Legalizing Marijuana: Lessons Learned? Elizabeth Libby Stuyt, MD University of Colorado, Department of Psychiatry Medical Director, Circle Program Colorado Mental Health Institute at Pueblo President NADA USA Cleveland, Ohio October 2,2015
The Problem is: We tend to not learn from our history
History of Marijuana 6000 BC Cannabis seeds used as food in China 4000 BC Textiles made of hemp in China 2727 BC first recorded medicinal use in Chinese Pharmacopoeia 1400 BC to AD trade moves product through India, Mediterranean countries, Europe numerous medicinal uses reported
History of Marijuana interesting facts 1378 Emir of the Ottoman Empire makes the first edict against eating hashish or smoking cannabis 1 st War on Drugs 1890 Hashish was made illegal in Turkey
History of Marijuana more interesting facts 1798 Napoleon declared total prohibition on marijuana after realizing much of the Egyptian lower class were habitual smokers 1868 Egypt 1st modern country to outlaw cannabis ingestion Emir of Egypt makes cannabis possession a capital offense
History of Marijuana - continued Introduced to North America in 1600s by Puritans Hemp for ropes, sails, clothing; cannabis a common ingredient in medicines, sold openly in pharmacies 1937 Marijuana Tax Act transfer of cannabis illegal throughout US except for medicinal and industrial use, expensive excise tax and detailed logs required 1969 found to be unconstitutional since it violated 5 th Amendment privilege against selfrecrimination
History continued 1970 Controlled Substance Act classified cannabis as having: High abuse potential No medical use Not safe to use under medical supervision 1975 FDA establishes Compassionate Use Program for Medical Marijuana Glaucoma, Multiple Sclerosis, Cancer However, compassionate use was not based on any research
Compassionate Use not based on any research Ex: Glaucoma - although IOP can be reduced by using cannabinoids and marijuana, the effect is too short lived and requires too high doses You would have to smoke 10-12 joints per 24 hours to maintain low IOP through out the day similar to the effect of current medications utilized for Glaucoma
November 2000 Colorado History Coloradoans passed Amendment 20 (54% for, 46% against) Colorado Department of Public Health and Environment was tasked with implementing and administrating the Medical Marijuana Registry program March 2001 Colorado Board of Health approved rules and regulations June 2001 Registry began accepting applications for Registry Identification Cards.
The Flood Gates Opened in February 2009 Obama administration indicated that Medical Marijuana prosecution would have low priority October 2009 Obama administration will not seek to arrest medical marijuana users and suppliers as long as they conform to state laws Applications increased dramatically September 2009 3,523 applications received/month December 2009 10,585 applications received/month
Storefront Medical Marijuana dispensaries sprouted like weeds!
Marijuana Growers Caregivers Legal Doctors making recommendations ($$$$) Grow Lights Vaporizers Pipes Edibles Advertising (Westword has gone green ) Festivals Delivery Services
September 30, 2009 July 31, 2015 19,691 new patient applications received 17,356 patients with valid ID cards 73% male, average age 40, 8 minors <18 57% in the Denver/metro area 67% have designated primary care-giver Over 800 different physicians have signed for patients in Colorado 304,858 new patient applications received 113,862 patients with Valid ID cards 65% male, average age 4, 424 minors <18 55% in the Denver/metro area 30% have designated primary care-giver 226 different physicians have signed for patients in Colorado during this month
Problems with the physicians In the fall of 2009 @ 900 doctors had written approval letters (7% of licensed MDs) 15 doctors 72% of forms 5 doctors 50 % of forms One doctor signed 3,500 in a two day period
Senate Bill 109-2010 Defines a bona fide relationship Physician must have an unrestricted medical and DEA license Addresses physician conflict of interest physician can not be employed by the dispensary Allows CMB to examine care of providers Two physicians need to independently examine those < 21.
Conditions (July 31, 2015) Condition # of Patients Percentage Cachexia 1,002 <1% Cancer 4051 4% Glaucoma 1,291 1% HIV/AIDS 661 <1% Muscle Spasms 20,362 18% Seizures 2,655 2% Severe Pain 106,051 93% Severe Nausea 12,488 11%
A New Meaning to: Rocky Mountain High Amendment 64 first state to legalize recreational marijuana Passed in 2012 by 55% of voters Doors opened January 1, 2013 Marijuana tourism is booming in Colorado Edibles account for 45% of the legal marijuana market
Colorado ranks 2nd in the nation for regular marijuana use.
Malignant versus Non-malignant While there definitely could be a place for Medical Marijuana when people are suffering with terminal conditions (ex: cancer, HIV) Cachexia appetite stimulant Nausea secondary to chemotherapy Pain mild improvement There are oral pharmaceutical preparations of THC which can eliminate the risks from smoking Neither opioid medications nor medical marijuana are the answer for chronic, nonmalignant pain
The average person does not have enough education about the downsides of marijuana Many people may have voted for medical marijuana truly believing this would be good for people who have severe medical problems Many people may have voted for recreational marijuana because they wanted to see it decriminalized and they truly thought it was safe
The safer, greener alternative For some adults with no mental illness and no problems with addiction issues marijuana effects can be similar to alcohol For babies, as in pregnant mothers and children and adolescents. marijuana is absolutely not safe In some adults its use can cause or worsen mental illness and lead to addiction and is therefore not safe for them
As a result of proceeding to legalize a substance that we really know very little about and did not prepare for adequately, there have been many UNINTENDED CONSEQUENCES
Legal Consequences Crime due to marijuana has not gone away - We still have illegal pot and legal weed costs 3 times as much as black-market weed January 2015 big bust in Denver illegal grow facility with hash oil extraction lab and 500 marijuana plants and 50#s of packaged pot February 2015 bust in Avondale man exceeded his legal limit of 75 plants 600 plants and 100#s of pot seized, no license as a caregiver
Legal Consequences September 2015 Federal Drug Bust Cotopaxi seized 1,000 plants and 20 indictments, mostly Cubans, planning to ship it to Cuba September 2015 11,700 plants, San Isabel National Forest Illegal grow sites found also in Routt National Forest, Pike National Forest
Legal Consequences Mexican cartels still active, increase in heroin availability in the state May 2015 - Governor Hickenlooper signed a law allowing people on probation and parole to use marijuana for medical purposes Nebraska and Oklahoma (neighboring states) are suing the State of Colorado seeking to kill Colorado s legalization law
Tax Revenues not nearly as high as anticipated In 2014 Gov Hickenlooper thought legal marijuana tax revenues would reach $134 million February 2015 only about $44 million TABOR - requires that new voter approved taxes be refunded if overall state collections rise faster than permitted Colorado is not rolling in the dough
Medical Consequences We can no longer say marijuana is not associated with death April 2014 Wyoming college student jumped to his death from a Denver hotel balcony after eating more than the recommended serving of a marijuana cookie April 2014 Man shot and killed his wife in front of their three children after consuming edibles Sept 2012 18 yo male smoked marijuana and then stabbed himself 20 times THC 38.2 ng (8 times the legal limit)
Medical Consequences Multiple children have been treated in hospitals after becoming critically ill from edible marijuana Marijuana-related calls to poison-control centers have spiked Rocky Mountain Poison and Drug Center received calls for marijuana exposure 61 in 2012 88 in 2013 151 in 2014 45 were age 8 or younger
Medical Consequences Assumption that there would be less medical marijuana users not true Number of red cards (MMJ cards) has increased somewhat Medical pot more lightly taxed and therefore 40% cheaper than recreational Pueblo May 15, 2015 One ounce medical marijuana = $175 One ounce recreation marijuana = $195
Attempts to add PTSD A growing number of states have identified PTSD as an approved condition Observational study of 2276 Veterans treated in VA PTSD treatment programs Never used marijuana significantly lower symptom severity 4 months later Starters highest levels of violent behavior and PTSD symptoms 4 months after treatment Stoppers lowest level of PTSD symptoms at 4 months after treatment Presented at AAAP meeting December 2014
Rocky Mountain High Intensity Drug Trafficking Area September 2015 report www.rmbidta.org Changes since 2014 Traffic Deaths 32% increase in marijuana related traffic deaths Driving under the influence - +THC increased 45% ER visits 29% increase in MJ related ER visits Hospitalizations 38% increase in MJ related hospitalizations
Denver Post/Leafly.com 88 strains for depression 25 for PTSD 40 for ADD/ADHD 23 for Bi-Polar No dosage, duration No screening No instruction for FDA approved meds or counseling
Cannabinergic system Two main cannabis receptors CB1 present throughout CNS Hippocampus Cortex Olfactory areas Basal ganglia Cerebellum Spinal cord CB2 located peripherally, linked with immune system Spleen macrophages
Effects on Developing Brains Impairs cognitive development May lower IQ May precipitate psychosis Endocannabinoid receptors play a role in strengthening and pruning synaptic connections in the prefrontal motor cortex THC exposure may disturb functioning of the endocannabinoid system
Medical Cotton Candy?
Side of a medical retail site Colorado Springs
Marijuana and Mental Illness Study in Australia tracked 1600 girls for 7 years Arseneault et al. BMJ 2002;325:1212 Daily marijuana use 5 times more likely to have depression/anxiety than non-users Increase risk in schizophrenia symptoms prior to 15 Psychosis increased by 40% in people who have used cannabis Cohen et al. Australian New Zealand J Psychiatry 2008;42:357-368 Early Cannabis use associated with psychosis related outcomes in young adults Arch Gen Psych 2010;67 Sibling pair analysis within a prospective birth cohort in Australia 3801 young adults
High Potency Cannabis associated with a tripled risk for Psychosis http://dx.doi.org/10.1016/s2215-0366(14)00117-5 DiForti et al. Lancet Psychiatry, 2015 London analyzed 780 people ages 18-65, 410 with first episode psychosis and 370 healthy controls High potency THC > 15% - 3X increased risk of psychosis Daily use 5X increased risk Psychosis not associated with Hash < 5% THC
Most Potent in the World Law enforcement from neighboring states agree, Colorado has strongest marijuana in the world. By Garrison Wells April 14, 2014 http://gazette.com/law-enforcement-from-neighboring-states-agree-colorado-has-strongestmarijuana-in-the-world/article/1518194#txa0jlqjs0k7wobd.99
THC Potency Nationally THC potency averaged 3.96% in 1995 12.55% in 2013 Colorado THC potency Average of 17.1% Denver has more licensed medical marijuana dispensaries (198) than pharmacies (117)
Marijuana and Cognitive Impairment Use of 4 joints or more per week resulted in a decrement in mental test performance, subjects who smoked regularly for a decade or more did the worst Messinis et al. Neurology 2006;66:737 Long-term marijuana users were impaired 70% of the time on a decision making test, compared to 55% for short-term users and 8% for non-users
Marijuana and Addiction Approximately 10% of regular marijuana users become addicted to it (1 in 6 adolescents) But this is old data, based on marijuana with less THC concentrations Some medicinal marijuana blends, ie Connie Chung strain contain 20 times more THC than marijuana found 40 years ago Marijuana is definitely a gateway drug to relapse to other drugs of addiction
The number of adults in the US with substance use disorders is trending upward and expected to double by the year 2020
Solutions/Recommendations Educate, educate, educate Eliminate medical marijuana and just have recreational marijuana Lobby to get DEA to reclassify marijuana as a schedule II so that research can occur more easily Strong ban on any advertising that appears to be directed toward youth for all drugs including,marijuana, tobacco and alcohol