21 st century marijuana. Meeting of the Minds April 5-6, 2018 LaTisha Bader, PhD, LP, LAC, CMPC

Transcription

1 21 st century marijuana Meeting of the Minds April 5-6, 2018 LaTisha Bader, PhD, LP, LAC, CMPC

2 Learning Objectives Identify new trends in use, potency, products, and marketing practices that make young adults vulnerable Describe how legalization of recreational cannabis has influenced public health, perception and consumption Review current research and present effective ways to communicate use deterrence

3 Special Thanks Ben Cort Laura Martin, MD Bari Platter, MS, RN, PMHCNS-BC 3

4 Know your intensions

5 The rule of thirds is applied by aligning a subject with the guide lines and their intersection points, placing the horizon on the top or bottom line, or allowing linear features in the image to flow from section to section. Rules of Attraction

6 Where have we been

7 Genesis 1:12 vs. 21 st Century I have given you all the seed bearing herbs and plants to use.

8 Timeline of Marijuana 2900 BC Chinese Emperor Fu Marijuana is popular medicine 1213 BC Egyptians Used for glaucoma, inflammation and enemas 200 BC Medical Cannabis used in Greece 70 AD Roman text claims cannabis treats ear infections and suppresses sexual longing 1450 BC Anointing Oil 100 BC India Cannabis and milk used as anesthetic, prolong life, improve judgment, lower fevers, induce sleep 1 AD Chinese Text Recommends Marijuana for 100 ailments 1500 Muslim doctor uses marijuana to reduce sexuality

9 1611 Jamestown settlers bring marijuana to North America 1621 Anatomy of Melancholy Treats depression 1850 Added to US Pharmacopeia 1906 Pure Food and Drug Act Required labeling of cannabis in OTC remedies 1619 Virginia Assembly passed law to grow hemp Late 19th Century Sold in public Rx Presidents grow crop 1889 Used for opium withdrawal 9

10 "As demand for marijuana-based medications accelerated, pharmaceutical firms attempted to produce consistently potent and reliable drugs from hemp. By the 1930s at least two American companies Parke-Davis and Eli Lily were selling standardized extracts of marijuana for use as an analgesic, an antispasmodic and sedative. Another manufacturer, Grimault & Company, marketed marijuana cigarettes as a remedy for asthma." 10

11 s Mexican Revolution Recreational use; Marijuana Menace 1917 Colorado was 8th state to outlaw states had outlawed marijuana 1911 Massachusetts 1st state to outlaw cannabis 1930 Fear of Marijuana 1936 Reefer Madness 11

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13 1937 Marijuana Tax Act 1942 Removed from US Pharmacopeia 1940 s Hemp for Victory 1960 Marijuana Popular in Counterculture 1968 University of Mississippi becomes official grower of US government 1937 Samuel R. Caldwell La Guardia Report 1951 Stricter Sentencing Laws 1964 THC first identified and synthesized 1970 Controlled Substance Act Schedule of Drugs No acceptable medical use 13

14 1970 Mandatory minimum sentencing repealed 1971 Nixon will not legalize 1973 DEA formed 1976 Parents movement begins 1971 NORML formed 1972 Shafer Commission 1974 High Times 1980 s War on Drugs 14

15 1980 Marinol tested on cancer patients 1988 Scientists Discover Cannabinoid Receptor in the Brain 1996 Medical Use Legalized in California 1999 Institute of Medicine (IOM) conducts comprehensive study on medical marijuana 1985 FDA approves Marinol 1992 Scientists Discover Endocannabinoid 1998 Alaska, Oregon and Washington legalize medical marijuana 1999 Marinol moved to Schedule II 15

16 2000 Colorado allows medical marijuana (7th state) 2006 Presbyterian Church approves resolution to support medical marijuana 2011 DEA places 5 synthetics into Schedule I Imminent Hazard 2014 Federal Banks can cooperate with marijuana sellers 2003 US government receives cannabinoid patent 2010 Washington expands list of medical professionals authorized to recommend marijuana 2013 Another denial to move Schedule 16

17 May 2015 Gov of Puerto Rico legalizes medical marijuana 2016 California, Nevada, Maine and Massachusetts legalized recreational marijuana June 2015 Federal government removes obstacle to marijuana research 2016 DEA considers schedule change Declines, but open doors to research 17

18 Who is using

19 National Trends

20 National Trends

21 Research

22 The human body produces its own cannabis-like compounds, called endocannabinoids, that react with the body s cannabinoid receptors. Cannabinoid receptors in the brain stem and spinal cord play a role in pain control, vomiting reflex, appetite, emotional responses, motor skills, and memory formation. 22

23 THC and the Developing Body

24 "Twenty-eight years after discovering THC, in 1992, Dr. Mechoulam, along with Dr. William Devane and Dr. Lumir Hanus, identified the brain's first endogenous cannabinoid (or endocannabinoid) - the brain's natural version of THC -which they called 'anandamide,' from the Sanskrit word 'ananda,' which means 'eternal bliss' or 'supreme joy.' Vigorous exercise stimulates the release of anandamide, and the sense of euphoric well-being that comes with a healthy workout - what jogging enthusiasts refer to as a 'runner's high' - is due to elevated levels of endocannabinoids. The endocannabinoid system in the brain is also believed to help mediate emotions, consolidate memory, and coordinate movement." 24

25 Controlled Substances Act Controlled Substances Act as having a currently accepted medical use in treatment in the United States, must meet a five-part test: (1) The drug s chemistry must be known and reproducible, (2) there must be adequate safety studies, (3) there must be adequate and well-controlled studies proving efficacy, (4) the drug must be accepted by qualified experts, and (5) the scientific evidence must be widely available. According to the DEA, botanical marijuana meets none of these requirements. First, marijuana s chemistry is neither fully known nor reproducible. Second, adequate safety studies have not been done. Third, there are no adequate, well-controlled scientific studies proving marijuana is effective for any medical condition. Fourth, marijuana is not accepted by even a significant minority of experts qualified to evaluate drugs. Fifth, published scientific evidence concluding that marijuana is safe and effective for use in humans does not exist

26 Who s selling

27 State Laws states with medical marijuana: Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Hawaii Illinois Maine Maryland Massachusetts Michigan Minnesota Montana Nevada New Hampshire New Jersey New Mexico New York North Dakota Ohio Oregon Pennsylvania Rhode Island Vermont Washington District of Columbia West Virginia 9 states with legalization: Alaska Colorado California Maine Massachusetts Nevada Oregon Vermont Washington 27

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29 Why are we using

30 Medicinal Therapeutic values: relieving nausea increasing appetite reducing muscle spasms and spasticity chronic pain* reducing intraocular pressure relieving anxiety Marijuana has been used to treat the symptoms of cancer and chemotherapy, chronic wasting disease associated with AIDS/HIV, spasticity of multiple sclerosis, epilepsy, and Dravet syndrome (CBD)

31 Recreational

32 What are we using Marijuana 101: Flower, Oil, Concentrates, Edibles, Vape, Topicals

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34 Plant MARIJUANA POTENCY Average THC and CBD Levels in the US: THC: Psychoactive Ingredient CBD: NON- Psychoactive Ingredient THC CBD Mehmedic et al.,

35 Plant - CO THC in CO THC in CO

36 The percent of THC, also known as potency, has been steadily increasin g in plants over the last 55 years, while CBD stayed the same.

37 Dab From Farming to Chemistry

38 Concentrates Potency Concentrates : 710 is the new 420 Butane-extracted hash oil (BHO) Not your granddad s weed Not your dad s weed Not even my weed A chunk of the stuff the size of a Tic Tac can be the equivalent of hoovering up an entire joint in one massive toke. Even for hardcore smokers, the experience which fans call dabbing can be like getting high for the very first time. Your head spins, your eyes get fluttery, a few beads of sweat surface on your forehead and, suddenly, you're cosmically baked. (Rolling Stone Magazine, 6/20/2013)

39 Concentrates But it s just a plant (80-99% THC) Concentrates Green Crack wax Ear Wax Butane Hash Oil (BHO) Shatter Hash Oil Capsules Budder

40 Concentrates

41 Concentrates

42 Concentrates

43 Concentrates

44 Concentrates

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46 Concentrates Marijuana or Marihuana means all the parts of the plant of the genus cannabis whether growing or not, the seeds thereof, the resin extracted from any part of the plant, and every compound, manufacture, salt, derivative, mixture, or preparation of the plant, its seeds, or its resin, including marihuana concentrate.

47 Vape What s undetectable, odorless, and immediate

48 Oil

49 Oil Increasingly popular and accessible 49

50 Oil

51 Oil

52 Eat Trending cannabis

53 Edibles

54 Edibles How many servings? 10 mg is a legal dose

55 Edibles Edible marijuana was sited as the culprit behind the most troubling cases arriving at the UCH and Children s Hospital Colorado emergency departments, including severe burns and cycling vomiting syndrome.

56 I can put it where?! Topical

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58 Hearts and Minds

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65 Hearts and Minds

66 Clinical Information

67 Intoxication A. Recent use of cannabis B. Clinically significant problematic behavioral or psychological changes (e.g., impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgment, social withdrawal) that developed during, or shortly after, cannabis use C. At least 2 of the following signs, developing within 2 hours of cannabis use: Conjunctival injection Increased appetite Dry mouth Tachycardia D. Symptoms not due to a general medical condition and not better accounted for by another mental disorder, including intoxication with another substance 67

68 Withdrawal A. Cessation of cannabis use that has been heavy and prolonged (ie, usually daily or almost daily use over a period of at least a few months). B. Three or more of the following signs and symptoms develop within approximately 1 week after cessation of heavy, prolonged use: Irritability, anger or aggression Nervousness or anxiety Sleep difficulty (ie, insomnia, disturbing dreams) Decreased appetite or weight loss Restlessness Depressed mood At least one of the following physical symptoms causing significant discomfort: abdominal pain, shakiness/tremors, sweating, fever, chills, or headache C. The signs or symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance. 68

69 It s addictive More adolescents are using marijuana than smoking tobacco 1 in 10 adults 1 in 6 adolescents who try marijuana will become addicted Adults users are more anxious, more psychotic, less alert, more disorganized, have dry mouth, and are more hypertensive and want to use more.

70 Toxiology absorbed into body tissues (including the brain, heart, and fat) or transformed by the liver Because THC is stored in fatty tissues, it accumulates faster than it can be eliminated in chronic repetitive smokers. Leads to extended retention of THC which is then eliminated from the body at a relatively constant rate with an average elimination half-life being estimated at hours. Urinary results difficult to interpret due to variables such as dosage of THC ingested, frequency of use, timing of urine collection relative to last exposure to marijuana, rate of release of stored cannabinoids in adipose tissue, and an individual's hydration state. 70

71 Criteria Substance Use Disorder (Addiction) 1. Taking the substance in larger amounts or for longer than the you meant to 2. Wanting to cut down or stop using the substance but not managing to 3. Spending a lot of time getting, using, or recovering from use of the substance 4. Cravings and urges to use the substance 5. Not managing to do what you should at work, home or school, because of substance use 6. Continuing to use, even when it causes problems in relationships 7. Giving up important social, occupational or recreational activities because of substance use 8. Using substances again and again, even when it puts the you in danger 9. Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance 10. Needing more of the substance to get the effect you want (tolerance) 11. Development of withdrawal symptoms, which can be relieved by taking more of the substance. DSM 5 2 3: mild 4 5: moderate 6 +: severe

72 Withdrawal Withdrawal symptoms peak at 4 days Acute withdrawal period lasts 16 days Most severe symptoms include craving, restlessness, nervousness and sleeplessness Marijuana Withdrawal checklist also includes irritability, depression, anger, strange dreams, loss of appetite and headache On the Clinical Global Impression Scale, patients were rated as markedly ill when they go through withdrawal Withdrawal symptoms more severe in women Withdrawal symptoms are a negative reinforcement for continued use and are associated with less treatment adherence Bonnet et al 2014

73 Cannabis Use Disorder 12% of those 12 and older have used cannabis in the last year 1 in 2 daily users develop cannabis dependence More adolescents are using marijuana than smoking tobacco Cannabis users have increased risk for use of other substances and development of other alcohol and drug use disorders (access, personality traits, change in reward system) Cannabis users have worsened prognosis for a cooccurring alcohol use disorder Reviewed in Hall, 2014; reviewed in Volkow et al; Schuermeyer et al 2014; Richmond et al 2013; Wall et al 2011; Cerda et al 2012, Weinberger et al 2016, Hassin et al 2016

74 What we actually know Science and stuff

75 Effects on the Body Acute Motor Diminished reaction time, motor coordination, and perceptual accuracy Distorted perception (sights, sounds, time, touch) Cardiovascular Greater difficulty for individuals to intake sufficient oxygen Increase heart rate ( % faster, for up to 3 hours) Increased risk of bronchitis, changes consistent with chronic obstructive pulmonary disease Increase risk of angina, heart attack in those with previous heart attack (blood pressure increases) Increased risk of heart attacks and strokes in those without a previous history Autonomic nervous system Inhibits sweating and temperature control Reviewed in Hall, 2014 and Volkow et al 2014; Hodcroft et al 2014; Asbridge et al 2014; Monte et al 2014

76 Effects on the Body Acute Electrolyte imbalances Respiratory system complications Second hand smoke exposure causes cardiovascular effects (animal study) ED visits: 1-2 are for intoxication for associated illnesses (anxiety, cyclical vomiting, unintentional ingestions, burns) Chronic Increased risk of chronic bronchitis Changes in physical structure of the brain Immune system Cannabinoid Hyperemesis Syndrome Reproductive systems Increased risk of testicular cancer (dose response related) Data on lung, head, and beck cancers associated with marijuana use is unclear Reviewed in Hall, 2014 and Volkow et al 2014; Hodcroft et al 2014; Asbridge et al 2014; Monte et al 2014

77 Acute Impaired memory, judgment Risk of depression 1.4 x higher Acute anxiety Increased risk of anxiety disorders Worsened outcomes in bipolar disorder Risk of suicide attempt requiring hospitalizations 2 x higher Chronic Effects on Mental Health Increased risk of: Impaired cognitive functioning, memory and decision making Depression, anxiety, and panic attacks Suicidal ideation and suicide attempts Reduced verbal learning, memory, attention Loss of up to 8 IQ points at adulthood Neonatal use: Altered brain development (change in sensitivity of the reward system, impaired neuronal connectivity) Reviewed in Hall, 2014; Di Forti et al 2014, Giordano et al 2014

78 Psychosis Use of cannabis associated with 1.4x increased risk of psychosis and regular users with a 2x risk of psychosis High potency cannabis, more frequent use, and genetic susceptibility can increase this risk up to 8x risk Use before age 18 has 2.4 times risk of dx of schizophrenia (dose response) Risk is 3.3x higher if cannabis use within 3 years of diagnosis, 1.6x higher if 7 years Reviewed in Hall, 2014; Di Forti et al 2014, Giordano et al 2014 Also, see Radhakrishnan et al Gone to Pot A review of the Association between Cannabis and Psychosis

79 Marijuana Use and associated behaviors(table 5.1) Behavioral Health Problems Strength of association Alcohol Use +++ Tobacco Use +++ Use of other Illicit Drugs + Bipolar Disorder ++ Unipolar Depression + Social Anxiety +++ Generalized Anxiety + Panic Disorder +++ Posttraumatic Stress Disorder + Attention-deficit / Hyperactivity Disorder +++ Sleep Disturbances + Suicidality and violence + 79

80 Medical Interactions May cause excessive sedation when combined with perioperative medications. Avoid marijuana if scheduled for surgery in the next 2 weeks. May increase the risk of bleeding when used with aspirin, anticoagulants, antiplatelet drugs, nonsteroidal antiinflammatory drugs, and ginko biloba May affect blood sugar; medications for diabetes many need to be adjusted (e.g. metformin or insulin). Use caution if taking herbs and supplements that affect blood sugar. May lower blood pressure. Use caution with medications, herbs or supplements that lower blood pressure, May increase drowsiness when used with benzodiazepines, barbiturates, narcotics, some antidepressants, and alcohol. Affects the liver s cytochrome P450 enzyme system (CYP450) and could result in increased blood levels of medications metabolized by CP450 leading to adverse reactions.

81 Effects on Behavior No lethal overdoses (due to THC in humans) Behaviorally mediated deaths through accidents, suicide, homicide Double the risk of motor vehicle accident Increased likelihood of non-fatal bicycle accident (9x risk) Reviewed in Hall, 2014; Reviewed in Volkow et al 2014; Hodcroft et al 2014; Asbridge et al 2014; Monte et al 2014

82 Use of Cannabis Associated with Worse Social Outcomes at Age 25 (New Zealand Study) % welfare dependent (ages 21-25) to to 299 % Unemployed (ages 21-25) mean personal income at age 25 % gained university degree by age 25 # of occasions using Cannabis ages to to 99 Never Number of occasions using Cannabis between ages Source: Fergusson and Boden. Addiction, 103, pp , 2008

83 Know your CANNABIS Conversation Finding your voice in the wellness movement

84 Give me your Instagram speech!

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86 SBIRT Screeners Severity of Dependence Scale SDS Cannabis Abuse Screening Test CAST Cannabis Use Disorders Test Revised CUDIT-R Problematic Use of Marijuana Cannabis Use Problems Identification Test CUPIT Marijuana Screening Inventory Abstinence challenge, decrease potency or frequency Participate in IOP treatment CANDIS Discuss legal risks Support medical interventions and education Teach refusal skills Harm reduction

87 Abstinence Know DSM5 criteria for accurate diagnosing Risks for co-occurring problems Medication interactions Risks for youth use versus adult use Exacerbating of cravings Legal consequences Challenge Reservations and the wellness movement begins

88 Treatment No current FDA approved medications Reviewed in Kelly and Levin Treatment of Cannabis Use Disorder, in 2015 Textbook of Substance Abuse Treatment; Allsop et al 2014

89 Thank you for your time LaTisha Bader