The Effects of Marijuana on Gambling Behavior: Clinical and Policy Implications

The Effects of Marijuana on Gambling Behavior: Clinical and Policy Implications Ken Winters, Ph.D. Adjunct Faculty, Dept. of Psychology University of Minnesota & Senior Scientist Oregon Research Institute winte001@umn.edu 19th Annual Wisconsin Council on Problem Gambling Statewide Conference Waukesha, WI March 16, 2018

Marijuana from 10,000 Feet Summary Effects of Marijuana on Cognitive Functioning & Gambling Behavior Policy Implications for Casinos Clinical Implications for the PG Treatment Field

Web-Based Resources on Marijuana https://www.drugabuse.gov/publications/drugfacts/marijuana www.learnaboutsam.org http://norml.org/

Marijuana from 10,000 Feet 1. Marijuana plant 2. Research complications 3. Historical perspective

1. What is Marijuana? Schedule 1 drug Contains over 400 chemicals delta-9-tetrahydrocannabinol (THC) delta-8-tetrahydrocannabinol cannabidiol (CBD) (not psychoactive) cannabinol cannabichromene cannabigerol etc. Slide courtesy of Sion Kim, MD; Source: Mechoulam R, Hanus L, The cannabinoid system from the point of view of a chemist. In Marijuana and Madness. ed. Castle, Murray. Cambridge University Press, 2004

Marijuana s Effects on the User The psychoactive effects of cannabis (THC) are experienced immediately after smoking; effects are still discernable 24-48 hours after use Believed to affect the brain s cannabinoid (CB1) receptors

Brain Development Memory & Cognition Motivational Systems & Reward Appetite Immunological Function Reproduction Movement Coordination Pain Regulation & Analgesia Marijuana Binds Cannabinoid Receptors Located Throughout the Brain (source NIDA).................................................................................................................................................................................................................................................

Cannabinoid receptors in our brains - Why? Animal studies show that without these receptors Experience more pain Can t control appetite More anxious Less able to cope with stress These receptors are the main volume controls for neurotransmitters that affect pleasure, mood, pain, appetite, motivation, memory Slide courtesy of Sion Kim, MD

Drugs Over-Activate the Reward Circuitry and Contribute to Addictive Behaviors % of Basal Release % of Basal Release frontal cortex nucleus accumbens VTA/SN 1100 1000 900 800 700 600 500 400 300 200 100 0 150 AMPHETAMINE 0 1 2 3 4 5 hr MARIJUANA 125 Drugs of abuse increase dopamine in the reward pathway region 100 0 20 40 60 80 Tanda, et al, Science 1997. Slide courtesy of Maureen Boyle, PhD

Percent Addictive Potential of Psychoactive Substances Estimated Prevalence of Dependence Among Users (lifetime; age 15-54) 35 30 25 20 15 10 5 0 32 15 9 17 11 8 5 23 * * Source: Anthony JC et al., 1994

Percent Addictive Potential of Psychoactive Substances Estimated Prevalence of Dependence Among Users (lifetime; age 15-54) Rates are higher if use begins 35 30 25 20 15 10 5 0 32 during adolescence 15 9 17 11 8 5 23 * * Source: Anthony JC et al., 1994

Percent Addictive Potential of Psychoactive Substances Estimated Prevalence of Dependence Among Users (lifetime; age 15-54) 35 30 25 20 15 10 5 0 32 15 9 17% If youth onset 17 11 8 5 23 * * Source: Anthony JC et al., 1994

Effects of Short-Term Marijuana Use (Volkow et al., 2014) Impaired short-term memory, making it difficult to learn and to retain information Impaired motor coordination, interfering with driving skills and increasing the risk of injuries Altered judgment, increasing the risk of sexual behaviors that facilitate the transmission of sexually transmitted diseases In high doses, paranoia and psychosis Impairing effects on cognitive functioning can linger for up to 3 weeks of abstinence and beyond, particularly with respect to decision making

Effects of Long-Term/Chronic Marijuana Use (Volkow et al., 2014) Addiction (in about 9% of users overall, 17% of those who begin use in adolescence, and 25 to 50% of those who are daily users)* Altered brain development* Poor educational outcome, with increased likelihood of dropping out of school* Cognitive impairment, with lower IQ among those who were frequent users during adolescence* Diminished life satisfaction and achievement (determined on the basis of subjective and objective measures as compared with such ratings in the general population)* Symptoms of chronic bronchitis Increased risk of chronic psychosis disorders (including schizophrenia) in persons with a predisposition to such disorders * effects more pronounced if use begins during adolescence

Interpreting Studies Examining Long- Term/Chronic Marijuana Use is Problematic Big problem: this literature includes very heterogeneous samples of non-short-term users former but now abstinent cannabis users current regular cannabis users heavy cannabis users early-onset and late-onset cannabis users

Increased Potency Today s marijuana is not the marijuana of the 1960s. In the past 15 years, marijuana potency has tripled, and since 1960 it s grown 5 times stronger. Source: Kevin Sabet & Mehmedic et al., (2010)

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 14% 12% 10% 8% 6% 4% Avg. % THC Content among Confiscated Cannabis Products in U.S. (1995-2016) ~4% Source: Potency Monitoring Program, U. of Mississippi, School of Pharmacy 38,681 samples ~13% 2% 0%

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 14% 12% 10% 8% 6% 4% 2% 0% Avg. % THC Content among Confiscated Cannabis Products in U.S. (1995-2016) Source: Potency Monitoring Program, U. of Mississippi, School of Pharmacy THC 38,681 samples Concentration ~4% in the 1970 s was around 1% ~13%

2a. Difficulties in Studying Cannabis: Complex Drug 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

2b. Difficulties in Studying Cannabis: Interpreting Cross-Sectional Studies In cases where cannabis is associated with a negative health outcome, four possible scenarios are plausible. 1. Cannabis use directly causes the outcome. 2. Presence of a pre-existing risk factor or condition increased the likelihood of cannabis use. 3. Another variable that is not systematically accounted for in the study is responsible for the outcome. 4. Some combination of the aforementioned scenarios is responsible for the findings.

percentages Prevalence of Past Year Serious Mental Illness Among Lifetime Marijuana Users Aged 18+ (SAMHSA, 2005; data collected 2002-2003) 25 20 21 17.4 15 10 12.2 10.5 5 0 < age 12 age 12-14 age 15-17 > age 17 age of marijuana onset

2c. Difficulties in Studying Cannabis: Confirmation Bias Confirmation Bias = the tendency to interpret new evidence as confirmation of one's existing beliefs or theories

Example A: Reports of Reduced Opioid Abuse in Medical Marijuana States 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 NOT SO FAST.

Example A: Reports of Reduced Opioid Abuse in Medical Marijuana States Epidemiological-based data is the weakest design to confer causation between two variables or domains. Several confounds of possible changes in opioid prescribing regulations and restrictions not considered. Individual-based data tells a different story!

Example A: Reports of Reduced Opioid Abuse in Medical Marijuana States Source: Olfson M., et al. (2017). Cannabis use and risk of prescription opioid use disorder in the United States. American Journal of Psychiatry.

Example B: Since legalization, pot use in Colorado has steadily climbed, well outpacing the national average Colorado legalized marijuana in 2012 and implemented legal marijuana stores in 2014

3a. Historical Perspective Historically, it has been the most frequently used illicit drug by Americans. Yet its popularity has historical cycles that mirrors other drugs tolerance.temperance.tolerance temperance

3b. Historical Perspective: Legalization Marijuana s popularity in recent times 40-50 s: tobacco use and alcohol popularized; illicit drugs dangerous; Reefer Madness 60 s late 70 s: Woodstock generation; push for decriminalization or legalization; Cheech & Chong 80 s early 90 s: crack epidemic; downturn in use of all illicit drugs 1996 current: resumption of push for legalization; MJ as medicine (Compassionate Use Act); despite federal law, more than half states have pro-mj laws

Support for Marijuana Legalization in the United States Has Reached Unprecedented Levels Sources: Gallup http://bit.ly/olrseq and GSS

Marijuana and Legalization, Nov., 2016 Total # of pro-mj states: 29 and D.C. Recreational use: 8 Medical use only: 21 and D.C. Decriminalized only: 5

3c. Historical Perspective: Media is Impacting Current Perceptions

How did we get here? MJ has long-standing status in the drug culture Nature of the drug Civil liberties Free market capitalism Health benefits Political climate

3d. Historical Perspective: Legalization & Gambling Among the 8 recreational-medical legal states 7 (89%) have casino (VLT) gaming 8 (100%) have lotteries Among the 21 medical-only states 18 (86%) have casino (VLT) gaming 21 (100%) have lotteries

Marijuana from 10,000 Feet Effects of Marijuana on Cognitive Functioning & Gambling Behavior

Representative Studies of Marijuana s Effects on Cognitive Functioning MJ Impairs? MJ Enhances? Learning Memory Attention Perception of Time Meier Grant Schreiner Schoener Grant Schreiner Schoener Crystal Risk Taking Crean Miles Decision Making Crean Whitlow Hermann Verdejo Vadham

Effects of Marijuana Use on Cognitive Functions Literature Reviews 1.Canadian Psychiatric Association Regular cannabis use in youth and young adults can affect aspects of cognition, including attention, memory, processing speed, visuospatial functioning and overall intelligence. Worse performance is related to earlier adolescent onset of use. Abstinence following regular use may improve some, but not all, of these cognitive domains.

Effects of Marijuana Use on Cognitive Functions Literature Reviews 2.Volkow et al., 2016 Cannabis use causes acute impairment of learning and memory, attention, and working memory. These impairments may persist if early of age of onset and frequency and duration is over an extended period. 3.Schuster et al., in press Converging cross-sectional data suggestive that MJ affects multiple cognitive systems; longitudinal data inconclusive

Effects of Marijuana Use on Learning Meier et al., 2012

Effects of Marijuana Use on Memory Conclusions from two meta-analyses (Grant et al. 2003; Schreiner et al., 2012) and literature review (Schoeler & Bhattacharyya, 2013) 1. Non-intoxicated MJ users show significant impairment of short-term verbal memory and working memory compared to nonusers. Even a single dose can impair memory. 2. Effects likely related to potency of THC. 3. Prolonged abstinence may restore these functions. 4. Yet heavy, chronic and early onset use may be linked to enduring impairments.

Working Memory and Gambling Working memory = system for temporarily storing and managing the information required to carry out complex cognitive tasks such as learning, reasoning, and comprehension. Gambling behavior often requires heavy lifting of working memory

Effects of Marijuana Use on Attention Several reviews: 1. Non-intoxicated marijuana users typically perform significantly worse on measures of attention compared to nonusers. 2. Elements of attention are negatively affected: difficulty concentrating, slowed reaction time, and altered peripheral vision. 3. Like memory functioning, prolonged abstinence may restore functioning. But long-term users may not show attention deficits

Effects of Marijuana Use on Time Crystal et al., 2003 A decline in sensitivity to time Disrupts ability to maintain attention

Effects of Marijuana Use on Risk Taking Crean et al., 2011: Short-term effect: MJ use promotes more impulsive behavior and less inhibition of maladaptive responses Miles et al., 2001: Twin study: History of MJ use and risk taking are positively associated Why? MJ use may increase tolerance of the negative effects of risk taking (e.g., easier to ignore problems linked to PG)

Effects of Marijuana Use on Decision Making Deleterious effect on decision making. 1. Impairs many facets of learning (e.g., memory, attention) 2. May contribute to amotivational syndrome (disrupts rewardbased learning) 3. May contribute to risk taking

Why Does Marijuana Affect Cognitive Functions? Marijuana produces overactivation and nonsynchronization of the numerous cannabinoid receptors The noise volume dials are turned-up Disjointed noise across multiple brain regions..................................................................................................................................................

Learning Memory Attention Perception of Time Risk Taking Decision Making MJ Impairs? Meier Grant Schreiner Schoener Grant Schreiner Schoener Crystal Crean Whitlow Hermann Verdejo Vadham MJ Enhances? Crean Miles Does Marijuana Impact Gambling Behavior? Likely in two ways: 1. Impairs multiple areas of cognitive functioning 2. Increases risk taking

Learning MJ Impairs? Meier MJ Enhances? Attempting spending limits? Attempting behavior limits? Memory Grant Schreiner Schoener Prone to gambler s fallacy? Attention Grant Schreiner Schoener Counting cards? Perception of Time Crystal Playing basic strategy? Risk Taking Decision Making Crean Whitlow Hermann Verdejo Vadham Crean Miles Processing odds (sports/parimutuel betting)?

Marijuana from 10,000 Feet Effects of Marijuana on Cognitive Functioning & Gambling Behavior Clinical Implications for the PG Treatment Field

Clinical Issues 1. No reason to suspend the standard clinic view that recovering from a gambling problem should include a drug-free lifestyle.

Myth 1: Marijuana is Not Addictive From Smart Approaches to Marijuana (https://learnaboutsam.org)

All DSM Systems Have Included Cannabis Use Disorder (CUD) DSM-5 symptoms for CUD are identical to other substances. Perhaps a more complicated pattern of tolerance and withdrawal symptoms with marijuana than with many other substances. From Smart Approaches to Marijuana (https://learnaboutsam.org)

Cannabis is Addictive Animal research (Chen et al., 1990) MJ is self-administered significantly increases dopamine levels in NA THC shows rewarding properties More THC and younger onset = greater likelihood of addiction Source: Tyler Oesterle, MD

Myth 2: Smoked or Eaten Marijuana is Medicine From Smart Approaches to Marijuana (https://learnaboutsam.org)

THC and CBD THC (psychoactive) As medicine? Increase appetite and reduce nausea Perhaps decrease pain, inflammation Cannabidiol (CBD) (not psychoactive) As medicine? Reduce pain, inflammation Control epileptic seizures

Marijuana-Based Medicines Cannabidiol (CBD): a presumed medicine in the plant, not psychoactive Sativex is in the process of being studied in the USA; has both CBD and THC. Administered via an oral mouth spray Already approved in Canada and Europe Epidiolex is pure CBD, no THC. Many non-smoking options. From Smart Approaches to Marijuana (https://learnaboutsam.org)

Myth 3: Marijuana is Harmless From Smart Approaches to Marijuana (https://learnaboutsam.org)

Marijuana is Associated with Negative Health Effects Strong evidence linking marijuana use to mental illness diminished cognitive functioning impaired driving lung cancer diminished life satisfaction Marijuana most certainly has a deleterious effect on gambling behavior. From Smart Approaches to Marijuana (https://learnaboutsam.org)

Myth 4: Abstaining Will Not Restore Cognitive Functioning

Restoration is Possible But Variable Some indications that abstaining from marijuana can reverse its negative effects. But do not over-promise full restoration. Cheech and Chong today

Clinical Issues 1. No reason to suspend the standard clinic view that recovering from a gambling problem should include a drug-free lifestyle. 2. Facts vs myths concerning marijuana. 3. How to deal with a client who is legally using medical marijuana? A legitimate CBD-based medicine is not addictive But some medical marijuana products contain THC

Marijuana from 10,000 Feet Effects of Marijuana on Cognitive Functioning & Gambling Behavior Policy Implications for Casinos Clinical Implications for the PG Treatment Field

Policy Implications for Casinos 1. In pro-marijuana states, casino industry is abiding by the federal view that marijuana is illegal. Why tempt fate given the Attorney General Session s get tough stance? looming Supreme Court ruling on the issue of sports betting?

Policy Implications for Casinos 1. In pro-marijuana states, so far the casino industry is abiding by the federal view that marijuana is illegal. 2. Will Las Vegas casinos host cannabis industry events? Jenny Kane; 9/20/17 Nevada's gaming industry might be cashing in on marijuana despite the industry's concerns. Governor Brian Sandoval announced Wednesday morning that he signed an executive order directing the state's Gaming Policy Committee to discuss and recommend policy on how casinos should work with marijuana businesses. Gaming regulators have been clear on the prohibition of marijuana consumption on licensed gaming properties, but there are additional policy considerations such as industry events and business relationships that should be contemplated, Sandoval said. The 12-member committee, which Sandoval is a member of, will discuss whether gaming establishments can exchange money with marijuana businesses and whether they can host events that promote the sale, cultivation or distribution of marijuana.

Policy Implications for Casinos 1. In pro-marijuana states, the casino industry is abiding by the federal view that marijuana is illegal. 2. Will Las Vegas casinos host marijuana-industry conventions? 3. Detecting customers and employees who are intoxicated on marijuana is difficult.

Policy Implications for Casinos 1. In pro-marijuana states, the casino industry is abiding by the federal view that marijuana is illegal. 2. Will Las Vegas casinos host marijuana-industry conventions? 3. Detecting a customer who is overly-intoxicated on marijuana is difficult. 4. Tribal casinos The DOJ federal marijuana policy applies to tribal reservations

Marijuana from 10,000 Feet Summary Effects of Marijuana on Cognitive Functioning & Gambling Behavior Policy Implications for Casinos Clinical Implications for the PG Treatment Field

1. Marijuana is an addictive drug associated with numerous short-term and long-term negative health effects. 2. Growing body of evidence supports the position that marijuana impairs cognitive functioning and increases risk taking tendencies, both of which may contribute to unsafe gambling behaviors.

3. Issues about marijuana use should be addressed in clinic settings. 4. Casino industry should develop marijuana policies for employees and patrons. Marijuana-free venue? Stay clear of hosting cannabis industry events?

THANK YOU winte001@umn.edu Questions and Discussion