public; popular culture has mostly abandoned dated concerns about marijuana.

23 Marijuana Legalization in the United States: Pew Research Center:

24 Marijuana Legalization in the United States: Pew Research Center: Millennial = born 1981-now Silent = born

25 Behind the Popularity Curtain America may be more split on legalization than Pew Surveys suggest. When choices are offered: decriminalization and/or medical MJ generally favored legalizing recreational MJ favored by a smaller percentage

26 Behind the Popularity Curtain Most states have not passed recreational laws. Marijuana and Legalization, Nov., 2016 Many medical marijuana states have strict restrictions on distribution and administration. Push-back from some promarijuana states?

27 Fact Checking the Marijuana Debate 2. Legalization is warranted because smoking marijuana appears to relatively safe. Two rigorous scientific reviews on this issue are worthy of consideration 2017 National Academies of Sciences report 2014 literature review by Volkow and colleagues

28 National Academies of Sciences, Engineering, and Medicine. (2017). The health effects of cannabis and cannabinoids: The current state of evidence and recommendations for research. Score Box for Negative Health Effects Nature of Evidence # of Health Domains Conclusive 0 Substantial 5 Moderate 6 Limited 7 None/Insufficient 7

29 National Academies of Sciences, Engineering, and Medicine. (2017). The health effects of cannabis and cannabinoids: The current state of evidence and recommendations for research. Substantial/moderate evidence that cannabis is associated with these adverse health effects: increased risk of motor vehicle crashes increased risk for lung cancer lower birth weight of the offspring (maternal cannabis smoking) cognitive impairments (acute effects) development of schizophrenia or other psychoses; highest risk among heavy users development of problem cannabis use when early onset of use

30 Adverse Health Effects of Chronic Marijuana Use (Volkow et al., 2014) Low Level of Confidence Lung cancer Medium Level of Confidence Altered brain development Progression to use of other drugs Increased risk of schizophrenia, depression and anxiety disorders (in persons with a predisposition to such disorders) High Level of Confidence Addiction Motor vehicle accidents Diminished life achievement (including poor educational outcome) Symptoms of chronic bronchitis

31 Adverse Health Effects of Chronic Marijuana Use: Those Effects Strongly Associated with Initial Marijuana Use Early in Adolescence (Volkow et al., 2014) Low Level of Confidence Lung cancer Medium Level of Confidence Altered brain development Progression to use of other drugs Cognitive impairment Increased risk of chronic psychosis disorders (including schizophrenia and depression) in persons with a predisposition to such disorders High Level of Confidence Addiction Diminished life satisfaction and achievement (including poor educational outcome) Symptoms of chronic bronchitis Source: US News & World Report, 2005

32 Adverse Health Effects of Short-Term Marijuana Use (Volkow et al., 2014) Impaired short-term memory Impaired motor coordination Altered judgement In high doses, paranoia and psychotic symptoms

33 Contextual Issue Discussions of marijuana harm are relevant in the context of harm associated with other drugs.

34 Assessing Harm of Psychoactive Substances (Nutt et al., 2007) Alcohol Tobacco Cannabis Harm ratings: Physical Social Dependence Class = U.K. Misuse Classification

35 Fact Checking the Marijuana Debate 3. Legalization is warranted because marijuana is medicine. Two main questions: 1. What evidence exists on marijuana s health benefits? 2. Is smoked marijuana medicine?

36 Is Marijuana Medicine? National Academies of Sciences, Engineering, and Medicine, 2017 Credible reports by individuals and growing body of evidence-based research that cannabis or cannabinoids may be uniquely beneficial for some conditions. Strengths of Evidence Score Box of Therapeutic Value # of Conditions/Ailments 1.Chronic pain 2.Nausea (chemo meds) 3.MS Conclusive/Substantial 3 Moderate 4 Limited 5

37 Do We Need to Smoke It? Challenges: 1. When raw marijuana is smoked, it is difficult to standardize the dosage for the patient. No physician could legally take responsibility for prescribing raw marijuana. 2. The smoking of almost any plant material is associated with mouth, throat and lung cancer. 3. MJ plant consists of only two compounds (THC and CBD) among the 400 that are believed to have medicinal properties. 4. Easy to manufacture own supply with home cultivation and avoid regulations.

38 Marijuana-Based Medicines Epidiolex (oil) is pure cannabidiol (CBD), a non-psychoactive compound in cannabis. Promising for epilepsy. Across three studies involving more than 500 patients, monthly seizures reduced by about 40%, compared to about 15-20% in the placebo groups. From Smart Approaches to Marijuana (

39 Marijuana-Based Medicines Sativex is in the process of being studied in the US. Orally administered spray, 1:1 CBD-THC extract. Currently in use in Canada and across Europe to treat neuropathic pain and spasticity and other symptoms of MS. Phase 3 trials in almost 60 research sites in the US in advanced cancer patients with significant pain. From Smart Approaches to Marijuana (

40 Fact Checking the Marijuana Debate 4. Legalization will help alleviate the opioid abuse crisis.

41 Opioid Abuse in Medical Marijuana States 1. Bachhuber et al., 2014: Medical cannabis laws (MCLs) are associated with significantly lower state-level opioid overdose mortality rates. 13 states with MCLs compared to non- MCL states MCL states had 25% lower mean annual opioid overdose mortality rate compared to non-mcl states

42 Billboard in Indiana

43 Opioid Abuse in Medical Marijuana States 2. Wen & Hockenberry, 2018: State implementation of medical marijuana laws was associated with a 5.88% lower rate of opioid prescribing. Moreover, the implementation of adultuse marijuana laws, which all occurred in states with existing medical marijuana laws, was associated with a 6.38% lower rate of opioid prescribing. NOT SO FAST

44 Opioid Abuse and Marijuana Epidemiological-based data is the weakest design to confer causation between two variables or domains. Several confounds not considered changes in opioid prescribing regulations and restrictions changes in use of medication-assisted therapies Individual-based data on actual use are vital to better understand this issue.

45 (MJ use wave 1) (MJ use wave 1) Opioid Abuse and Marijuana: Individual-Level Data (Olfson et al., Based on NESARC data, comparing and ) Wave 1 MJ users but not opioid users, and their odds of Wave 2 opioid abuse

46 Opioid Abuse and Marijuana: Individual-Level Data (Olfson et al., Based on NESARC data, comparing and )

47 Opioid Abuse and Marijuana: Individual-Level Data The Minnesota Department of Health recently reported that more than approximately 4 in 10 people struggling with difficultto-control pain of moderate and high levels indicated that medical cannabis provided significant relief. The study also found that of the 353 patients who self-reported taking opioid medications when they started using medical cannabis, 63 percent (n=221) reduced or eliminated opioid use after six months.

48 Fact Checking the Marijuana Debate 5. Legalization will reduce underage use of marijuana.

49 Complicated Issue Some published surveys (and media reports) indicate no significant increase, and in some instances a drop, in teenage marijuana use in pro-marijuana states.

50

51 percentages Another Look: Colorado Teenagers (12-17): Trend Data Past Year (NSDUH) Colorado legalized marijuana in 2012, not yet implemented Marijuana Use

52 percentages Another Look: Colorado Teenagers (12-17): Trend Data Past Year (NSDUH) Colorado implemented legal marijuana stores in Marijuana Use

53 Complicated Issue Most epidemiological data so far indicates no significant increase in underage marijuana use in promarijuana states. Some indications that marijuana use has increased among young adults.

54 percentages A Closer Look: Colorado Young Adults (18-25): Trend Data Past Year (NSDUH) 70 Colorado implemented legal marijuana stores in Marijuana Use

55 Complicated Issue Most epidemiological data so far indicates no significant increase in underage marijuana use in pro-marijuana states. Some indications that marijuana use has increased among young adults. Reliable trends may not emerge until significant time has passed after a change in laws and access.

56 Fact Checking the Marijuana Debate 6. Developing a marijuana use disorder is relatively rare among marijuana users. (Often cited figures: 9 percent of adults who try marijuana become dependent, compared with 15 percent of those who try alcohol and 32 percent of those who try tobacco.)

57 Percent Addictive Potential of Psychoactive Substances Estimated Prevalence of Dependence Among Users (lifetime; age 15-54) * * Source: Anthony JC et al., 1994

58 Percent Addictive Potential of Psychoactive Substances Estimated Prevalence of Dependence Among Users (lifetime; age 15-54) Rates are higher if use begins during adolescence * * Source: Anthony JC et al., 1994

59 Percent Addictive Potential of Psychoactive Substances Estimated Prevalence of Dependence Among Users (lifetime; age 15-54) % If youth onset * * Source: Anthony JC et al., 1994

60 Avg. % THC Content among Confiscated Cannabis Products in U.S. ( ) 14% 12% 10% Source: ElSohly et al., Biological Psychiatry, ,681 samples ~12% 8% 6% ~4% 4% 2% 0%

61 1. Marijuana Use in Minnesota 3. Policy Implications 2. Myths

62 1. If Recreational Marijuana is Legal, Employ a Strong Regulation System Governance and compliance checks regarding access and distribution Regulation of edibles, candies Epidemiological (hopefully prospective) research on trend changes in use patterns and health effects Compare extra tax revenue vs. social and health costs Source:

63 Benefits and Costs Analysis: Complicated to Compare But Important Benefit-Only View is Misleading By Carlos Illescas PUBLISHED: May 26, 2016 at 4:40 pm UPDATED: October 2, 2016 at 4:09 pm

64 The Projected Costs and Benefits if Marijuana Were Legalized in Connecticut (see learnaboutsam.org) Although a full cost accounting of marijuana legalization would be impossible at present, enough data exists to make rough-and-ready estimates of certain likely direct and short-term costs.

65 2. Regulations for Medical Marijuana Can Be Rigorous Minnesota s Medical MJ Law: Grown by the state; only usable in oil (for vaporizing), pill or liquid forms Dispensed at only a handful of state-run clinics Only prescribed by MDs and, for the most part, limited to specific disorders

66 Indications for Medical Marijuana In Minnesota (not all included on the conclusive/substantial evidence list from the National Academies report) Cancer (severe nausea, pain) Glaucoma HIV/AIDS Tourette Syndrome ALS Seizures MS Inflammatory bowel disease Terminal illness (probable life expectancy of less than a year) Intractable pain PTSD Sleep Apnea Autism this summer

67 Challenges to Rigorous Recreational/Medical Regulations and Enforcement

68 3. Re-Schedule Cannabidiol (CBD) CBD may have significant medicinal value for seizure disorders, and perhaps pain and MS Move it from Schedule I to either a Schedule II or III drug; doing so would make it easier to research this compound

69 4. Get FDA Approval for Marijuana- Based Medicines The FDA requires carefully conducted clinical trials in hundreds to thousands of human subjects benefits? risks? Some progress to date

70 5. Clinical Issues Increasing proportion of drug treatment admissions now involves Marijuana Use Disorder as the primary drug of abuse or part of a polydrug pattern (particularly among youth).

71 Percent of Admissions Treatment Admissions by Primary Drug Marijuana Alcohol Methamphetamine Heroin approx. 9 out of 10 adolescent treatment admissions involved marijuana Slide courtesy of Sion Kim, MD; Source: SAHMSA, Treatment Episode Data Set Age in years

72 5. Clinical Issues Increasing proportion of drug treatment admissions now involves Marijuana Use Disorder as a primary drug of abuse or part of a polydrug pattern (particularly among youth). Address possible misperceptions about marijuana with clients. For those taking medical marijuana: abuse potential with many THC-based medicines may exist; this issue needs more study.

73 percentages 6. Youth Prevention Perceptions of Great Harm y.o y.o y.o y.o. MJ/Once Mth Drink 5+/1-2 Times Wk

74 Percent of US 12 th Graders Reporting Using Substance in Lifetime, % Alcohol % 49% Tobacco 62% 45% % Marijuana 27% Illicit drugs other than marijuana 20% 0 Source: National Monitoring the Future Survey, 2017

75 Major Ongoing Projects on Brain Development Adolescent Brain Cognitive Development National Longitudinal Study Ten year longitudinal study of 10,000 children from age 10 to 20 years to assess effects of drugs on individual brain development trajectories

76 1. Marijuana Use in Minnesota 4. Summary 2. Myths 3. Policy Implications

77 1. Marijuana is an addictive drug associated with numerous short-term and long-term negative health effects. 2. Some elements of the marijuana plant may have medicinal benefits. 3. The public health, free-market capitalism and libertarian points of view about marijuana are too often informed with misinformation. 4. Policy makers and clinicians: Be smart.

78 Volkow et al., 2016: Current efforts to normalize cannabis use are being driven largely by a combination of grassroots activism, pharmacological ingenuity, and private profiteering, with a worrisome disregard for scientific evidence, gaps in our knowledge, or the possibility of unintended consequences. We need to learn as much and as rapidly as we can from the ongoing changes in local policies to minimize the harms and maximize the potential benefits.

79 THANK YOU Questions and Discussion

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