Cannabis Use: Scope of the Issue

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1 Three Areas of Focus How Changing Cannabis Policy Will Affect Your Practice Kevin P. Hill, MD, MHS Director, McLean Hospital Division of Alcohol and Drug Abuse Belmont, MA Assistant Professor of Psychiatry, Harvard Medical School Boston, Massachusetts Supported by NIDA K99/R00 DA (Kevin P. Hill, MD, MHS, PI) Clinical work: McLean Substance Abuse consultation service, private practice, professional sports teams and leagues Clinical research: 3 cannabis clinical trials Educational outreach: Science vs Public perception, schools, policymakers Why Cannabis? Alcohol & Drug Abuse Treatment Program (ADATP): 40% alcohol, 40% opioids, 20% everything else Around 60%: Time when smoked cannabis daily for years How many of these folks would you see down the road if an effective cannabis intervention existed? Cannabis Use: Scope of the Issue National Statistics: Not Going Away About 22 million Americans used cannabis in the past year, use doubled in past 10 years Powerful messages medical marijuana, legalization, celebrities Most messages off the mark, contribute to gap between science and public perception Development of Problems: About 9% of users may become dependent; 17% (1 in 6) who start use in adolescence Estimated Prevalence of Dependence among Users Hasin DS, et al. JAMA Psychiatry. 2015;72(12): Anthony J, et al. Experimental and Clinical Psychopharmacology. 1994;2: Lopez-Quintero C, et al. Drug Alcohol Depend. 2011;115(1-2):

2 Current Trends in Cannabis Use 12th Graders Past Year Cannabis Use vs Perceived Risk of Occasional Cannabis Use Compton WM, et al. Lancet Psychiatry. 2016;3(10): University of Michigan. Monitoring the Future study. December 13, Accessed June 20, Marijuana Myths Not harmful Not addictive No withdrawal Harmful: Dose Matters Early onset poor cognitive function, IQ decline anxiety depression risk of psychosis Halah MP, et al. Current Addiction Reports. 2016;3(4): Pope HG Jr, et al. Drug Alcohol Depend. 2003;69(3): Gruber SA, et al. Psychol Addict Behav. 2012;26(3): Meier MH, et al. Proc Natl Acad Sci U S A. 2012;109(40):E2657-E2664. Crippa JA, et al. Hum Psychopharmacol. 2009;24(7): Degenhardt L, et al. Addiction. 2003;98(11): Kuepper R, et al. BMJ. 2011;342:d738. Large M, et al. Arch Gen Psychiatry. 2011;68(6): Di Forti M, et al. Lancet Psychiatry. 2015;2(3): IT IS ADDICTIVE! There is Withdrawal! Drugs of abuse increase dopamine in the Nucleus Accumbens triggers the neuroadaptions that result in addiction? Tanda G, et al. Science. 1997;276(5321): Di Chiara G. Eur J Pharmacol. 1999;375(1-3): Vandrey RG, et al. Am J Addict. 2005;14(1): Vandrey RG, et al. Drug Alcohol Depend. 2008;92(1-3): Budney AJ, et al. Int Rev Psychiatry. 2009;21(2):91-95.

3 Pharmacology of Cannabis 100+ pharmacologicallyactive cannabinoids THC: Euphoria, antiinflammatory, psychosis CBD: Non-psychoactive, anti-anxiety, antipsychotic? Potency Rising 60s, 70s, 80s: Average THC content 3% to 4% Now: Average THC content 12% BUT you can get cannabis (plant not oil) in the 20s and low 30s ElSohly MA, et al. Biol Psychiatry. 2016;79(7): Other Forms of Marijuana Cannabis Policy in the United States: Ideas vs Implementation 2008: Decriminalization of less than an ounce in Massachusetts 2012: Medical Marijuana Ballot Initiative

4 Cannabis Use and Cannabis Use Disorder Access Complex issue where we need more data Health problems, addiction, decreased work productivity, 57% increase in ED visits in Colorado all result in financial costs MMJ states have not seen an increase in youth use vs non-mmj states Dueling Statistics? HIDTA: Youth past month use increased 20% in 2-year average following legalization of recreational marijuana in Colorado, compared to 2-year average prior to legalization ED = emergency department; MMJ = medical marijuana. Hasin DS, et al. JAMA Psychiatry. 2015;72(12): HIDTA = High Intensity Drug Trafficking Area. Colorado Department of Public Health & Environment. Marijuana Use Among Youth in Colorado. Healthy Kids Colorado Survey Digital.pdf. Accessed June 20, Cannabis Use Disorder Trends Cerdá M, et al. JAMA Pediatr. 2017;171(2): Hasin DS, et al. JAMA Psychiatry. 2017;74(6):

5 Cannabis and Psychosis Other Psychiatric Illness Association consistently reported, but causality hard to establish from observational studies Magnitude, effects of strains, high-risk groups RCTs follow-up periods too short RCT = randomized controlled trial. Gage SH, et al. Biol Psychiatry. 2016;79(7): Cohort Studies Odds ratios between mostly Outcomes: Psychotic symptoms or diagnoses Consistent relationship, perhaps causal If causal, schizophrenia lifetime risk equates to 2% High-Risk Groups Unclear: Age COMT, AKT1 (replicated but questioned) 3 studies found childhood trauma and cannabis use increased absolute risk for psychosis High THC increases risk for psychotic outcomes Gage SH, et al. Biol Psychiatry. 2016;79(7): Gage SH, et al. Biol Psychiatry. 2016;79(7): State of the Science: Medical Cannabis

6 FDA-Approved Cannabinoids Dronabinol oral THC Nabilone CB1 agonist FDA-approved for 1) Nausea and vomiting associated with chemotherapy 2) Appetite stimulation in wasting illnesses like AIDS Maybe CBD (or other cannabinoids), and cannabis therefore, offer some things that dronabinol and nabilone don t Medical Indications According to Laws Laws in various states Cancer, glaucoma, AIDS, Hepatitis C, amyotrophic lateral sclerosis (ALS), Crohn s Disease, Parkinson s, multiple sclerosis Many of the same conditions, but 53 conditions overall Data suggest that majority of people with medical cannabis cards do not have one of the above conditions Medical Indications Based on Good Quality Evidence Over 50 clinical trials of cannabinoids, including cannabis High quality evidence (approximately half of studies positive) for chronic pain, neuropathic pain, spasticity associated with multiple sclerosis Hill KP. JAMA. 2015;313(24): Other Reviews Conclusive or substantial evidence that cannabis or cannabinoids are effective: chronic pain in adults, chemotherapy-induced nausea and vomiting, patient-reported multiple sclerosis spasticity symptoms Moderate quality: chronic pain and spasticity National Academies of Sciences, Engineering, and Medicine The health effects of cannabis and cannabinoids: The current state of evidence and recommendations for research. Washington, DC: The National Academies Press. Accessed June 20, Whiting PF, et al. JAMA. 2015;313(24):

7 Boston Globe 1/17/16 Medical Marijuana: Where things stand NOW We ve Got A Long Way To Go Issue #1: Quantities Top 3 Medical Marijuana Issues (Using Massachusetts as an Example) MA: 60-day supply = 10 oz BUT A certifying physician may determine and certify that a qualifying patient requires an amount of marijuana exceeding ten ounces as a 60-day supply and shall document the amount and the rationale in the medical record and in the written certification. For that qualifying patient, that amount of marijuana constitutes a 60-day supply. My studies: 2.1 oz per month ± 3.0 oz Issue #2: Indications MA: Debilitating medical condition such as cancer, glaucoma, AIDS or HIV, Hepatitis C, Crohn s, Parkinson s, MS Or other conditions as determined in writing by physician Suggestion: Other conditions upon approval by DPH (like medication PAs)

8 Issue #3: Financial Incentives Automatic hardship for MassHealth, SSI patients They are granted hardship to grow their own Will this lead to unintended consequences? (No Longer) Hypothetical Scenario Mr. A, a patient on MassHealth, gets MMJ card to treat his migraine headaches He smokes ¼ ounce a week, or 2 oz/60 days He recognizes that he can grow another 8 oz (approximate street value of $3200, or $19,200/year) MMJ: Suggestions on what you should do Have a policy! Engage in conversation about why the patient feels this may help Be open to evaluating patients who want it yours or colleagues The Appropriate Candidate Debilitating condition with evidence Multiple failed trials of first- and second-line treatments Failed trial of FDA-approved cannabinoid No active Axis I condition Best Practices Ensure purity and potency Avoid edibles resembling candy or childoriented food products Avoid high potency extractions (wax, shatter) Require all dispensaries to participate in DEA Prescription Monitoring programs Best Practices Mandatory informed consent (driving, heavy machinery) Patient education kiosks at dispensaries, again documenting risks (including onset of action of edibles) Ensure an ongoing doctor-patient relationship with regular follow-up consistent with general medical practice

9 Policy Ahead of the Science Critical Period We can provide a service to patients and colleagues by being informed and thoughtful on this topic We need research on medical cannabis efficacy and best practices Acknowledgments Matt Palastro

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