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Medical Marijuana: Pros and Cons A

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Before cannabinoids can be considered for treating spasticity and neuropathic pain, further valid randomized controlled studies are needed. – PowerPoint PPT presentation

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Title: Medical Marijuana: Pros and Cons A


1
Medical Marijuana Pros and ConsA Prescription
for Trouble?
  • Elizabeth Libby Stuyt, MD
  • University of Colorado, Department of Psychiatry
  • Medical Director, Circle Program
  • Colorado Mental Health Institute at Pueblo
  • 2012 Colorado Behavioral Healthcare Council
  • Annual Training Conference, Sept 28, 2012

2
Conflicts
  • The Circle Program is now funded in part by
    Medical Marijuana Tax proceeds

3
Cannabis
  • Complex alkaloid mixture of more than 400
    compounds derived from the Cannabis sativa plant
  • 60 different compounds described with activity on
    the cannabinergic system
  • Most abundant cannabinoids are
  • Delta-9 tetrahydrocannabinol (most psychoactive)
  • Cannabidiol
  • Cannabinol

4
Cannabinergic system
  • Two main cannabis receptors
  • CB1present throughout CNS
  • Hippocampus
  • Cortex
  • Olfactory areas
  • Basal ganglia
  • Cerebellum
  • Spinal cord
  • CB2 located peripherally,
  • linked with immune system
  • Spleen
  • macrophages

5
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6
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

7
History of Marijuana
  • 1378 Emir of the Ottoman Empire makes the first
    edict against eating hashish or smoking cannabis
    1st War on Drugs
  • 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
  • 1890 Hashish made illegal in Turkey

8
History of Marijuana
  • 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 5th Amendment privilege against
    self-recrimination

9
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10
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
  • 1986 Dronabinol placed into Schedule II by DEA
  • 2003 Canada 1st country in world to offer
    medical marijuana to patients

11
Compassionate Use not based on any research
  • Glaucoma - 1 cause of blindness
  • 1992 American Academy of Ophthalmologys
    Committee on Drugs no scientific verifiable
    evidence that the use of marijuana is safe and
    effective in the treatment of glaucoma
  • 1997 NEI no studies have demonstrated that
    marijuana can safely and effectively lower IOP
    any more than a variety of drugs on the market

12
Glaucoma
  • 1999 Institute of Medicine although IOP can
    be reduced by using cannabinoids and marijuana,
    the effect is too short lived and requires too
    high doses.
  • There are too many side effects to recommend
    lifelong use in the treatment of glaucoma
  • Would have to smoke 10-12 joints per 24 hours to
    maintain low IOP through out the day

13
Indications
  • Dronabinol (Marinol) and nabilone (Cesamet)
    indicated for chemotherapy-induced nausea and
    vomiting
  • Dronabinol (Marinol) approved for HIV-associated
    anorexia
  • Sativex (oromucosal spray) conditionally approved
    for neuropathic pain in multiple sclerosis and
    cancer pain
  • Herbal smoked marijuana found to be safe and
    effective for HIV-associated disorders

14
Canada
  • Four cannabinoid products available
  • Herbal cannabis extract, Sativex, delta-9-THC
    and cannabidiol in oromucosal spray
  • Dronabinol synthetic delta-9-THC, Marinol
  • Nabilone synthetic derivative of delta-9-THC,
    Cesamet
  • Herbal form of cannabis medical marijuana

15
Research Issues
  • MJ is a Schedule I drug a barrier to conducting
    prospective RCTs, DB w/ placebo
  • Studies are short - two weeks average, ranging
    from a few hours to one year
  • Most studies conducted with oral TCH preps rather
    than smoked cannabis
  • Most studies exclude anyone with a history of
    major psychiatric disorder other than depression
    and/or history of substance abuse
  • Most studies done to date
  • Short in length (average two weeks)
  • Small N (lacking power)
  • Retrospective in nature
  • Confounded by uncontrolled variables
  • Concomitant tobacco use
  • Comorbid illnesses

16
Studies of Effects on Pain
  • Lit review of cannabinoids given by any route for
    treatment of pain Campbell et al. BMJ
    20013231-6
  • 9 RCTs, 222 patients, 5 trials cancer pain 2
    chronic non-malignant pain 2 post-operative
    pain none evaluated cannabis
  • Cannabinoids are no more effective than codeine
    in controlling pain and have depressant effects
    on the CNS that limit their use. In acute
    postoperative pain they should not be used.
    Before cannabinoids can be considered for
    treating spasticity and neuropathic pain, further
    valid randomized controlled studies are needed.

17
Side Effects of Cannabis
  • Most of our knowledge about the negative effects
    of marijuana come from recreational use
  • Literature review of safety studies of medical
    cannabinoids over past 40 years 23 RCTs (median
    exposure to cannabinoids 2 weeks, range 8 hrs to
    12 months) Wang et al. CMAJ 2008171669-1678

18
Side Effects
  • 4779 adverse events reported in those assigned to
    the intervention
  • 96.6 were not serious
  • 164 serious events no different from controls
    (RR) 1.04
  • Rate of nonserious events higher among those
    assigned medical cannabinoids than controls
    (RR)1.86 dizziness most common event

19
Studies with Smoked Cannabis
  • Double-blind, placebo controlled, crossover trial
    of smoked cannabis for the short term treatment
    of neuropathic pain associated with HIV five
    study phases over 7 weeks five days of active
    or placebo smoking with washout periods
  • Participants had documented HIV, neuropathic pain
    refractory to a least two previous analgesics, 5
    or higher on pain scale (Ellis et al.
    Neuropyschopharmacology 200934672-680)

20
Studies of Smoked Cannabis
  • Four smoking sessions per day, titrating dose
    (1-8 THC) to achieve maximum tolerable dose
  • Exclusion criteria
  • Current substance use disorder
  • Lifetime history of dependence on cannabis
  • Concurrent use of medication with cannabinoids
  • Previous psychosis with or intolerance to
    cannabinoids

21
Results
  • significantly reduced neuropathic pain intensity
    compared to placebo
  • 46 with cannabis reported a 30 reduction in
    pain versus 18 with placebo
  • Another study with almost identical outcomes
    52 vs 24, gt30 reduction in pain with 3 smoking
    sessions/day (Abrams et al. Neurology
    200768515-521)
  • All patients were required to have prior
    experience smoking marijuana so they would know
    how to inhale and what neuropsychological effects
    to expect

22
More Studies of Smoked Cannabis
  • Ware et al. CMAJ. 2010E694-E701.
  • N21
  • Inclusion Criteria
  • Outpatients with gt 3 month hx neuropathic pain
  • Pain caused by physical trauma or surgery
  • Pain intensity gt 4 (0 to 10 scale)
  • Randomized, double-blind, placebo-controlled,
    four-period crossover design
  • THC concentration 0, 2.5, 6 or 9.4
  • Three daily dosages x 5 days
  • 9 day washout period.
  • Participants advised not to drive a vehicle or
    operate heavy machinery while on study drug

23
Ware et al. CMAJ. 2010E694-E701(cont)
  • Average daily pain intensity
  • 5.4 on 9.4 THC cannabis
  • 6.1 on Placebo(0 THC)
  • (p0.023difference 0.7, 95 CI 0.02-1.4)
  • No difference observed between 2.5, 6, 0
  • The reduction is modest when compared with that
    from other drugs for neuropathic pain such as
    gabapentin or pregabalin
  • A joint with a 9.4 THC content would impair
    the majority of us

24
Dose-dependent effects of smoked cannabis on
Capsaicin-induced pain and hyperalgesia in
healthy volunteers (Wallace et al.
Anesthesiology. 2007107785-796)
  • Randomized, double-blinded, placebo-controlled,
    crossover design
  • High dose training session, 15 subjects
  • 100 mg capsaicin injected intradermally ventral
    forearm spontaneous pain
  • Stroking and von Frey hair stimulation elicited
    pain
  • Low dose 2 THC, medium dose 4THC, high dose 8
    THC

25
Results
  • Capsaicin injections induced spontaneous and
    elicited pain in all subjects
  • No difference in pain perception between any of
    the cannabis doses and placebo during early
    (right arm) course
  • Low dose did not differ from placebo at any time
    point
  • During late course (left arm) medium dose
    subjects reported decreased pain sensation, high
    dose subjects reported increased perception of
    pain consistent with other reports that chronic
    delivery of cannabinoids can cause thermal
    hyperalgesia

26
So To Review
  • Marijuana (smoked/oral) used as a therapeutic,
    not recreational agent, is a drug as defined by
    the FDA
  • All new drugs must be scientifically evaluated
    before they may be allowed to enter the stream of
    interstate commerce
  • The drug does not have to be proven superior to
    already approved drugs, its benefits must
    outweigh the risks when used for the purpose for
    which it has been approved

27
The fact that it is a botanical does not preclude
scientific investigation
  • Digitalis purpurea fox glove - CHF
  • Papaver somniferum opium poppy
  • Atropa belladonna nightshade -IBS
  • Ephedra sinica ephedrine - hypotension
  • Salix alba willow tree - ASA
  • Taxis brevifolia Pacific Yew tree breast
    cancer

28
DEA Scheduling Drugs depends on
  • Does the drug have a currently accepted medical
    use in the United States?
  • What is the drugs safety under medical
    supervision?
  • What is its addiction liability?
  • Is there a potential for significant diversion
    for illegal use?
  • Are individuals using it on their own initiative
    or only on physicians prescription?
  • Is the drug similar in its pharmacology to other
    controlled drugs?

29
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30
Rocky Mountain HighColorado
  • November 2000
  • Coloradoans passed Amendment 20
  • 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
  • MMJ Registry began accepting applications
    for Registry Identification Cards.

31
The Flood Gates Opened
  • 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

32
The Passage of Amendment 20
  • Storefront Medical Marijuana dispensaries
    sprouted like weeds!

33
MMJ A Recession Proof Industry
  • Marijuana Growers
  • Caregivers
  • Legal
  • Doctors making recommendations ()
  • Grow Lights
  • Vaporizers
  • Pipes
  • Edibles
  • Advertising (Westword has gone green)
  • Festivals
  • Delivery Services

34
There are more medical marijuana dispensaries in
Denver than Starbucks and liquor stores
combinedThe Denver Post
35
September 30, 2009 June 30, 2012
  • 19,691 new patient applications received
  • 17,356 patients with valid ID cards
  • 73 male, average age 40, 8 minors lt18
  • 57 in the Denver/metro area
  • 67 have designated primary care-giver
  • Over 800 different physicians have signed for
    patients in Colorado
  • 184,002 new patient applications received
  • 99,960 patients with Valid ID cards
  • 68 male, average age 42, 47 minors lt18
  • 56 in the Denver/metro area
  • 54 have designated primary care-giver
  • Over 900 different physicians have signed for
    patients in Colorado

36
Conditions (as of June 2012)
Condition of Patients Percentage
Cachexia 1,215 1
Cancer 2,583 3
Glaucoma 1,021 1
HIV/AIDS 632 1
Muscle Spasms 17,286 17
Seizures 1,708 2
Severe Pain 93,679 94
Severe Nausea 11,567 12
37
Either our state is experiencing an epidemic of
severe pain in youthful males or..Amendment
20 is being exploited by recreational users
38
Rules and Regulations
  • Patient will be deemed to have established an
    affirmative defense to such allegation
    (possession of marijuana) where
  • Patient was previously diagnosed by a physician
    as having a debilitating medical condition
  • Patient was advised by his or her physician, in
    the context of a bona fide physician-patient
    relationship, that the patient might benefit from
    the medical use of marijuana in connection with a
    debilitating medical condition

39
Conditions considered debilitating
  • Cachexia
  • Severe Pain
  • Severe Nausea
  • Seizures
  • Persistent Muscle Spasms
  • Any other medical condition approved by the state
    health agency

40
Lobbying for New Conditionsunsuccessful so far
  • Opioid Dependence
  • PTSD
  • Bipolar Disorder
  • Anxiety Disorders
  • Depression
  • Tourettes Disorder
  • Asthma
  • Atherosclerosis
  • Crohns Disease
  • Diabetes Mellitus
  • Hepatitis C
  • Hypertension
  • MRSA
  • Rheumatoid Arthritis

41
Rules and Regulations
  • Patient may engage in the medical use of
    marijuana with no more marijuana than is
    medically necessary to address a debilitating
    medical condition
  • No more than 2 ounces and no more than six
    plants, 3 or fewer being mature
  • No patient shall engage in medical use of
    marijuana in plain view of, or in a place open
    to, the general public

42
Problems with the physicians
  • In the fall of 2009 _at_ 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

43
SB 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 lt 21.

44
Implications
  • The vast majority of these patients dont have
    debilitating illnesses
  • The majority of the patients are young males who
    will be exposed to the long term effects of
    cannabis exposure
  • Studies conducted are all short term
  • Therefore their risks may be the same as for
    recreational users and/or addicts

45
Therefore Physicians Recommending Medical
Marijuana
  • Will need to get a thorough history - medically,
    psychiatrically and substance abuse keep a
    chart and have a patient/physician relationship
  • Will need to attempt to decide what level of
    marijuana use is most appropriate
  • Will need to recommend patients not drive etc.
    when under the influence
  • Will need to follow patients closely for side
    effects and unintended consequences

46
Marijuana use and Cancer risk
  • Marijuana smoke contains several of the same
    carcinogens and co-carcinogens as tobacco smoke
  • Benzoapyrene, a procarcinogenic polycyclic
    aromatic hydrocarbon, is present in marijuana tar
    at higher concentrations than in tobacco tar
  • Marijuana smoking involves inhalation of 3 times
    the amount of tar as tobacco smoke

47
Cancer Studies involving Marijuana
  • Studies are small in number and are retrospective
    in nature
  • Confounded by concomitant use of tobacco
  • Confounded by underreporting of marijuana use
    because such use is often illegal

48
Cannabis use and risk of Lung Cancer Aldington et
al. Eur Respir J. 200831280-286
  • Case-controlled study of lung cancer in adults lt
    55yrs of age in New Zealand
  • 79 cases of lung cancer and 324 controls
  • Risk of lung cancer increased 8 for each
    joint-yr (1 joint/day for one year) of cannabis
    smoking after adjustment for confounding
    variables including tobacco
  • Risk increased 7 for each pack-yr tobacco
  • Long-term cannabis use increases risk of lung
    cancer in young adults

49
Head and Neck Cancers
  • Retrospective, case-controlled study, 173 proven
    cases of head and neck cancer and 176 controls
    matched with respect to age, sex, race,
    education, tobacco, alcohol use
  • Risk of cancer 2.6 fold greater in cannabis users
    than non-users
  • 3-fold greater increase in those lt 55 yrs
  • Zhang et al. Cancer Epidemiol Biomark Prev
    199981071-1078.

50
Other Cancers
  • In a cohort study among non-tobacco smokers,
    ever-marijuana smokers had increased risk for
    prostate cancer - RR3.1, and cervical cancer -
    RR1.4 Sidney et al. Cancer Causes Control
    19978722-728.
  • Another cohort study found an increased risk of
    malignant primary adult-onset glioma for
    ever-marijuana smokers RR1.9 Efird et al. J
    Neurooncol 20046857-69

51
Metabolism of Marijuana
  • Massive first pass metabolism via the oral route
    only 10-20 reaches systemic circulation
    unchanged takes 30 60 minutes to achieve an
    effect key side effect on CNS can be dysphoria
    rather than euphoria
  • Via the lungs onset of action within seconds
    high experienced with serum concentration of 3
    ng/ml, produced by as little as 2-3 mg D9THC,
    average joint contains 0.5 1.0 g of cannabis

52
Routes of Administration
  • Where theres smoke, theres harm, There is no
    future in smoking marijuana as a conventional
    medicine Janet Joy PhD
  • Until there is an alternative, for a small
    segment of the population there is a modest
    clinical benefit of smoked marijuana
  • Sound theoretical reasons for intrathecal or
    epidural cannabinoids may produce spinal cord
    analgesia without effects on cerebral receptors
    that are associated with psychotropic effects

53
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 200666737
  • 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

54
Marijuana and Cognitive Impairment
  • Heavy marijuana use (daily for at least one
    month) is associated with residual
    neuropsychological effects even after a day of
    supervised abstinence from the drug Harrison et
    al. JAMA 1996275521
  • Unknown whether this is due to residue of drug in
    the brain, withdrawal effects or frank neurotoxic
    effect of the drug

55
How Drugs of Abuse affect the Learning and Memory
part of the Brain
56
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57
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58
Natural Rewards Elevate Dopamine Levels
59
Effects of Drugs on Dopamine Levels
Source Di Chiara and Imperato
60
Effects of Drug Use on the Hippocampus
  • Drugs of abuse are potent negative regulators of
    adult neurogenesis in the hippocampus
  • Chronic administration of opiates, THC, ethanol
    or nicotine decreases hippocampal function,
    decreasing ability of adult brain to adapt to new
    information

61
Regional Brain Abnormalities Associated with
Long-term heavy Cannabis Use Arch Gen Psychiatry
200865694-701
  • 15 long term (gt10 years) and heavy (gt5 joints
    daily) cannabis using men compared with 16 age
    matched non using controls by MRIs of brains
  • Cannabis users had bilaterally reduced
    hippocampal and amygdala volumes p.001
  • Increase in positive symptoms (psychotic) plt.001
  • Significantly worse performance on measures of
    verbal learning plt.001

62
Multiple Sclerosis and Cannabis A cognitive and
psychiatric study
  • 10 subjects with MS and current cannabis users
    compared with 40 subjects with MS who did not use
    cannabis
  • psychiatric diagnosis higher in cannabis users
    p0.04
  • Slower mean performance time on SDMT (index of
    information processing speed, working memory and
    sustained attention) in the cannabis users
    p0.006
  • Neurology 200871164-169

63
Marijuana and Driving
  • Laboratory tests and driving studies show that
    cannabis may acutely impair several
    driving-related skills in a dose related fashion
  • Effects between individuals vary more than for
    alcohol because of tolerance, differences in
    smoking technique, and different absorptions of
    THC Sewell et al. Am J Addictions
    200918185-193.
  • More pronounced with highly automatic driving
    functions less with complex tasks that require
    conscious control opposite from that seen with
    alcohol

64
Effects of Marijuana Intoxication and Pilot
Performance Am J Psychiatry 19851421325-1329
  • Ten experienced licensed private pilots trained
    for 8 hours on a flight stimulator landing task
  • Each smoked a THC cigarette (19 mg)
  • 24 hours later their mean performance on the
    flight task showed trends toward impairment in
    all variables, some tasks showed significant
    impairment
  • Despite the deficits, the pilots reported no
    awareness of impaired performance

65
Marijuana and Mental Illness
  • Study in Australia tracked 1600 girls for 7 years
    Arseneault et al. BMJ 20023251212
  • Those who used marijuana every day were 5 times
    more likely to suffer from depression and anxiety
    than non-users
  • Teenage girls who used the drug a least once a
    week were twice as likely to develop depression
    than those who did not use
  • Cannabis use increased the risk of developing
    schizophrenia symptoms specific to cannabis and
    early onset prior to age 15

66
Risk of Psychosis
  • Increased by 40 in people who have used cannabis
    Cohen et al. Australian New Zealand J Psychiatry
    200842357-368.
  • Dose-response effect leading to an increased risk
    of 50-200 in the most frequent users
  • Approximately 14 of psychotic outcomes in young
    people would not have occurred if cannabis had
    not been consumed

67
Early Cannabis use associated with psychosis
related outcomes in young adults Arch Gen Psych
201067
  • Sibling pair analysis within a prospective birth
    cohort in Australia
  • 3801 young adults cannabis use and 3
    psychosis-related outcomes (nonaffective
    psychosis, hallucinations, and Delusional
    Inventory score)
  • Early cannabis use is associated with
    psychosis-related outcomes in young adults

68
Marijuana and Schizophreniadouble-edged sword
  • Low doses may improve frontal lobe functioning by
    acutely increasing blood flow to cortices
    concerned with cognition, mood and perception
    increasing availability and utilization of
    dopamine
  • Continued use depresses cerebral flow and high
    doses augment mesolimbic dopamine release,
    opposing therapeutic effects of antipsychotic
    drugs and exacerbating psychosis
  • It also suppresses PFC dopamine utilization
    resulting in cognitive dysfunction

69
Spice
  • Synthetic cannabinoids AM694 and HU210 found in
    Spice products are 500 to 600 times more potent
    than the THC found in traditional marijuana
  • The THC in high potency marijuana and Spice
    products are potentially harmful to embryonic
    development as early as 2 weeks after conception
  • Utero exposure to THC linked to anencephaly,
    ADHD, Depression, Aggression

70
Rats exposed to nicotine as adolescents
self-administer more nicotine than rats exposed
as adults Levin ED et al. Psychopharm
2000169141-149
71
Rats First Exposed to Nicotine in Adolescence
Show Greater Sensitization to Cocaine Than Rats
First Exposed as Adults
Activity level after cocaine administration was
measured by counting the number of times in 10
minutes each rat crossed light beams projected in
a grid across its cage.
Sources Collins et al, 2004, Levin et al, 2003,
NIDA Notes v19.2
72
Marijuana and Addiction
  • Approximately 10 of regular marijuana users
    become addicted to it
  • 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
  • Compared with 15 for alcohol, 32 for nicotine
    and 26 for opiates

73
The number of adults with substance use disorders
is trending upward and expected to double by the
year 2020
74
Colorado ranks 5th in the nation for adolescent
marijuana use.
75
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76
Pros and Cons of Marijuana
  • Not associated with death
  • Not as addicting as other drugs
  • Modest benefit demonstrated for small segment of
    the population in short term use
  • Marked negative cognitive effects
  • Very dangerous to adolescent brain development
    and occurrence of mental illness
  • Cancer risk
  • Driving impairment

77
Whats the going rate?
  • One joint weighs _at_ 0.9 grams with 3.56 THC
    (Abrams study)
  • 0.9 g 0.03 oz
  • ¼ oz 7.1 g
  • 1 oz 28 g
  • 1 oz 31 joints at 3 joints per day need 3 oz
    per month
  • 900/month

78
The Hippocratic Oath
  • First.do no harm
  • The practice of medicine is a privilege. not a
    right!

79
Malignant versus Non-malignant
  • There is definitely a place for Medical Marijuana
    when people are suffering with terminal
    conditions
  • Cachexia appetite stimulant
  • Nausea secondary to chemotherapy
  • Pain mild improvement
  • Neither opioid medications nor medical marijuana
    is the answer for chronic, non-malignant pain

80
Physician Motives
  • Financial incentives and/or personal political
    views should not influence treatment
    recommendations
  • Conflicts of interest ethically/legally
    proscribed
  • Investment in dispensaries
  • kickbacks for referrals

81
Societal Costs
  • Public Safety
  • Cognitive impairment in safety sensitive
    positions
  • Workplace accidents
  • Driving and Accidents
  • National Transportation Safety Board
  • Studied 182 fatal truck accidents in 1999
  • Just as many accidents were caused by drivers
    impaired by MJ as by drivers impaired by Etoh
  • Increased criminal activity?
  • A large percentage of those arrested for crimes
    test positive for MJ
  • Nationwide 40 of adult males tested positive for
    MJ at the time of their arrest

82
Societal Costs
  • Sending the wrong message to children?
  • Soda pot
  • Edibles (colorful cookies, cupcakes, candy)
  • Its organic, green, natural
  • Wellness ads (promoting MJ)
  • Case Example Peanut Butter spiced with MJ

83
Case Vignette Denver Post December 2009
  • 44-year-old female, grandmother and advocate for
    medical marijuana used the drug for chronic
    back pain most of her life
  • Gave her 3-year-old grandson a peanut butter
    cookie made with cannabis butter
  • The next day she had trouble rousing the boy and
    called an ambulance
  • Police seized the jar of cannabis butter and the
    boy had the drug in his system
  • A week later the grandmother took her own life

84
In the End Prevention is Key
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