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Marijuana

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Title: Marijuana


1
Marijuana
  • ADDICTION MEDICINE EDUCATIONAL SERIES WORKBOOK

2
Marijuana
  • STEVEN KIPNIS, MD, FACP, FASAM
  • MEDICAL DIRECTOR
  • OASAS
  • ROBERT KILLAR, CASAC
  • DIRECTOR
  • COUNSELOR ASSISTANCE PROGRAM
  • OASAS
  • KAITLYN PICKFORD, MA
  • FELLOW CENTER FOR WOMEN IN GOVERNMENT AND CIVIL
    SOCIETY
  • GOVERNMENT AFFAIRS OFFICE
  • OASAS

3
FLOWERING PLANTS
  • There are 250,000 350,000 species of flowering
    plants
  • We have tested most of them
  • Medicinal value
  • Poisons
  • Psychoactive
  • Religious ceremonies
  • Magic
  • Initiation into puberty
  • Escape reality
  • Fashionable
  • Social pleasure

4
FLOWERING PLANTS
  • Psychoactive substances are found in various
    parts of the plant
  • Resin
  • Fleshy fruit
  • Stems
  • Leaves
  • Seeds
  • Roots

5
FLOWERING PLANTS
  • Psychoactive substances can be introduced into
    the body by
  • Eating
  • Drinking (teas)
  • Smoking
  • Inhalation
  • Ointments
  • Enemas

6
FLOWERING PLANTS
  • Psychoactive substances are usually members of
    the chemical class
  • Alkaloids
  • Contain nitrogen
  • Many are toxic
  • Some are teratogenic (can interfere with normal
    embryonic development)
  • Indole rings
  • 8 carbon atoms and 1 nitrogen
  • Same structure is seen in serotonin
  • This group may interfere with serotonin in the
    brain

7
CANNABIS FAMILY
  • Cannabaceae contains two genera
  • Cannabis
  • Humulus (hop plant)
  • Resin used as a preservative and as a natural
    flavor in beer

8
CANNABIS
  • Known as cannabis, hashish, hemp and marijuana
  • Source of
  • Strong fiber for rope and paper
  • Nutritious fruit
  • Industrial oil
  • Medicine
  • Cannabis Sativa is a fiber plant
  • Cannabis Indica is a resin plant

9
CANNABIS
  • Male and female plants
  • Female plants are better resin producers
  • If female plant is not allowed to be fertilized,
    it flowers but does not produce seeds
    sinsemilla (spanish for without seeds)
  • Greatest resin producers

10
CANNABIS
  • Resin contains
  • Hallucinogenic compounds called cannabinoids
  • Delta-1 Tetrahydrocannabinol, also known as
  • Delta-1-THC
  • THC
  • Major active compound in the cannabis plant

11
CANNABIS
  • How is it used?
  • Leaves and flowering tips are dried
  • Smoked
  • Consumed as tea
  • Mixed into food
  • Resin from flowering heads
  • Smoked
  • Mixed with tobacco
  • Alcohol extract (cannabis oil) is mixed with
    tobacco and smoked

12
CANNABIS HISTORY
  • 4,000 BC - used as a medicine
  • Rheumatism loss of yin (female energy)
  • 2,700 BC - Chinese emperor said liberator of sin
    - good for female weakness, gout, rheumatism,
    malaria, beri beri, constipation and
    absent-mindedness

13
CANNABIS HISTORY
  • 1,400 BC - in India used to treat anxiety
  • Bhang (drink from leaves)
  • Ganja (dried resin)
  • 1,200 BC - found in a Chinese burial site, also
    used for bow strings and paper (mixed with
    mulberry bark)

14
CANNABIS HISTORY
  • First century AD
  • Chinese use it to treat constipation, malaria and
    absent-mindedness
  • Greeks use it to treat earaches and as a
    pleasurable dessert made from the seeds
  • Indian physicians used it for treatment of fever,
    insomnia, appetite stimulation, headaches and
    sexually transmitted diseases

15
CANNABIS HISTORY
  • 200 A.D. Chinese use it as anesthesia for
    operations
  • 13th century, Marco Polo learned of a band of
    thugs in Iran whose leader controlled his
    followers using hashish. These murderers were
    called hashishins which was modified to assassins
    later on.

16
CANNABIS HISTORY
  • Folk medicine in Europe
  • Germany - to treat seizures, aid in childbirth
  • Poland - for toothache (seeds put on hot stones
    and vapors inhaled)
  • Czechoslovakia - to treat fever
  • Russia - to treat jaundice
  • Serbia - as an aphrodisiac

17
CANNABIS HISTORY
  • Pilgrims grew it for fiber ropes and clothing
  • 1843 U.S. Medical text, treatment for
  • Gout
  • Tetanus
  • Hysteria
  • Depression
  • Insanity
  • Dysentery

18
CANNABIS HISTORY
  • Sumo wrestler with hemp belt which is part
    of the ritual to cleanse the ring prior to a match

19
CANNABIS HISTORY
  • 1850 listed in US pharmacopoeia
  • Abolished use in 1937 Marijuana Tax Act
  • 1951 Boggs Act
  • Increased penalties for marijuana use because it
    was thought to lead to heroin addiction
  • 1956 Narcotics Act
  • Imposed mandatory prison sentences for cannabis
    possession
  • 1965 THC first isolated

20
CANNABIS HISTORY
  • 2003 - 75 million people in the US have tried
    marijuana at least once (34 of population)
  • DAWN data of emergency room visits show
    marijuana is number 1, alcohol number 2 and
    cocaine number 3
  • New hydroponically grown marijuana with increased
    THC levels
  • Age of onset of use declining from 16 year old to
    13.6 year olds
  • Brain is still not completely developed

The Drug Abuse Warning Network (DAWN) is a
public health surveillance system that monitors
drug-related hospital emergency department visits
and drug-related deaths to track the impact of
drug use, misuse and abuse in the U.S.
21
ER VISITS VS. POTENCYCAUSE AND EFFECT?
22
CANNABINOIDS
  • 60 cannabinoids have been isolated from the
    hemp plant and there are naturally occurring
    cannabinoids in most species called
    endocannabinoids, in a similar fashion as
    endorphins (opiates) have been found.

23
CANNABINOIDS
  • There are two main receptors for cannabinoids in
    humans
  • CB1(in brain) if stimulated produces
  • Euphoria
  • Impaired short term memory and sense of time
  • CB2 (in spleen, peripheral sites) if stimulated
    produces
  • Immunosuppressant activity
  • Not psychoactive

24
CANNABINOIDS
  • Receptors have also been found in the
  • Cerebellum body movement and coordination
  • Cortex higher cognitive functions
  • Nucleus accumbens reward
  • Basal ganglia movement control
  • Hypothalamus body temperature, salt and water
    balance, reproductive functions
  • Amygdala emotional responses, fear

25
CANNABINOIDS
  • Receptors have been found in the hippocampus - an
    area that controls food intake
  • Works through leptin system a peptide that
    controls satiety
  • A defect in the leptin or endocannabinoid system
    may lead to obesity

26
SPECT SCANHEATHLY SURFACE VIEWS
TOP DOWN VIEW
UNDERSIDE VIEW
27
SPECT SCANTHC Abuse
A SPECT scan showing the underside of the brain
with area that is showing no activity
28
CANNABINOIDS
  • Cannabis use in the adolescent is highly
    correlated with subsequent alcohol use.

29
PREPARATION OF CANNABIS
  • Marijuana
  • Not a single drug but a complex mixture of over
    400 chemicals
  • Dried flowering tops and leaves of the plant
  • THC concentration 0.5 - 5 in the past, now up
    to 20 25

Dried cannabis buds
30
PREPARATION OF CANNABIS
  • Hashish dried cannabis resin and flowers
  • THC concentration, 2 - 8 or higher

Pieces of Hash
31
PREPARATION OF CANNABIS
  • Hash oil extraction of THC from hashish with an
    organic solvent
  • THC concentration 15 - 50

32
CANNABIS
  • Routes of marijuana administration
  • Joints
  • Average is 500 mg of marijuana
  • inside of rolling papers
  • 20 - 50 of the THC makes it into the
    bloodstream
  • Blunts (marijuana in hollowed out cigar)
  • 6 times the amount of marijuana
  • 20 of the THC makes it into the bloodstream

33
CANNABIS
  • Routes of marijuana administration
  • Pipes
  • Stone, ceramic or glass
  • 50 of the THC makes it into the bloodstream
  • Water pipes
  • Bongs most efficient
  • 90 of the THC makes it into the bloodstream

34
PREPARATION OF CANNABIS
  • Fry / fry sticks / wets / wac
  • Marijuana soaked in embalming fluid or
    formaldehyde
  • In NYC, it has been reported that marijuana has
    been cooked in butter and spread on toast

35
CANNABIS KINETICS
  • THC
  • Noncrystalline
  • Waxy liquid at room temperature
  • (-) Trans-isomer is 6 to 100 times more potent
    than () trans-isomer
  • Psychoactive effect when bound to CB1 receptor

36
CANNABIS KINETICS
  • THC mechanism of action
  • Peripheral and central effect
  • Low dose
  • Mixture of depression and stimulation
  • High dose
  • CNS depression

37
CANNABIS KINETICS
  • Typical joint
  • 0.5 - 1 gram cannabis
  • THC concentration 5 - 150mg
  • 20 to 70 of THC is delivered in the smoke
  • 2 - 3 mg THC can produce a brief high
  • Lipid soluble so deposited into fat tissue

38
CANNABIS KINETICS
  • 80 probable biologically inactive metabolites of
    THC
  • 11-hydroxy - THC is the primary active metabolite
  • THC is eliminated in the feces and 33 in the
    urine

39
CANNABIS KINETICS
  • Oral use
  • Psychoactive effects slowed to about one hour
  • Absorption is erratic
  • High is less intense, but lasts longer than if
    smoked
  • IV use
  • Water insoluble so cannot be injected

40
CANNABIS KINETICS
  • SMOKING three cannabis joints will cause you to
    inhale the same amount of toxic chemicals as a
    whole packet of cigarettes.
  • The French Consumer Institute tested regular
    Marlboro cigarettes alongside 280 specially
    rolled joints of cannabis leaves and resin in an
    artificial smoking machine.
  • The tests examined the content of the smoke for
    tar and carbon monoxide, as well as for the toxic
    chemicals nicotine, benzene and toluene.
  • Cannabis smoke contains seven times more tar and
    carbon monoxide.
  • Someone smoking a joint of cannabis resin rolled
    with tobacco will inhale twice the amount of
    benzene and three times as much toluene as if
    they were smoking a regular cigarette, the study
    said.

41
CANNABINOIDS
  • Desired effects of the user
  • Sense of well being
  • Relaxation
  • Euphoria
  • Modified level of consciousness
  • Altered perceptions
  • Intensified sensory experiences
  • Altered time sense
  • Sexual disinhibition

42
PHARMACOLOGIC ACTIONS
  • Psychomotor effects
  • Behavioral effects
  • Cognitive effects

43
PHARMACOLOGIC ACTIONS
  • Psychomotor effects
  • Object distance distortion
  • Object outlines distorted
  • Inability to make rapid judgment
  • Slowed reaction time
  • Impaired tracking behavior
  • Slowed time perception
  • All are dose-related

44

PHARMACOLOGIC ACTIONS

Cannabis and Motor Function fMRI Changes
Following 28 Days of Discontinuation
  • The authors hypothesized that supplementary motor
    cortex (SMA) and anterior cingulate cortex (ACC)
    activation in chronic cannabis users, studied 4
    to 36 hours after their last episode of use,
    would disappear by Day 28 of abstinence during
    finger-tapping tests.
  • The results suggest that residual diminished
    brain activation is still observed 28 days after
    discontinuing cannabis use in motor cortical
    circuits.
  • Source Experimental and Clinical
    Psychopharmacology Volume 16, Issue, Feb. 2008,
    Pages 22-32.

45
PHARMACOLOGIC ACTIONS
  • Behavioral effects
  • Amotivational Syndrome
  • Little scientific evidence for the existence of
    this
  • Tolerance to marijuana was supposed to be a
    manifestation of desensitization of brain cells,
    and in addition to contributing to the supposed
    dependence liability this desensitization of
    brain cells was supposed to create an
    amotivational syndrome characterized by apathy
    and inactivity.
  • The hypothesis was that this desensitization
    would impede normal brain operations and render
    individuals somewhat sluggish and unmotivated.
    The hypothesis has been challenged on both
    behavioral and pharmacological grounds.

46
PHARMACOLOGIC ACTIONS
  • Increased focus on taste
  • Increased appetite (street slang - munchies)
  • Dry mouth

47
PHARMACOLOGIC ACTIONS
  • Cognitive effects may be due to a reduction in
    blood flow to the brain - seen even 30 days after
    last use in heavy smokers. (A study in February
    2005 found increase blood flow indicative of
    narrowed arteries much like those seen in
    hypertension.)
  • Impaired short-term memory
  • Especially verbal IQ
  • Impaired attention
  • Impaired integration of complex information
  • Chronic marijuana user College was the best 6
    years of my life.

48
PHARMACOLOGIC ACTIONS
  • Psychomotor effects
  • Behavioral effects
  • Cognitive effects
  • Evidence of brain damage is equivocal in the
    chronic user

49
PHARMACOLOGIC ACTIONS
  • British Medical Journal 2006
  • 2.9 prevalence of cannabis in the driving
    population
  • 2.5 of fatal crashes
  • 2.7 prevalence of alcohol in a similar
    population
  • 28.6 of fatal crashes

50
TEEN USE
  • University of Marylands center for substance
    abuse research published in Sept 2004
  • Warning signs of teen use ( 34,000 6th, 8th, 10th
    and 12th graders)
  • Use of cigarettes and alcohol before age 15
  • Arrests for alcohol and other drugs
  • 20 or more unexcused absences from school
  • Attitude that smoking cigarettes and marijuana is
    safe

51
Effects of Exposure During Pregnancy
  • Research has shown that some babies born to women
    who abused marijuana during their pregnancies
    display altered responses to visual stimuli,
    increased tremulousness, and a high-pitched cry,
    which may indicate neurological problems in
    development.
  • During the preschool years, marijuana-exposed
    children have been observed to perform tasks
    involving sustained attention and memory more
    poorly than nonexposed children do. In the
    school years, these children are more likely to
    exhibit deficits in problem-solving skills,
    memory, and the ability to remain attentive.
  • Fried PA, Makin JE. Neonatal behavioral
    correlates of prenatal exposure to marihuana,
    cigarettes and alcohol in a low risk population.
    Neurotoxicology and Teratology 9(1)17, 1987.
  • Lester BM, Dreher M. Effects of marijuana use
    during pregnancy on newborn crying. Child
    Development 60(23/24)764771, 1989.
  • Fried PA. The Ottawa prenatal prospective study
    (OPPS) Methodological issues and findings. Its
    easy to throw the baby out with the bath water.
    Life Sciences 56(2324)21592168, 1995.
  • Fried PA, Smith AM. A literature review of the
    consequences of prenatal marihuana exposure An
    emerging theme of a deficiency in aspects of
    executive function. Neurotoxicology and
    Teratology 23(1)111, 2001.

52
ADDICTION LIABILITY
  • 9 of those who ever used become dependent
  • Dependence associated with gradual increase in
    use
  • No scientific evidence that it is a gateway
    drug
  • Study by Royal Childrens Hospital Center in
    August 2004 showed that teenagers who smoked
    cannabis daily for at least a month are 4 times
    more likely to become addicted to nicotine by the
    time they reach their 20s.
  • Reverse directionality cannabis ? tobacco ?
    alcohol ? drugs and not tobacco ? alcohol ?
    cannabis ? drugs

53
ADDICTION LIABILITY
  • Withdrawal difficult to demonstrate
  • 10 hour onset and 5 day duration
  • Anxiety
  • Mental clouding
  • Insomnia
  • Anorexia
  • Irritability
  • Tremor
  • Depression
  • Headache
  • Craving
  • Very similar to nicotine withdrawal, except there
    is weight loss in marijuana and weight gain in
    nicotine withdrawal

54
ADDICTION LIABILITY
  • Withdrawal may be due to the release of
    corticotropin releasing factor (CRF) in the
    amygdala
  • Similar release in opiate, alcohol and cocaine
    withdrawal
  • 71 of marijuana users relapse to marijuana use
    within 6 months after achieving initial 2 weeks
    of abstinence

55
Cannabis Use and Later Life Outcomes
  • Research to examine the associations between the
    extent of cannabis use during adolescence and
    young adulthood and later education, economic,
    employment, relationship satisfaction and life
    satisfaction outcomes.
  • A longitudinal study of a New Zealand birth
    cohort studied to age 25 years.
  • Measures of cannabis use at ages 14-25
    university degree attainment to age 25 income at
    age 25 welfare dependence during the period
    21-25 years unemployment 21-25 years
    relationship quality life satisfaction. Also,
    measures of childhood socio-economic
    disadvantage, family adversity, childhood and
    early adolescent behavioral adjustment and
    cognitive ability and adolescent and young adult
    mental health and substance use.

56
Cannabis Use and Later Life Outcomes
  • There were statistically significant bivariate
    associations between increasing levels of
    cannabis use at ages 14-21 and lower levels of
    degree attainment by age 25 (P?income at age 25 (P?welfare dependence (P?unemployment (P?relationship satisfaction (P?levels of life satisfaction (P?associations were adjusted for a range of
    potentially confounding factors including family
    socio-economic background family functioning
    exposure to child abuse childhood and adolescent
    adjustment early adolescent academic
    achievement and comorbid mental disorders and
    substance use. After adjustment, the associations
    between increasing cannabis use and all outcome
    measures remained statistically significant
    (P?

57
Cannabis Use and Later Life Outcomes
  • The results of the present study suggest that
    increasing cannabis use in late adolescence and
    early adulthood is associated with a range of
    adverse outcomes in later life. High levels of
    cannabis use are related to poorer educational
    outcomes, lower income, greater welfare
    dependence and unemployment and lower
    relationship and life satisfaction. The findings
    add to a growing body of knowledge regarding the
    adverse consequences of heavy cannabis use.
  • Source Fergusson, David M. Boden, Joseph M.
    Addiction Volume 103, Number 6, June 2008 , pp.
    969-976(8).

58
TOXICITY AND ADVERSE EFFECTS
  • Mental health issues have been seen to co-occur
    in users.
  • Transient panic and anxiety
  • Depersonalization
  • Bizarre behavior
  • Delusions
  • Hallucinations
  • Acute mania
  • Acute paranoia
  • Depression (possibly)
  • Psychosis (possibly)
  • Aggression

59
TOXICITY AND ADVERSE EFFECTS
  • MENTAL HEALTH ISSUES
  • Depression?
  • Mixed evidence from a variety of research studies
  • Degenhardt et al in a longitudinal study
    concluded that regular cannabis use and
    depression co-occur more often than would be
    expected by chance.
  • Psychosis?
  • Inconclusive research
  • Arseneault et al concluded that heavy cannabis
    use (regular and long-term) contributes as one of
    many factors, forming a causal constellation of
    factors including psychological vulnerability and
    genetics.

60
TOXICITY AND ADVERSE EFFECTS
  • MENTAL HEALTH ISSUES
  • Psychosis?
  • 2005 research in Biological Psychiatry described
    a common gene (comt) that makes cannabis five
    times more likely to trigger schizophrenia.
  • Comt plays a part in the production of dopamine
  • 25 of the population have this gene
  • 15 of this group are likely to develop psychotic
    conditions if exposed to cannabis early in life
  • The self medication hypothesis has been
    discounted
  • Aggression
  • Using is associated with decrease aggression
    unless taken in periods of high stress

61
TOXICITY AND ADVERSE EFFECTS
  • IMMUNE SYSTEM
  • CB2 receptors on immune system cells immune
    modulation
  • Decrease macrophage function
  • Decrease killer cell function
  • Increase in HIV - 1 host infections
  • Randomized, placebo controlled study in Annals
    2003 no increase in HIV RNA or protease
    inhibitor levels in 21 day trial of oral and
    smoked cannabinoids

62
TOXICITY AND ADVERSE EFFECTS
  • CARDIOVASCULAR SYSTEM
  • Increase heart rate
  • Marijuana alone 29-36 beat/min increase
  • Marijuana cocaine 49 beat/min increase
  • Decrease blood pressure
  • Increase myocardial infarction risk
  • PULMONARY
  • Tracheitis (inflammation of the trachea)
  • 3 cannabis cigarettes 20 tobacco cigarettes
    with significantly more carcinogens

63
TOXICITY AND ADVERSE EFFECTS
  • REPRODUCTIVE / ENDOCRINE SYSTEM
  • Alters pituitary hormones
  • Decreases prolactin (a pituitary hormone that
    stimulates lactation after childbirth)
  • Decreases growth hormone
  • Decreases luteinizing hormone
  • Galacctorhea (the production of breast milk in
    men - or in women who are not breastfeeding)
  • Decrease testosterone in males
  • Decrease sperm production
  • Decrease sperm motility

64
TOXICITY AND ADVERSE EFFECTS
  • MISCELLANEOUS
  • Questionable effect on fetus probably due to
    polypharmacy (use of multiple medications)
  • Decrease effectiveness of SSRI anti-depressants
  • Increase drowsiness if used with tricyclic
    antidepressants
  • Heavy sedation if used with benzodiazepines
  • Alcohol toxicity causes vomiting due to an
    increase in acetaldehyde. Marijuana anti-emetic
    effect can suppress the chemo-trigger point and
    lead to severe alcohol toxicity
  • Multiple cavities in youth?
  • Dry mouth and eating sweets?
  • Lethal doses of marijuana are not known

65
MEDICAL USES
  • Difficult to determine doses if smoked
  • Significant adverse effects associated with any
    smoked medication, especially if to be used in a
    hospital setting

66
MEDICAL USES
  • Relieve nausea
  • Most trials used dronabinol and not smoked
    marijuana however, in trials that compared the
    two, dronabinol was more effective.

67
MEDICAL USES
  • The U.S. Food and Drug Administration (FDA) has
    given the green light to Valeant Pharmaceuticals
    International to bring the synthetic cannabinoid
    drug nabilone (Cesamet) back to market after 17
    years. Nabilone is also sold in Canada.
  • The drug, similar to the THC medication, Marinol,
    was originally marketed by Eli Lilly and Co. but
    withdrawn from the market in 1989. It is now
    approved by the FDA for treatment of vomiting and
    nausea caused by chemotherapy and is listed as a
    Schedule II controlled substance.

68
MEDICAL USES
  • Increase appetite
  • Dronabinol does appear to work
  • No controlled studies in smoked marijuana
  • Smoked and oral form increased weight (fat not
    lean body mass)
  • Annals 2003139258-266
  • Decrease muscle spasm
  • Suggested for multiple sclerosis
  • Anecdotal information
  • Decrease intraocular (eye) pressure
  • Better preparations available for the control of
    intraocular pressure as seen in glaucoma

69
MEDICAL USES
  • Decrease chronic pain
  • Anecdotal
  • NIDA study at University of Arizona (Dr.Malan)
  • Compound am1241
  • Acts on CB2 receptors
  • Pain relief without the central nervous system
    side effects such as sleepiness and anxiety
  • Study done on neuropathic pain

70
MEDICAL USES
  • Anticonvulsant
  • First used in the 1940s for the treatment of
    seizures
  • Better therapeutic agents today
  • University of Saskatchewan (8/2004) showed one
    dose of THC in rats could decrease grand mal
    seizures, but multiple doses lead to an increase
    in convulsions.

71
MEDICAL USES
  • 2004 - Israeli soldiers suffering from combat
    stress were treated with cannabis to relieve
    their symptoms
  • PTSD trials are ongoing
  • August 2004 issue of Cancer Research article by
    Guzman
  • THC may inhibit genes that make protein, vascular
    endothelial growth factor (VEGF)
  • This protein stimulates the growth of blood
    vessels in tumors

72
MEDICAL USES
  • Sativex
  • Whole plant medicinal cannabis extract
  • Produced by Bayer and GW pharmaceuticals and
    approved for use in Canada for multiple sclerosis
    and neuropathic pain (2005)
  • Contains THC and nabidiolex, not delta - THC
  • Phase 3 trials in multiple sclerosis patients
    showed that sublingual spray was safe and
    effective for symptom relief

73
MEDICAL USES
  • Journal of Psychopharmocology 6/05
  • Marijuana may have a benefit in treating bipolar
    disorder
  • Cannabidiol (a cannabinoid found in cannabis) has
    a calming effect
  • THC prevented severe highs and lows

74
MEDICAL USES
  • The main active ingredient in marijuana is more
    effective at blocking an enzyme that causes the
    brain damage common to Alzheimer's disease than
    approved drugs already on the market, according
    to researchers from the Scripps Research
    Institute.
  • low doses of THC inhibits an enzyme that breaks
    down acetylcholine, needed for learning and
    memory.
  • The drug also appears to prevent the formation of
    fibrils, which damage healthy brain tissue.
  • ReferenceEubanks, L.M., et al. (2006) A
    Molecular Link between the Active Component of
    Marijuana and Alzheimer's Disease Pathology.
    Molecular Pharmaceutics

75
MEDICAL USES
  • Bowel study backs cannabis drugs
    Gastroenterology 2005
  • People with inflammatory bowel disease had an
    abundant number of a type of cannabinoid
    receptors in their body.
  • They believe this is part of the body's attempt
    to dampen down the inflammation and that giving a
    drug that binds to these receptors could boost
    this.
  • When people have Crohn's disease or ulcerative
    colitis - collectively known as inflammatory
    bowel disease or IBD - their immune system goes
    into overdrive, producing inflammation in
    different areas of the digestive tract.
  • Both the patients and the healthy people had
    similar numbers of CB1 receptors in their gut.
    However, the IBD patients had far greater numbers
    of CB2 receptors.
  • The normal job of CB1 and CB2 receptors is to
    switch immune responses on or off. CB1 receptors
    also help to promote wound healing in the lining
    of the gut.
  • Potential therapy - very selective
    cannabis-derived treatments may be useful as
    future therapeutic strategies in the treatment of
    Crohn's and ulcerative colitis.
  • More trials are needed

76
MEDICAL USES
  • Overall problems of use
  • Mode of administration
  • No smoking in hospitals
  • No standard dose of smoked marijuana
  • Smoke is hazardous in and of itself
  • Smoking may impair immune system response
  • Difficulty concentrating on complex tasks
  • Slowed reaction times
  • Tolerance develops quickly
  • Effect is 4 - 6 hrs

77
MEDICAL USES
  • Overall problems of use
  • Chronic bronchitis can develop
  • Pharyngitis (inflammation of the pharynx) can
    develop
  • Large airway obstruction can be seen
  • Acute panic reactions can develop
  • Acute paranoia can develop
  • Heart rate increases 20 - 100 for 2 - 3 hrs
  • Decreased blood pressure seen with use

78
MARIJUANA AND THE LAW
  • MEDICAL MARIJUANA FOR PATIENTS WITH A
    DEBILITATING CONDITION
  • OTHER RELATED LAWS
  • US SUPREME COURT CASES
  • FEDERAL GOVERNMENT
  • NEW YORK

79
MARIJUANA AND THE LAW
  • Favorable medical marijuana laws were enacted in
    35 states since 1978 however laws are ineffective
    due to federal governments overarching
    prohibition
  • 5 states have since let their laws expire or they
    have been repealed

80
MARIJUANA AND THE LAW
  • Federal trafficking penalties for 1st offense
  • 1000 kg or not less than 10 yrs
  • 100 to 999 kg not less than 5 yrs or 40 yrs
  • 50 to 100kg or 10kg hash not 20 yrs
  • 5 yrs

81
MARIJUANA AND THE LAW
12 STATES HAVE LEGISLATION JUSTIFYING MARIJUANA
USE FOR MEDICINAL PURPOSES
82
TIMELINE OF MEDICAL MARIJUANA LEGISLATION
California Proposition 215 November 1996
Washington State Ballot Initiative 692 November
1998
Oregon Measure 67 December 1998
Alaska Ballot Measure 8 March 1999
Maine Citizen Initiative Question 2 December 1999
Hawaii Senate Bill 862 December 2000
Colorado General Election Amendment 20 June
2001
Nevada Referendum Question 9 October 2001
Vermont Senate Bill 76 July 2004
Montana Initiative 148 November 2004
Rhode Island Senate Bill 70 January 2006
New Mexico Senate Bill 523 July 2007
83
CALIFORNIACompassionate Use Act
  • 1st state to pass such legislation
  • Limits possession to 8 ounces of usable marijuana
    and 6 mature plants or 12 immature plants
  • Voluntary registry system as of January 08, 36
    counties participated in the registry system and
    18,847 cards were issued

84
WASHINGTONState Ballot Initiative 692
  • Washington State Medical Quality Assurance Board
    determines the list of qualifying debilitating
    conditions
  • No official registry for patients
  • State license and signed notice of a physician
    must be produced upon the request of an officer
    of law

85
OREGON THE OREGON MEDICAL MARIJUANA ACT
  • Must possess an identification card to circumvent
    criminal penalties
  • Possession limited to 6 mature plans and up to 24
    ounces of usable marijuana
  • Must have been diagnosed with debilitating
    condition at least 12 months prior to arrest to
    use medical necessity defense
  • Program overseen by The Advisory Committee on
    Medical Marijuana in the Department of Human
    Services

86
ALASKA MEDICAL MARIJUANA INITIATIVE
  • Possession limited to 1 ounce of usable marijuana
    and 6 plants
  • Mandatory state registry for all patients
  • Identification cards must be renewed annually

87
MAINE CITIZEN INITIATIVE QUESTION 2
  • No patient registry established by law
  • Possession limited to 2 ½ ounces of usable
    marijuana

88
HAWAIISENATE BILL 862
  • The benefits of medical use of marijuana would
    likely outweigh the health risks
  • Patient must have a valid identification card to
    possess marijuana
  • Possession is limited to 1 ounce of usable
    marijuana and 7 plants, 3 of which can be mature

89
COLORADO GENERAL ELECTION AMENDMENT 20
  • Medical Marijuana Registry was implemented by the
    Colorado Department of Public Health and
    Environment
  • If patients do not register with the state, they
    may argue an affirmative defense of medical
    necessity if convicted of possession.

90
NEVADA REFERENDUM QUESTION 9
  • Voluntary state registry identification card
    program
  • Possession limited to 1 ounce of usable marijuana
    and 7 plants, 3 of which can be mature.

91
VERMONT SENATE BILL 76
  • Mandatory state registry program - 50.00 fee
  • Possession limited to 2 ounces of usable
    marijuana and 9 plants, 2 of which can be mature
  • The Medical Marijuana Review Board reviews all
    denial appeals
  • Physicians from neighboring states are permitted
    to recommend medical marijuana to Vermont
    residents

92
MONTANAINITIATIVE 148
  • Mandatory registry identification system
  • Limits possession to 1 ounce of usable marijuana
    and 6 plants

93
RHODE ISLAND THE EDWARD O. HAWKINS AND THOMAS C.
SLATER MEDICAL MARIJUANA ACT
  • Possession limited to 2 ½ ounces of usable
    marijuana and 12 plants
  • Senate Bill S.791aa/House Bill H.6005aa repealed
    the 1 year sunset clause, making the Medical
    Marijuana Act permanent.

94
NEW MEXICO THE LYNN AND ERIN COMPASSIONATE USE
MEDICAL MARIJUANA ACT
  • The legislation creates the Medical Marijuana
    Board
  • Made up of 7 appointed members
  • Purpose is to evaluate applications and make
    recommendations regarding the identification card
    system as well as the qualifications for medical
    marijuana use

95
ARIZONA and MARYLAND
  • ARIZONA AND MARYLAND HAVE CREATED LAWS THAT DO
    NOT OUTRIGHT PERMIT THE USE OF MEDICAL MARIJUANA

96
ARIZONA BALLOT PROPOSITION 200
  • This legislation legalizes the use of medical
    marijuana when a physician prescribes the drug,
    which requires the Federal Drug Administrations
    (FDA) approval.
  • The FDA has not approved the drug, and therefore,
    it cannot be prescribed by Arizona physicians.

97
MARYLAND HOUSE BILL 702
  • Allows specified individuals in specified
    prosecutions to introduce, and requiring the
    court to consider as a mitigating factor,
    specified evidence related to medical necessity
  • This very vague law permits the defense of
    criminal necessity if arrested for marijuana
    possession
  • If defendant can prove medical necessity, the
    maximum fine cannot exceed 100.00

98
THE FEDEAL GOVERNMENT DOES NOT RECOGNIZE THE
MEDICINAL USE OF MARIJUANA
99
THE CONTROLLEDSUBSTANCES ACT
  • Establishes 5 classifications or schedules of
    drugs
  • Department of Justice and the Department of
    Health and Human Services jointly determine a
    drugs classification
  • Cannabis is placed in Schedule 1 meaning it has a
    high potential for abuse and no acceptable
    medical use

100
MEDICAL MARIJUANA CASES THAT REACHED THE HIGHEST
COURT
101
UNITED STATES V. OAKLAND CANNABIS BUYERS
COOPERATIVE (OCBC) AND JEFFERY JONES
  • OCBC organized to supply marijuana in California
    subsequent to the passage of Proposition 215
  • The court concluded that because the Controlled
    Substance Act did not recognize the medical
    necessity of marijuana under any circumstances,
    it could not be used as a defense in court

102
GONZALES V. RAICH
  • Supreme Court ruled the federal government can
    arrest and charge individuals on cannabis related
    crimes, regardless of the defendant's state law
    in regard to cannabis
  • Rationale Federal law (Controlled Substance
    Act) preempted state law
  • Also took into account the Commerce Clause of the
    US Constitution as marijuana would affect
    interstate commerce

103
MEDICAL MARIJUANA CASES THAT REACHED THE HIGHEST
COURT
A.4867B - THE NYS MEDICAL MARIJUANA BILL IS IN
REVIEW IN THE NEW YORK STATE ASSEMBLY. IT DOES
NOT HAVE A SAME AS BILL IN THE NEW YORK STATE
SENATE AT THIS TIME
104
JUSTIFICATION
  • Emphasizes the need for alternative medical
    relief for New Yorkers suffering from a
    debilitating condition
  • Reaffirms New Yorks strong stance against the
    use of marijuana for reasons other than medical
    necessity
  • Claims that state government does have the
    authority to permit such use

105
PATIENT CERTIFICATION PROCESS
  • Debilitating condition must be documented in
    health care record
  • Patient must be under the care of a licensed
    practitioner
  • Other treatments have proven ineffective

106
POSSESSION
  • Patient must possess a valid registry
    identification card to evade criminal
    interference
  • Possession limited to 2 ½ ounces of usable
    marijuana and 12 plants
  • Must purchase marijuana from a registered
    organization

107
REGISTERED ORGANIZATIONS
  • Pharmacy
  • Licensed facility
  • Not-for-profit organization
  • Local health department
  • Registered producers (requiring agricultural
    expertise)

108
CHANCES OF SUCCESS
  • Assembly Bill 4867-B, sponsored by Assemblyman
    Gottfried, passed the New York State Assembly in
    2007 but died in the New York State Senate
  • Without a same as senate sponsor, the bill has
    no chance of success

109
FEDERAL VS. STATE
  • As stated in A.4867-B, this policy would not go
    into effect until such time that there was a
    change in federal law that permits the medical
    use of marijuana or New York is granted
    permission by the federal government to implement
    its policy
  • Both options are unforeseeable
  • The legislation could not go into effect

110
WHAT DOES THE FUTURE HOLD FOR MEDICAL MARIJUANA?
  • The federal government has not allowed states to
    make medical marijuana decisions without
    interference.
  • HOWEVER, the Supreme Court did not reverse
    current state laws nor did it prohibit future
    states from enacting similar legislation.
  • This very well could open the door for other
    states to pass medical marijuana legislation,
    including New York state.

111
LAW OUTSIDE THE USA
  • Canada
  • July 2003 the Canadian government started to
    deliver to physicians marijuana seeds in order to
    treat 582 approved patients so that the
    patients can start to grow the plants themselves
  • A bag of 30 seeds will cost 20
  • US border patrol will increase activity?
  • Counter to the Canadian governments policy of
    urging people to stop smoking
  • Fall 2004, pharmacies in British Columbia started
    to sell marijuana for medicinal purposes without
    a prescription
  • A pilot project of the national health service
  • Strong criticism of the proposal has come from
    patients
  • 110 an ounce and it is lousy pot, tastes like
    lumber

112
LAW OUTSIDE THE USA
  • Netherlands
  • Government made medical marijuana legal in
    September 2003

113
AND THEN THERE IS
  • Chronic Candy is a marijuana-flavored lollipop
    and gumdrop line. The developers claim, "every
    lick is like taking a hit." Chronic Candy is a
    hemp-based confection. There have been no illegal
    substances found in the candy. A breakdown of the
    ingredients reveals a lot of sugar in the forms
    of glucose, dextrose, sugar, inverted sugar, and
    starches, along with different dyes for color and
    a "natural hemp flavor", presumably, hemp oil
    flavoring. There is no drug in the candy. The
    candy is imported from Switzerland and contains
    no THC, the psychoactive ingredient in marijuana.
    They are distributed through a very small (two
    person) business out of California.
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