MONITORING THE FUTURE 2013 TEEN DRUG USE

Transcription

1 COCAINE PRESCRIPTIONS POT BOOZE VICODIN CRACK ALCOHOL INHALANTS CIGARETTES RITALIN STEROIDS hookahs K2/Spice BATHSALTS CigaretteS MONITORING THE FUTURE 2013 TEEN DRUG USE OxyContin cigarettes SEDATIVES Heroin barbiturates ADDERALL methamphetamine ECSTASY marijuana COLD MEDICINES Monitoring the Future is an annual survey of 8th, 10th, and 12th-graders conducted by researchers at the University of Michigan, Ann Arbor, under a grant from the National Institute on Drug Abuse, part of the National Institutes of Health. Since 1975, the survey has measured drug, alcohol, and cigarette use and related attitudes in 12th-graders nationwide. Eighth and 10th graders were added to the survey in Overall, 41,675 students from 389 public and private schools participated in the 2013 survey. LAST TWO DECADES OF ALCOHOL, CIGARETTE, AND ILLICIT DRUG USE* *Past 30 day use. 60% 50% 40% 30% % % Alcohol Cigarettes Illicit drugs 39.2% OF 12TH GRADERS 16.3% OF 12TH GRADERS 25.5% OF 12TH GRADERS % OF 10TH GRADERS 10.2% OF 8TH GRADERS 9.1% OF 10TH GRADERS 4.5% OF 8TH GRADERS 19.4% OF 10TH GRADERS 8.5% OF 8TH GRADERS MARIJUANA: AS PERCEIVED HARM DROPS, USE GOES UP 35.6% 34.9% 36.4% *Past-year use in 12 th graders. 26.0% 1993 USING % % PERCEIVED HARM (saw great risk in smoking marijuana occasionally) 36.4% EQUATES TO ABOUT 11 STUDENTS IN THE AVERAGE CLASS 60% of high school seniors do not view regular marijuana use as harmful, which is nearly double from 20 years ago. The potency of marijuana, as measured by THC content, has steadily increased over the last few years, which means that daily use of today s marijuana may have greater health consequences than use of marijuana from 10 to 20 years ago. PRESCRIPTION/OVER-THE-COUNTER VS. ILLICIT DRUGS* Adderall 7.4% Vicodin 5.3% Cold Medicines 5.0% * The percentage of 12th graders who have used these drugs in the past year. Tranquilizers 4.6% OxyContin 3.6% Ritalin 2.3% Marijuana 36.4% K2/Spice 7.9% MDMA/Ecstasy 4.0% Salvia 3.4% After marijuana, prescription and over-the-counter medications account for most of the top drugs abused by 12th graders in the past year. Powder Cocaine 2.6% PRESCRIPTION ILLICIT DRUGS ABUSE OF SOME SYNTHETIC DRUGS IS DOWN. These are substances that are chemically similar to and/or mimic the effects of illicit drugs. This year, 7.9% of high school seniors reported past-year use of K2/Spice (sometimes called synthetic marijuana), down from last year s number of 11.3%. Past-year use of the substances called bath salts was low for all three grades - at or below 1%. FOR MORE INFORMATION, VISIT OR DRUGABUSE.GOV. The National Institute on Drug Abuse is a component of the National Institutes of Health, U.S. Department of Health and Human Services. NIDA supports most of the world s research on the health aspects of drug abuse and addiction. Fact sheets on the health effects of drugs of abuse and information on NIDA research and other activities can be found at

2 Opinion VIEWPOINT Samuel T. Wilkinson, MD Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut. Deepak Cyril D Souza, MBBS, MD Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, Abraham Ribicoff Research Facilities, Connecticut Mental Health Center, New Haven, Connecticut, and Schizophrenia and Neuropharmacology Research Group, VA Connecticut Healthcare System, West Haven, Connecticut. Corresponding Author: Deepak Cyril D Souza, MBBS, MD, Department of Psychiatry, Yale University School of Medicine, Psychiatry Service 116A, VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT Problems With the Medicalization of Marijuana Medical marijuana is approvedin 21 states and the District of Columbia for numerous conditions, including glaucoma, Crohn disease, posttraumatic stress disorder, epilepsy, Alzheimer disease, and chemotherapyinduced nausea and vomiting. Both the number of states and the number of approved indications for medical marijuana are expected to increase. Physicians will bear the responsibility of prescribing marijuana and thus have an obligation to understand the issues involved in its medicalization. Medical marijuana differs significantly from other prescription medications. Evidence supporting its efficacy varies substantially and in general falls short of the standards required for approval of other drugs by the US Food and Drug Administration (FDA). Some evidence suggests that marijuana may have efficacy in chemotherapy-induced vomiting, cachexia in HIV/AIDS patients, spasticity associated with multiple sclerosis, and neuropathic pain. However, the evidence for use in other conditions including posttraumatic stress disorder, glaucoma, Crohn disease, and Alzheimer disease relies largely on testimonials instead of A significant but largely overlooked problem with the medical marijuana movement is the message the public infers from its legalization and increasing prevalence. adequately powered, double-blind, placebo-controlled randomized clinical trials. For most of these conditions, medications that have been subjected to the rigorous approval process of the FDA already exist. Furthermore, the many conditions for which medical marijuana is approved have no common etiology, pathophysiology, or phenomenology, raising skepticism about a common mechanism of action. There is no clear optimal dose of marijuana for its various approved conditions. The concentration of Δ 9 -tetrahydrocannabinol (THC) and other cannabinoids in each marijuana cigarette, the size of cigarettes, and the quantity of smoke inhaled by users can vary considerably. The relative lack of controlled clinical trial data makes finding the appropriate dose even more challenging. Furthermore, given that medical marijuana is approved for mostly chronic conditions that require long-term dosing, physicians must be aware of the development of tolerance and dependence (as evidenced by downregulation of the brain cannabinoid receptors), as well as withdrawal on discontinuation. 1 Prescription drugs are produced according to exacting standards to ensure uniformity and purity of active constituents and excipients. Because regulatory standards of the production process vary by state, the composition, purity, and concentration of the active constituents of marijuana are also likely to vary. This is especially problematic because unlike most other prescription medications that are single active compounds, marijuana contains more than 100 cannabinoids, terpenoids, and flavonoids that produce individual, interactive, and entourage effects. Although THC is believed to be the principal psychoactive constituent of marijuana, other cannabinoids present in marijuana may have important effects that may offset THC s negative effects. For instance, cannabidiol has been shown to have anxiolytic and antipsychotic effects that might offset the anxiogenic and psychotogenic potential of THC. 2,3 Yet cannabidiol is sometimes bred out to increase the THC potency of some medical marijuana strains. 4 Benefits notwithstanding, the potential harms associatedwithmedicalmarijuananeedtobecarefullyconsidered. No other prescription medication is smoked; concerns remain about the long-term risks of respiratory problems associated with smoking marijuana, which are a subject of active investigation. 5 THC is already available in a pill approved by the FDA, yet this form seems to be less desirable to those seekingmedicalmarijuana;thismayinpartbe because its euphoric effects are not immediate and cannot be reliably controlled, unlike smoked marijuana. 6 Furthermore, there is evidence that marijuana exposure is associated with an increased risk of psychotic disorders in vulnerable individuals. 7 Clearly, some but not all individuals are at risk of psychosis with exposure to marijuana, but it is not possible to identify at-risk individuals. In individuals with established psychotic disorders, marijuana use has a negative effect on the course and expression of the illness. 7 Furthermore, recent findings suggest that longterm marijuana exposure is associated with structural brain changes as well as a decline in IQ. 8 The current system of dispensing marijuana does not safeguard adequately against the potential for diversion and abuse. Many states, for instance, allow patients to grow their own marijuana. Furthermore, marijuana may be contaminated with pesticides, herbicides, or fungi, the latter being especially dangerous to immunocompromised individuals such as patients with HIV/ AIDS or cancer. 9 Central regulatory oversight by the FDA makes possible the recall of harmful drugs or contaminated batches and the dissemination of new information about drug safety. Is there sufficient oversight to jama.com JAMA Published online May 20, 2014 E1 Copyright 2014 American Medical Association. All rights reserved. Downloaded From: on 05/23/2014

3 Opinion Viewpoint monitor potential contamination of marijuana, especially when patients are permitted to grow it themselves? A significant but largely overlooked problem with the medical marijuana movement is the message the public infers from its legalization and increasing prevalence. There is an increasing perception, paralleling trends in legalization, that marijuana is not associated with significant or lasting harm; data from 3 decades indicate that among adolescents, risk perception is inversely proportional to prevalence of cannabis use. 4 As legalization has spread for medical or recreational purposes, it is possible that the perception of risk by adolescents will continue to decrease, with a subsequent increase in use. This is especially problematic given that many of the negative effects of marijuana are most pronounced in adolescents. 10 Projections of substantial revenue rather than evidence-based medicine may explain the eagerness of many states to legalize medical marijuana. Physicians have been invited to participate in the development of medical marijuana programs late in the process. In some instances (eg, Connecticut), legislators approved medical marijuana but consulted physicians with relevant expertise only afterward. An unmet need remains for treatments of a number of debilitating medical conditions. Specific constituents of marijuana may have therapeutic promise for specific symptoms associated with these disorders. However, if marijuana is to be used for medical purposes, it should be subjected to the same evidence-based review and regulatory oversight as other medications prescribed by physicians. Potentially therapeutic compounds of marijuana should be purifiedandtestedinrandomized, double-blind, placebo- andactivecontrolled clinical trials. Toward this end, the federal government should actively support research examining marijuana s potentially therapeutic compounds. These compounds should be approved by the FDA (not by popular vote or state legislature), produced according to good manufacturing practice standards, distributed by regulated pharmacies, and dispensed via a conventional and safe route of administration (such as oral pills or inhaled vaporization). Otherwise, states are essentially legalizing recreational marijuana but forcing physicians to act as gatekeepers for those who wish to obtain it. ARTICLE INFORMATION Published Online: May 20, doi: /jama Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr D Souza reports that he has received research grant support administered through Yale University School of Medicine from AbbVie and Pfizer Inc and is a consultant for Bristol-Meyers Squibb and Johnson & Johnson. No other disclosures were reported. REFERENCES 1. Budney AJ, Hughes JR. The cannabis withdrawal syndrome. Curr Opin Psychiatry. 2006;19(3): Leweke FM, Piomelli D, Pahlisch F, et al. Cannabidiol enhances anandamide signaling and alleviates psychotic symptoms of schizophrenia. Transl Psychiatry. 2012;2:e Bhattacharyya S, Morrison PD, Fusar-Poli P, et al. Opposite effects of delta-9-tetrahydrocannabinol and cannabidiol on human brain function and psychopathology. Neuropsychopharmacology. 2010;35(3): Kleber HD, DuPont RL. Physicians and medical marijuana. Am J Psychiatry. 2012;169(6): Callaghan RC, Allebeck P, Sidorchuk A. Marijuana use and risk of lung cancer: a 40-year cohort study. Cancer Causes Control. 2013;24(10): Cooper ZD, Comer SD, Haney M. Comparison of the analgesic effects of dronabinol and smoked marijuana in daily marijuana smokers. Neuropsychopharmacology. 2013;38(10): Castle DJ, Murray RM, D Souza DC, eds. Marijuana and Madness. 2nd ed. New York, NY: Cambridge University Press; Meier MH, Caspi A, Ambler A, et al. Persistent cannabis users show neuropsychological decline from childhood to midlife. Proc Natl Acad SciUSA. 2012;109(40): Verweij PE, Kerremans JJ, Voss A, Meis JF. Fungal contamination of tobacco and marijuana. JAMA. 2000;284(22): Moore TH, Zammit S, Lingford-Hughes A, et al. Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review. Lancet. 2007;370(9584): E2 JAMA Published online May 20, 2014 jama.com Copyright 2014 American Medical Association. All rights reserved. Downloaded From: on 05/23/2014

4

5

6

7

8

9

10

11

12

13