Medical Marijuana Program Research Articles

Point/Counterpoint: Opioid Abuse in the United States

Point/Counterpoint: Opioid Abuse in the United States

Cannabinoids in treatment-resistant epilepsy: A review.

Treatment-resistant epilepsy (TRE) affects 30% of epilepsy patients and is associated with severe morbidity and increased mortality. Cannabis-based therapies have been used to treat epilepsy for millennia, but only in the last few years have we begun to collect data from adequately powered placebo-controlled, randomized trials (RCTs) with cannabidiol (CBD), a cannabis derivative. Previously, information was limited to case reports, small series, and surveys reporting on the use of CBD and diverse medical marijuana (MMJ) preparations containing: tetrahydrocannabinol (THC), CBD, and many other cannabinoids in differing combinations. These RCTs have studied the safety and explored the potential efficacy of CBD use in children with Dravet Syndrome (DS) and Lennox-Gastaut Syndrome (LGS). The role of the placebo response is of paramount importance in studying medical cannabis products given the intense social and traditional media attention, as well as the strong beliefs held by many parents and patients that a natural product is safer and more effective than FDA-approved pharmaceutical agents. We lack valid data on the safety, efficacy, and dosing of artisanal preparations available from dispensaries in the 25 states and District of Columbia with MMJ programs and online sources of CBD and other cannabinoids. On the other hand, open-label studies with 100mg/ml CBD (Epidiolex®, GW Pharmaceuticals) have provided additional evidence of its efficacy along with an adequate safety profile (including certain drug interactions) in children and young adults with a spectrum of TREs. Further, Phase 3 RCTs with Epidiolex support efficacy and adequate safety profiles for children with DS and LGS at doses of 10- and 20-mg/kg/day. This article is part of a Special Issue titled "Cannabinoids and Epilepsy".

Reefer Sanity

Reefer Sanity Marc Jampole (bio) Brave New Weed: Adventures into the Uncharted World of Cannabis Joe Dolce Harper Wave www.harperwave.com 275 Pages; Print, $25.00 In Brave New Weed, Joe Dolce envisions what the world of marijuana consumption will look like once other states and countries follow the lead of California, Oregon, Colorado, the Netherlands and Israel—yes, Israel!—and marijuana becomes available ubiquitously for smoking, vaping, chewing and tasting in myriad medicinal and recreational varieties. In this new age, consumers will be able to select from dozens upon dozens of varieties, knowing exactly what kind of high each will produce and/or what medical and health benefits each will provide. Dolce, a former editor-in-chief of Details and Star magazines who has also written for the New York Times, Gourmet and other periodicals, takes readers on an exhilarating, if bizarre world tour of companies, communities and individuals on the cutting, and sometimes bleeding, edge of marijuana research, cultivation, processing and marketing. We stop in Israel, where smoking pot isn't legal, but where much of the research into the medicinal properties of the devil weed is now taking place. Israel has some 20,000 people participating in the largest state-run medical marijuana program in the world. Israeli researchers are investigating marijuana as a treatment for depression, loss of appetite, pain, post-traumatic stress and sedation. Dolce speaks at length with Israeli scientists investigating the body's endocannabinoid system, which comprises the network of receptors in the brain and nervous system involved in a variety of physiological processes including appetite, pain-sensation, mood and memory and may be related to the evolution of the runner's high. Another stop on Dolce's long, strange trip is Denver, to learn how recreational marijuana is being marketed like wine, as experts evaluate the color, smell, taste and effects of sundry varieties of smoke. In Los Angeles, he talks to a researcher who is working on how different dosages affect the high and how THC, CBD, CBN, CBG, terpenoids, flavinoids and the other components of marijuana act and interact. In Amsterdam, he attends the 25th Cannabis Cup, the oldest festival dedicated to sampling and honoring the best strains of marijuana and hashish grown each year. He speaks with medical researchers, marijuana marketers and brand specialists, "budmasters" and a number of very wealthy business people who have thrown their financial support behind legalization, including long-time users like Progressive Insurance founder Peter Lewis and Men's Wearhouse founder George Zimmer. Interspersed through Dolce's reporting is a fairly good popular history of marijuana use since ancient times. The American part of the story is disappointing and alarming, because it reflects both our inherent racism and anti-science bias. Dolce cites a study that shows that the primary reason many states passed legislation criminalizing pot use during the prohibition era (roughly 1913-1930) had very little to do with rampant drug abuse and everything to do with an anti-immigration furor. When the Great Depression suppressed tax revenues and threatened his department, an ambitious bureaucrat named Harry Anslinger, with financial backing from alcohol beverage companies, created a new anti-Mexican marijuana scare campaign that led to the passage of the Marijuana Tax Act, which essentially ended the practice of some doctors prescribing marijuana tinctures for various ailments. After a loosening of social mores regarding marijuana in the 1960's, Nixon started his war on drugs. Along the way, our various levels of government ignored the research suggesting that pot was relatively harmless and would approve only research which had the purpose of demonstrating its dangers. Thus, from the 1970's on, those few American medical researchers allowed to investigate the devil weed accumulated studies showing the damage it did not do, but very little showing how it could help manage pain, relieve anxiety, make soldiers forget traumatic experiences and perhaps even ward off certain cancers. In short, our government took the same anti-science approach that Congress took when it banned all research into gun violence and many elected officials and lobbyists take by denying human-induced climate change and the theory of evolution...

Substance Use, Health, and Functioning Characteristics of Medical Marijuana Program Participants Compared to the General Adult Population in Ontario (Canada)

ABSTRACTExistent profiles of Medical Marijuana Program (MMP) participants indicate common and co-morbid chronic diseases, yet evidence on disability or functioning as well as comparisons with general populations are largely lacking. This study compared health, substance use, and functioning status among formally approved MMP participants with the general adult population in Ontario (Canada). A community-recruited sample (n = 53) of MMP participants was compared to a sub-sample (n = 510) of the representative Centre for Addiction and Mental Health (CAMH) Monitor (2015 cycle) survey of Ontario general population adults (ages 18+) based on identical telephone-based interviews regarding substance use, health, and functioning measures. Means and standard deviations for all indicators were computed by sex, controlled for age and education, and compared by regression techniques. MMP participants were more likely to be male, younger, and less socio-economically integrated; they indicated more common psychoactive substance (e.g., tobacco, daily cannabis) and psychotropic medication use, as well as overall worse physical and mental health and functioning status. Marked differences between MMP participants and general population adults were observed. MMPs appear to attract individuals with complex chronic health problems; however, little is known about the impact of MMP participation on these.

Splendor in the Grass? A Pilot Study Assessing the Impact of Medical Marijuana on Executive Function.

Currently, 25 states and Washington DC have enacted full medical marijuana (MMJ) programs while 18 states allow limited access to MMJ products. Limited access states permit low (or zero) tetrahydrocannabinol (THC) and high cannabidiol (CBD) products to treat specified conditions such as uncontrolled epilepsy. Although MMJ products are derived from the same plant species as recreational MJ, they are often selected for their unique cannabinoid constituents and ratios, not typically sought by recreational users, which may impact neurocognitive outcomes. To date, few studies have investigated the potential impact of MMJ use on cognitive performance, despite a well-documented association between recreational marijuana (MJ) use and executive dysfunction. The current study assessed the impact of 3 months of MMJ treatment on executive function, exploring whether MMJ patients would experience improvement in cognitive functioning, perhaps related to primary symptom alleviation. As part of a larger longitudinal study, 24 patients certified for MMJ use completed baseline executive function assessments and 11 of these so far have returned for their first follow-up visit 3 months after initiating treatment. Results suggest that in general, MMJ patients experienced some improvement on measures of executive functioning, including the Stroop Color Word Test and Trail Making Test, mostly reflected as increased speed in completing tasks without a loss of accuracy. On self-report questionnaires, patients also indicated moderate improvements in clinical state, including reduced sleep disturbance, decreased symptoms of depression, attenuated impulsivity, and positive changes in some aspects of quality of life. Additionally, patients reported a notable decrease in their use of conventional pharmaceutical agents from baseline, with opiate use declining more than 42%. While intriguing, these findings are preliminary and warrant further investigation at additional time points and in larger sample sizes. Given the likelihood of increased MMJ use across the country, it is imperative to determine the potential impact of short- and long-term treatment on cognitive performance as well as the efficacy of MMJ treatment itself.

Agitation in Alzheimer Disease as a Qualifying Condition for Medical Marijuana in the United States

To determine the extent to which states and localities include dementia as a qualifying condition for medical marijuana and how common this indication is. The authors reviewed authorizing legislation and medical marijuana program websites and annual reports for the states and localities where medical marijuana is legal. Of the 24 states and localities where medical marijuana is legal, dementia is a qualifying condition in 10 (41.7%), primarily for agitation of Alzheimer disease. In the five states where information was available regarding qualifying conditions for certification, dementia was the indication for <0.5% of medical marijuana certifications. Dementia is somewhat commonly listed as a potential qualifying condition for medical marijuana. Currently, few applicants for medical marijuana list dementia as the reason for seeking certification. However, given increasingly open attitudes toward recreational and medical marijuana use, providers should be aware that dementia is a potential indication for licensing, despite lack of evidence for its efficacy.

Cannabis Use and Risk of Psychiatric Disorders: Prospective Evidence From a US National Longitudinal Study.

With rising rates of marijuana use in the general population and an increasing number of states legalizing recreational marijuana use and authorizing medical marijuana programs, there are renewed clinical and policy concerns regarding the mental health effects of cannabis use. To examine prospective associations between cannabis use and risk of mental health and substance use disorders in the general adult population. A nationally representative sample of US adults aged 18 years or older was interviewed 3 years apart in the National Epidemiologic Survey on Alcohol and Related Conditions (wave 1, 2001-2002; wave 2, 2004-2005). The primary analyses were limited to 34 653 respondents who were interviewed in both waves. Data analysis was conducted from March 15 to November 30, 2015. We used multiple regression and propensity score matching to estimate the strength of independent associations between cannabis use at wave 1 and incident and prevalent psychiatric disorders at wave 2. Psychiatric disorders were measured with a structured interview (Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV). In both analyses, the same set of wave 1 confounders was used, including sociodemographic characteristics, family history of substance use disorder, disturbed family environment, childhood parental loss, low self-esteem, social deviance, education, recent trauma, past and present psychiatric disorders, and respondent's history of divorce. In the multiple regression analysis of 34 653 respondents (14 564 male [47.9% weighted]; mean [SD] age, 45.1 [17.3] years), cannabis use in wave 1 (2001-2002), which was reported by 1279 respondents, was significantly associated with substance use disorders in wave 2 (2004-2005) (any substance use disorder: odds ratio [OR], 6.2; 95% CI, 4.1-9.4; any alcohol use disorder: OR, 2.7; 95% CI, 1.9-3.8; any cannabis use disorder: OR, 9.5; 95% CI, 6.4-14.1; any other drug use disorder: OR, 2.6; 95% CI, 1.6-4.4; and nicotine dependence: OR, 1.7; 95% CI, 1.2-2.4), but not any mood disorder (OR, 1.1; 95% CI, 0.8-1.4) or anxiety disorder (OR, 0.9; 95% CI, 0.7-1.1). The same general pattern of results was observed in the multiple regression analyses of wave 2 prevalent psychiatric disorders and in the propensity score-matched analysis of incident and prevalent psychiatric disorders. Within the general population, cannabis use is associated with an increased risk for several substance use disorders. Physicians and policy makers should take these associations of cannabis use under careful consideration.

Improving Sample Preparation Methods For Cannabis-Infused Edible And Topical Products

With implementation of medical marijuana programs in 34 US states, new cannabis products are being developed at a rapid pace, challenging quality control chemists to quickly develop analytical methods to comply with testing requirements. Traditional extraction methods don't always work with complex food or topical matrices. Problems such as non-homogenous samples can lead to inaccurate measurements when using traditional solvent based extraction methods. In addition, large amounts of chlorinated solvents are often needed.

Medical Marijuana and Crime

State medical marijuana programs have proliferated in the United States in recent years. Marijuana sales are now estimated in billions of dollars per year with over two million patients, yet it remains unlawful under Federal law, and there is limited and conflicting evidence about potential effects on society. We present new evidence about potential effects on crime by estimating an economic crime model following the general approach developed by Becker. Data from 11 states in the Western United States are used to estimate the model and test hypotheses about potential effects on rates of violent and property crime. Fixed effects methods are applied to control for state-specific factors, with adjustments for first-order autocorrelation and cross-section heteroskedasticity. There is no evidence of negative spillover effects from medical marijuana laws (MMLs) on violent or property crime. Instead, we find significant drops in rates of violent crime associated with state MMLs.

Borders Up in Smoke: Marijuana Enforcement in Nebraska After Colorado’s Legalization of Medicinal Marijuana

With the passage of Amendments 20 (2000) and 64 (2012), Colorado legalized the medicinal and recreational use of marijuana. Nebraskan law enforcement in border counties subsequently reported increases in arrests and reductions in jail space. In response, the Nebraska state legislature passed LR-520 to study the potential increased costs incurred by criminal justice agencies in border counties. To investigate this situation, we compare trends in drug arrests and jail occupancy across three areas: border counties, those that contain Interstate 80 (I-80) as a major transportation route, and the remaining counties in the state of Nebraska from 2000 through 2013. We found that border counties, but not necessarily those along the I-80 corridor, experienced significant growth in marijuana-related arrests and jail admissions after the expansion of the medical marijuana program in Colorado. Implications for research and policy are discussed.

Medical marijuana programs — Why might they matter for public health and why should we better understand their impacts?

ObjectiveAlthough cannabis is an illegal drug, ‘medical marijuana programs’ (MMPs) have proliferated (e.g., in Canada and several US states), allowing for legal cannabis use for therapeutic purposes. While both health risks and potential therapeutic benefits for cannabis use have been documented, potential public health impacts of MMPs — also vis-à-vis other psychoactive substance use — remain under-explored. MethodsWe briefly reviewed the emerging evidence on MMP participants' health status, and specifically other psychoactive substance use behaviors and outcomes. ResultsWhile data are limited in amount and quality, MMP participants report improvements in overall health status, and specifically reductions in levels of risky alcohol, prescription drug and — to some extent — tobacco or other illicit drug use; at the same time, increases in cannabis use and risk/problem patterns may occur. ConclusionMMP participation may positively impact — for example, by way of possible ‘substitution effects’ from cannabis use — other psychoactive substance use and risk patterns at a scale relevant for public health, also influenced by the increasing population coverage of MMPs. Yet, net overall MMP-related population health effects need to be more rigorously and comprehensively assessed, including potential increases in cannabis use related risks and harms.

Medical Marijuana programs: Implications for cannabis control policy – Observations from Canada

While prohibition has been the dominant regime of cannabis control in most countries for decades, an increasing number of countries have been implementing cannabis control reforms recently, including decriminalization or even legalization frameworks. Canada has held out from this trend, although it has among the highest cannabis use rates in the world. Cannabis use is universally criminalized, and the current (conservative) federal government has vowed not to implement any softening reforms to cannabis control. As a result of several higher court decisions, the then federal government was forced to implement a ‘medical marijuana access regulations’ program in 2001 to allow severely ill patients therapeutic use and access to therapeutic cannabis while shielding them from prosecution. The program's regulations and approval processes were complex and subject to extensive criticism; initial uptake was low and most medical marijuana users continued their use and supply outside the program's auspices. This year, the government introduced new ‘marijuana for medical purposes regulations’, which allow physicians to ‘authorize’ medical marijuana use for virtually any health condition for which this is considered beneficial; supply is facilitated by licensed commercial producers. It is expected that some 500,000 users, and dozens of commercial producers will soon be approved under the program, arguably constituting – as with medical marijuana schemes elsewhere, e.g. in California – de facto ‘legalization’. We discuss the question whether the evolving scope and realities of ‘medical cannabis’ provisions in Canada offer a ‘sneaky side door’ or a ‘better third way’ to cannabis control reform, and what the potential wider implications are of these developments.

Not ashamed anymore: Longitudinal changes in barriers to treatment entry for online treatment seekers

s / Drug and Alcohol Dependence 140 (2014) e86–e168 e95 Medical marijuana cardholders seen in the emergency department Mark A. Ilgen1,2, Amy S. Bohnert1,2, K. Barry1,2, S. Chermack1,2, R.M. Cunningham3, M.A. Walton2, F.C. Blow1,2 1 VA Serious Mental Illness Treatment Research and Evaluation Center, Department of Veterans Affairs Healthcare System, Ann Arbor, MI, United States 2 Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States 3 Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States Aims: Although the number of individuals who participate in statemedical marijuana programs continues to increase, very little is knownabout how these individuals interactwith other aspects of the healthcare system. The present study examines a large sample of Emergency Department (ED) patients to describe the prevalence and characteristics of adults who report participation in statemedical marijuana programs. Methods: Research staff screened a representative sample of 2049 ED patients in Michigan for participation in a larger brief alcohol intervention trial between February and August 2012. The present study focuses on the self-report by participants that they have ever been issued a medical marijuana card. Results: Approximately 4.3% (n=89) of the sample of ED patients reported that theywere participants in statemedical marijuana programs. The vast majority of these patients (77.5%; n=69) reported that their medical marijuana card was obtained for the managementof chronicpain.Onaverage, patientswhoparticipated in state medical marijuana programs reported use of marijuana 12.9 (SD=12.7) days out of the past month. Close to 12% medical marijuanapatients reported that a physicianhad refused toprovide them with an opioid within the past year. Conclusions: Adultswhoparticipate in statemedicalmarijuana programs represent a small but importantminority of patients seen in the ED. It is critical to better characterize the types and quality of care provided to these individual within traditional medical settings. Financial support: This project was supported by NIAAA, R01AA018659. http://dx.doi.org/10.1016/j.drugalcdep.2014.02.275 Not ashamed anymore: Longitudinal changes in barriers to treatment entry for online treatment seekers Adi Jaffe1,2, D. Murphy1, Tariq Shaheed2, A. Coleman2, Y. Hser1 1 Integrated Substance Abuse Programs, University of California, Los Angeles, Los Angeles, CA, United States 2 California Treatment Services, LLC, Beverly Hills,

Clearing the smoke: What do we know about adolescent cannabis use and schizophrenia?

While cannabis has been used as a recreational drug in many cultures around the world for centuries, it is only recently that we have begun to understand the biology of how this drug affects the brain. The discovery of the primary compon ents of the endocannabinoid system (the cannabinoid CB1 and CB2 receptors and the endogenous ligands anandamide and 2-arachidonoylglycerol) in the late 1980s and early 1990s allowed for discrete and focused research to occur. In the last 25 years, it has been determined that many of the prototyp ical effects of cannabis use (increased feeding, sedation, re duced anxiety, reduced blood pressure) mimic the actions of endocannabinoid signalling. 1 That being said, many of the ef fects of cannabis remain a mystery. The past few decades have been rife with debate regarding the safety and medical utility of cannabis, little of which has actually been rooted in scientific evidence. The extremes of these opinions state that cannabis is a completely innocuous and harmless substance, or that it is a highly dangerous drug whose use provokes a series of adverse health complications. While both of these opinions are for the most part inaccurate, these unfortunately are the types of debates that often occur in a political sphere and can have substantial impact on pol icy decisions. The need for evidence-based decisions to guide cannabis access is imperative given that in the states of Col orado and Washington recreational sale of cannabis is now legal and that in Canada there is currently substantial revi sion and overhaul occurring with the medical marijuana pro gram. While many conditions, including lung cancer and car diac arrthymias, have been at the forefront of the cannabis safety debate for some time, interestingly the discussion has predominantly moved to psychiatry — specifically the asso ciation between adolescent cannabis use and the develop ment of schizophrenia. The first study that brought this association to the forefront of the research community was a paper published in Lancet in 1987 that demonstrated a significant association between cannabis use and the development of schizophrenia in a 15year longitudinal study of more than 45 000 healthy Swedish army conscripts. 2 Individuals who consumed a high level of cannabis (defined as use of cannabis on more than 50 occa sions by the age of 18 years) had a greater risk of schizophrenia developing. This finding was interesting, as several historical reports had documented psychotic-like reactions to cannabis, suggesting that there may be a basis for associating cannabis use with the development of schizophrenia. In the decades that followed, several other reports confirmed this association (see the reviews by Malone and colleagues, 3

Trends in Detection Rates of Risky Marijuana Use in Colorado Health Care Settings

ABSTRACT. Background: Over the past several years, many states, including Colorado, have approved medical marijuana legislation. There is concern that increased access to and visibility of medical marijuana may lead to harmful use. Methods: This study examined changes in patients’ marijuana use in 12 health care settings through a statewide screening, brief intervention, and referral to treatment (SBIRT) initiative. Results: Beginning in 2009, the odds of screening positive for risk-prone marijuana use significantly increased, coinciding with dramatic increases in use of Colorado's medical marijuana program. Young males were most likely to screen positive. Among users, there was a small, statistically significant increase in severity of use over time. Conclusions: Findings suggest that health care providers may be serving increasing numbers of patients using marijuana for medical or recreational perposes.

The Rhode Island Medical Marijuana Program

On January 3, 2006, the Rhode Island General Assembly enacted legislation that mandated the Department of Health (DOH) to implement a program to register qualified patients and their caregivers to allow possession and cultivation of limited amounts of marijuana for personal use for statutorily defined illnesses and debilitating conditions. This study was designed to describe the formulation and implementation of the program; identify stakeholder expectations and perceptions of the program; identify patient's expectations prior to enrollment; and identify patient's perceived experience of the enrollment process. The study findings indicated that 309 different practitioners had certified 980 patients was an indication of a level of program effectiveness meeting patient needs; that there was no indication that patients had been arrested or prosecuted for participating in the program; and that despite ongoing concerns with consistent access to marijuana, patients were pleased that the program existed.

Irrational Basis: The Legal Status of Medical Marijuana

In a growing number of states, medical marijuana occupies a dual legal status. The federal Controlled Substances Act (CSA) classifies marijuana as a Schedule I drug, signifying that it has both a high potential for abuse and no acceptable medical use. Patients and physicians are thus subject to the same federal criminal penalties as any other individuals who produce, distribute, or possess marijuana. By mid-2009, however, fourteen states had decided to permit medical marijuana under certain circumstances. Through voter initiatives or legislation, these states have exempted patients and physicians from prosecution for violating state laws governing the use, possession, or cultivation of marijuana. The disparate legal regimes have generated much litigation, including two cases that reached the U.S. Supreme Court. Both cases rejected challenges to federal enforcement of the CSA in California, the state with the most liberal provisions on medical marijuana. Under the Court decisions, federal authorities could continue to take action against patients, physicians, and others who were protected under state medical marijuana laws. Two recent legal developments are more favorable to states seeking to permit medical marijuana, however. First, U.S. Attorney General Eric Holder announced that the federal Drug Enforcement Agency would limit future raids and other enforcement activity to individuals violating both federal and state criminal law. This means that people complying with state medical marijuana laws will no longer be targeted by federal law enforcement officials. Holder said that under his leadership, the agency would focus its efforts on large-scale commercial marijuana operations. (1) In a second development with implications for state marijuana laws, the U.S. Supreme Court declined to review a court decision upholding legislation implementing California's medical marijuana law. In 1996, California voters approved Proposition 215, designed to ensure that seriously ill Californians have the right to obtain and use marijuana for medical purposes where that medical use is deemed appropriate and has been recommended by a physician. (2) Seven years later, the California legislature enacted the Medical Marijuana Program Act to supplement the earlier law. (3) The 2003 law requires counties to participate in a system that enables patients and caregivers to register and obtain identification cards protecting them from arrest for violating state marijuana prohibitions. County versus State versus Federal Authority California officials unhappy with the state's permissive stance on medical marijuana balked at the mandate to create the identification system. San Diego and San Bernardino counties brought a lawsuit seeking a judicial declaration that they were not required to comply with the state's mandate. According to the plaintiffs, the California law was preempted by the CSA, which fails to exempt medical marijuana from the usual criminal penalties. The U.S. Constitution gives Congress the power to supersede state law. Over the years, courts have developed principles for determining when federal law preempts state law. Congressional purpose is the central consideration in resolving preemption claims. The easiest case arises when Congress includes in the legislative text an explicit provision on whether the law is intended to preempt state rules. In other cases, courts consider factors such as whether the state law under challenge presents an obstacle to achieving Congress's objectives in enacting the pertinent federal law. In 2008, a California appellate court ruled against the counties, holding that preemption failed to bar implementation of the California identification card program. (4) As the court noted, the CSA itself states that it is not intended to preempt state laws unless there is a positive conflict between [the CSA and state law] so that the two cannot consistently stand together. …