Marijuana

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Marijuana

• ADDICTION MEDICINE EDUCATIONAL SERIES WORKBOOK

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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

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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

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FLOWERING PLANTS

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

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FLOWERING PLANTS

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

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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

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CANNABIS FAMILY

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

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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

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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

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CANNABIS

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

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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

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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

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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)

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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

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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.

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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

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CANNABIS HISTORY

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

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CANNABIS HISTORY

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

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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

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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.
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ER VISITS VS. POTENCYCAUSE AND EFFECT?
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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.

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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

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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

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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

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SPECT SCANHEATHLY SURFACE VIEWS
TOP DOWN VIEW
UNDERSIDE VIEW
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SPECT SCANTHC Abuse
A SPECT scan showing the underside of the brain
with area that is showing no activity
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CANNABINOIDS

• Cannabis use in the adolescent is highly
  correlated with subsequent alcohol use.

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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
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PREPARATION OF CANNABIS

• Hashish dried cannabis resin and flowers
• THC concentration, 2 - 8 or higher

Pieces of Hash
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PREPARATION OF CANNABIS

• Hash oil extraction of THC from hashish with an
  organic solvent
• THC concentration 15 - 50

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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

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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

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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

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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

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CANNABIS KINETICS

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

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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

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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

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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

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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.

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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

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PHARMACOLOGIC ACTIONS

• Psychomotor effects
• Behavioral effects
• Cognitive effects

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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

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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.

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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.

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PHARMACOLOGIC ACTIONS

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

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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.

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PHARMACOLOGIC ACTIONS

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

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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

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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

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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.

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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

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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

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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

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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.

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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?

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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).

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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

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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.

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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

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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

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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

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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

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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

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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

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MEDICAL USES

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

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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.

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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

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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

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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.

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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
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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

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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.