Upload
lora-montgomery
View
220
Download
0
Tags:
Embed Size (px)
Citation preview
Medical Marijuana:The “Need for Weed” Movement
Might Like Getting High OnSome Science
Medical Marijuana:The “Need for Weed” Movement
Might Like Getting High OnSome Science
Donald R. Vereen, M.D., M.P.H.Director
Community Academic EngagementPrevention Research Center of Michigan
School of Public HealthUniversity of Michigan
Former Medical Officer and Special AssistantNational Institutes of Health Former “Deputy Drug Czar”
White House Office of National Drug Control Policy
Donald R. Vereen, M.D., M.P.H.Director
Community Academic EngagementPrevention Research Center of Michigan
School of Public HealthUniversity of Michigan
Former Medical Officer and Special AssistantNational Institutes of Health Former “Deputy Drug Czar”
White House Office of National Drug Control Policy
University of Michigan Substance Abuse CenterMember SymposiumSeptember 16, 2011
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
TIMELINE OF MEDICAL MARIJUANA LEGISLATION
Michigan Medical Marihuana Act
The Law• Approved by Michigan voters on November 4, 2008 by
ballot initiative• The Michigan Medical Marihuana Program (MMMP) is a
state registry program within the Bureau of Health Professions at the Michigan Department of Licensing and Regulatory Affairs.
Michigan Medical Marihuana ActThe Law
• Program Statistics: – 181,303 original and renewal applications received since April 6, 2009.
– 105,458 patient registrations issued. Sept 2, 2011
– The number of caregivers will be posted as soon as an accurate number can be obtained.
– 19,705 applications denied -- most due to incomplete application or missing documentation.
Michigan Medical Marihuana ActThe Law
• Responsibilities of the MMMP – Review applications submitted by patients and caregivers wishing to
participate in the MMMP and issue medical marihuana registration identification cards to those individuals whose applications are approved.
– Maintain the confidentiality of program records in accordance with applicable
state and federal confidentiality laws.– Collect and disseminate statistics about participation in the MMMP including,
but not limited to:• Number of applications filed and approved.
• Nature of the debilitating medical conditions of qualified patients.
• Number of registration identification cards revoked.
• Number of physicians providing written certifications for qualifying patients.
Michigan Medical Marihuana ActThe Law
• The people of the State of Michigan find and declare that:– National Academy of Sciences’ Institute of Medicine (IOM) report of 1999
has “found” / “discovered” beneficial uses of marihuana.– FBI’s Uniform Crime Reports show that nearly 99 out of 100 marihuana
arrests occur under “state” law rather than “federal” law. Consequently, changing state law will have the practical effect of protecting from arrest the vast majority of seriously ill people who have a medical need for marihuana.
– States are not required to enforce federal law which prohibits the use of marihuana except under very limited circumstances. Michigan joins 12 other states which do not penalize the medical use and cultivation of marihuana.
Michigan Medical Marihuana ActThe Law
• Protections:– A qualifying patient (diagnosed by a licensed physician as having a
debilitating medical condition) who has been issued and possesses a registry identification card (a document issued by the MDCH that identifies a person as a registered qualifying patient or registered primary caregiver (a person at least 21 years old who has agreed to assist with a patient’s medical use of marihuana and who has never been convicted of a felony involving illegal drugs)) shall not be subject to arrest, prosecution, or penalty...for the medical use of marihuana in accordance with this act…may possess up to 2.5 ounces of usable marihuana, 12 marihuana plants kept in an enclosed, locked facility, and any incidental amount of seeds, stalks, and unusable roots.
Michigan Medical Marihuana ActThe Law
• Certification:– To be eligible for the Registry Identification Card one must: Complete an application Complete information about a ‘primary caregiver” – if applicable Patient’s physician must complete and sign the Physician Certification Form
and indicate the appropriate medical condition(s):Cancer Glaucoma Cachexia/
WastingHepatitis C ALS Severe/Chronic
PainAgitation of Alzheimer’s Nail Patella Severe nausea
HIV/AIDS+ Crohn’s Disease Seizures
Severe Muscle Spasms
Institute for Behavior and Health (IBH) – March 18, 2011-based on American Society of Addiction
Medicine
1. Only seriously-ill patients who have exhausted other treatment options are permitted access 2. These patients receive high quality care and supervision from their treating physicians3. Marijuana products are tested for quality and potency in licensed labs by qualified individuals4. Strict procedures are implemented from physician’s office to point of distribution and use by the intended patient to detect and deter marijuana abuse and diversion to thers in the community
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
CANNABIS KINETICS
• SMOKING three cannabis joints will cause you to inhale the same amount of toxic chemicals as one pack 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.
Overall problems of use
Mode of administrationNo smoking in hospitalsNo standard dose of smoked marijuanaSmoke is hazardous in and of itselfSmoking may impair immune system responseDifficulty concentrating on complex tasksSlowed reaction timesTolerance develops quicklyEffect is 4 - 6 hrs
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
Cannabinoid Receptors:
Cerebellum – body movement and coordinationCortex – higher cognitive functionsNucleus accumbens – reward, feeding and other appetitive behaviorsBasal ganglia – movement controlHypothalamus – body temperature, salt and water balance, reproductive functions, analgesia, feeding behaviorAmygdala – emotional responses, fearHippocampus – learning and memory
Endocannabinoids (e.g. anandamide)
constitute one of the first lines of defense against pain, the anatomical locus and the precise receptor mechanisms underlying cannabinergic modulation of pain are uncertain. Clinical exploitation of the system is severely hindered by the cognitive deficits, memory impairment, motor disturbances and psychotropic effects resulting from the central actions of cannabinoids.
Agarwa, N., et al, Neurosci. 2007 Jul;10(7):870-9. Epub 2007 Jun 10.
R. Mechoulam et al. 2003. Cannabidiol: an overview of some pharmacological aspects.
Neuroscience Letters 346: 61-64;
Cannabidiol (CBD) non-psychoactive cannabinoid
clinically demonstrated to have analgesic, antispasmodic, anxiolytic, antipsychotic, antinausea, and anti-rheumatoid arthritic properties.
The U.S. Food and Drug Administration (FDA) has given the green light to Valeant Pharmaceuticals International to bring the synthetic cannabinoid nabilone (Cesamet) back to market after 17 years. Nabilone, sold in Canada is similar to 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.
SativexWhole plant medicinal cannabis extractProduced by Bayer and GW pharmaceuticals and approved for use in Canada for multiple sclerosis and neuropathic pain (2005)Contains THC and nabidiolex, not delta - THCPhase 3 trials in multiple sclerosis patients showed that sublingual spray was safe and effective for symptom relief
nucleusaccumbens
hippocampusstriatum
frontalcortex
substantianigra/VTA
Dopamine PathwaysPrincipal “Pleasure” System of the Brain
Dopamine PathwaysPrincipal “Pleasure” System of the Brain
0
50
100
150
200
0 60 120 180
Time (min)
% o
f B
asal
DA
Ou
tpu
t
NAc shell
EmptyBox Feeding
Di Chiara et al.Di Chiara et al.
FOOD
100
150
200
DA
Co
nce
ntr
atio
n (
% B
asel
ine)
MountsIntromissionsEjaculations
15
05
10
Co
pu
latio
n F
req
ue
nc
y
SampleNumber
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
ScrScrBasFemale 1 Present
ScrFemale 2 Present
Scr
Fiorino and PhillipsFiorino and Phillips
SEX
Natural Rewards Elevate Dopamine LevelsNatural Rewards Elevate Dopamine Levels
00
100100
200200
300300
400400
00 11 22 33 44 5 hr5 hrTime After CocaineTime After Cocaine
% o
f B
as
al
Re
lea
se
% o
f B
as
al
Re
lea
se
DADA
AccumbensAccumbens COCAINECOCAINE
00100100200200300300400400500500600600700700800800900900
1000100011001100
00 11 22 33 44 5 hr5 hrTime After AmphetamineTime After Amphetamine
% o
f B
as
al
Re
lea
se
% o
f B
as
al
Re
lea
se
DADA
AccumbensAccumbens AMPHETAMINEAMPHETAMINE
Source: Di Chiara and ImperatoSource: Di Chiara and Imperato
Effects of Drugs on Dopamine LevelsEffects of Drugs on Dopamine LevelsEffects of Drugs on Dopamine LevelsEffects of Drugs on Dopamine Levels
PFCPFC
ACGACG
OFCOFCSCCSCC
HippHipp
NAccNAccVPVP
AmygAmyg
REWARDREWARD
CONTROL INHIBITORY
CONTROL
CONTROL INHIBITORY
CONTROL
MOTIVATION/DRIVE
MOTIVATION/DRIVE
MEMORY/LEARNING MEMORY/
LEARNING
Circuits Involved In Drug Abuse and Addiction
Circuits Involved In Drug Abuse and Addiction
All of These Must Be ConsideredIn Developing Strategies to
Most Effectively Treat Addiction
All of These Must Be ConsideredIn Developing Strategies to
Most Effectively Treat Addiction
Marijuana brain changes
DriveOFCDriveOFC
Saliency NAcSaliency NAc
MemoryAmygdalaMemoryAmygdala
Control CG Control CG
Non-Addicted BrainNon-Addicted Brain
AddictedBrainAddictedBrain
STOP STOP
GOGODriveDrive
MemoryMemory
Saliency Saliency
ControlControl
DriveDrive
MemoryMemory
Saliency Saliency
Adapted from: Volkow et al., J Clin Invest 111(10):1444-1451, 2003. Adapted from: Volkow et al., J Clin Invest 111(10):1444-1451, 2003.
ADDICTION IS A DEVELOPMENTAL DISEASE starts in adolescence and childhood
ADDICTION IS A DEVELOPMENTAL DISEASE starts in adolescence and childhood
NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003
% in
eac
h a
ge g
rou
p w
ho
dev
elop
fir
st-
tim
e ca
nn
abis
use
dis
ord
er%
in e
ach
age
gro
up
wh
o d
evel
op f
irst
-ti
me
can
nab
is u
se d
isor
der
0.0%0.0%
0.2%0.2%
0.4%0.4%
0.6%0.6%
0.8%0.8%
1.0%1.0%
1.2%1.2%
1.4%1.4%
1.6%1.6%
55 1010 1515 1818 2525 3030 3535 4040 4545 5050 5555 6060 6565 7070AgeAge
Age at cannabis use disorder as per DSM IV
Brain areas where volumes are smaller in adolescents than young adults.
Sowell, E.R. et al., Nature Neuroscience, 2: 859-861, 1999Sowell, E.R. et al., Nature Neuroscience, 2: 859-861, 1999