Heavy users suffer from severe nausea and pain that can only be relieved by bathing in hot water several times a day

PUBLISHED: 14:00, 31 August 2015 |

A bizarre syndrome that makes heavy cannabis users violently ill and leads them to take frequent hot baths to ease the pain has been reported by doctors.

Symptoms of the illness include severe stomach pain, nausea and vomiting – and bathing in very hot water up to five times a day for relief.

At least two cases of the syndrome which involve multiple visits to accident and emergency have been reported in the UK and worldwide the conditions is ‘increasing acutely’.

* Cannabinoid hypermesis syndrome was first recorded in Australia

* Symptoms include severe stomach pain, nausea and vomiting

* Sufferers often report having a hot bath up to 5 times a day to relieve pain

* Expert warns condition is responsible for a rise in ‘unecessary’ hospital admissions for heavy cannabis users – and is ‘increasing acutely’

But doctors in the UK warn that the failure to recognise CHS is likely to be draining hospital resources as it is being wrongly diagnosed.

Dr Sauid Ishaq, professor of gastroenterology at Birmingham City University, who was one of the first to observe the syndrome in the UK said: ‘This is a highly unrecognised condition, resulting in numerous unnecessary admissions. ‘There is an urgent need to highlight this.’

In the US, doctors in Colorado report an ‘acute’ rise in cases of the syndrome there since marijuana laws became relaxed.

CHS, which stands for cannabinoid hyperemesis syndrome, was first reported in medical literature in 10 patients in Adelaide, Australia in 2004.

Recognition of the condition is increasing and doctors are now recognising the condition in patients regularly visiting hospital with severe nausea.

Dr Ishaq, of Russells Hall Hospital, Dudley, reported a 42-year-old man presented on eight occasions with vomiting, abdominal pain, fever and dehydration last year in the east Midlands. Dr Ishaq and colleagues found the man had been a chronic cannabis smoker since the age of 14.

After a series of investigations, they found the symptoms ceased when the patient stopped smoking the drug.

In the medical journal GHFBB the authors write better awareness of the condition ‘would result in fewer hospital admissions and needless investigations, and may provide patients with real motivation to abstain from cannabis’.

At Macclesfield General Hospital, a 21-year-old chef had been admitted on seven occasions over a two year period with profuse vomiting – but his symptoms ended after he stopped smoking the drug.

Cannabinoid hypermesis syndrome is characterised by heavy use of the drug, triggering nausea and vomiting as well as frequent hot baths or showers.

Despite studies promoting the use of marijuana’s anti-emetic (anti-sickness) qualities, there is increasing evidence of its negative affect on the gastrointestinal tract, triggering CHS.

Sufferers have reported frequent hot bathing helps to provide temporary relief from the nausea, vomiting and abdominal pain typical of the illness.

Lead author Dr Enrico Roche wrote in the journal Gut: ‘The observation that the patient wanted to take regular baths because he had found that bathing eased the sickness was documented in the nursing notes but its significance was not appreciated.’

In one case reported in the Journal of American Family Medicine a man ‘spent three days in a hot shower while awake’ to alleviate his symptoms.

His case was not the most extreme however, as researchers reported that one sufferer reported spending ‘300 out of 365 days’ in the bath.

The findings that cannabis can cause severe nausea runs counter to a widespread view that the drug has a powerful anti-nausea effect.

Doctors in Colorado – where cannabis has been legalised – suspected that some of the cases of extreme nausea they had been seeing may have been caused by chronic cannabis use. They reviewed admission data to hospitals and found an acute rise in the condition since marijuana became legalised and widely available for medical use.

The research, in Academic Emergency Medicine, compared the numbers of people suffering from the condition from November 1, 2008 to October 31, 2009, after which cannabis use became liberalised in the state and between June 1, 2010 to May 31, 2011.

They found 41 cases of suspected CHS – where patients had been admitted three or more times for nausea – before legalisation,  rose to 87 cases after legalisation at two hospitals, Denver Health and the University of Colorado.  The sufferers were predominantly female (71 per cent) and white (72 per cent) with an average age of 31, the authors note.

The authors, led by Dr Kim Howard, wrote they think that the most likely explanation for the marijuana use contributed to an increased rate of cyclic vomiting presentations.

Marijuana is the most commonly used illicit substance in the United States, the authors note, with 18.9 million users in 2012.

But they add: ‘Unfortunately, there is little information on the deleterious effects of chronic use and its implications for public health. ‘As the number of new and chronic marijuana users grows annually, it is important to measure its effect on public health…the rate of cyclic vomiting seems to have increased acutely.’

By COLIN FERNANDEZ, SCIENCE CORRESPONDENT FOR THE DAILY MAIL

Source: http://www.dailymail.co.uk/health/   UPDATED:  31/08/15 

There is, naturally, a hope amongst parents whose child is desperately ill with seizures that a new treatment will help.  Many parents in the USA have been convinced that medical marijuana may be the answer – and some have even moved home in order to be able to legally purchase this substance.  Sadly however, it has been shown that whilst this substance may be able to help some patients it can also have disastrous effects on others.  There is much research going on with a purified and uniform preparation of cannabidiol (CBD) called Epidiolex to see if this can indeed become a genuine treatment for epileptic seizures.  Until then, parents should be advised not to use the products available in ‘medical marijuana dispensaries’ – which are not regulated for purity or uniformity and could be dangerous for their children. (see letter below).

This situation has come about because of the shameful way so called medical marijuana has been used as a wedge to introduce the recreational use of the substance – dating from the statement made in the seventies  by Keith Stroup in a post debate encounter at Emory University in the USA when he said “we’ll be using the issue as a red herring to give marijuana a good name’.

This is the current position of the American Epilepsy Society, as written in a letter from Dr. Brooks-Kayal to a Pennsylvania legislator:

March 22, 2015

Dear Representative,

As Pennsylvania considers enacting new cannabis legislation (HB 193), I write to offer the perspective of the American Epilepsy Society (AES), the leading U.S. organization of clinical and research professionals specializing in the treatment and care of people with epilepsy.

Epilepsy is the most common and potentially devastating neurological disease that affects people across the lifespan. In America, one in 26 people will be diagnosed with epilepsy at some time in the course of their life – more will experience an isolated seizure. Epilepsy is associated with significant morbidity and mortality and is associated with many co-morbidities including depression, cognitive dysfunction, and autism. Today between 2.2 and 3 million Americans, including almost 400,000 children, live with epilepsy, with one third living with treatment-resistant seizures that do not respond to current medications.

The American Epilepsy Society position on medical marijuana as a treatment option for people with epilepsy is informed by the current research and supported by the position statements from the American Academy of Neurology, the American Academy of Pediatrics and the American Medical Association. Additionally, a 2014 survey of practitioners published in the journal Epilepsy Currents found that the majority of epilepsy practitioners agreed with and supported the AES position.

Specifically, AES has called for more research, for the rescheduling of marijuana by the DEA to ease access for clinical studies, and has supported the compassionate use program of GW Pharmaceuticals, where a is being administered under the guidance and close monitoring of an appropriate medical professional. AES has also been highly supportive of the double-blind clinical trial now underway by GW Pharmaceuticals and of the forthcoming clinical trial by INSYS Therapeutics.

These clinical trials utilize a vastly different substance than the artisanal cannabis products that are being considered for use in Pennsylvania, and that have been used in Colorado. As you likely know, medical marijuana and its derivatives are legal in Colorado, but you may not realize that the content of these products is not regulated for purity or uniformity. A study by a team from Children’s Hospital Colorado that was presented during the AES Annual Meeting in December 2014 and has recently been accepted for publication in the journal Epilepsy & Behavior, found that artisanal “high CBD” oils resulted in no significant reduction in seizures in the majority of patients and in those for whom the parents reported improvements, these improvements were not associated with improvement in electroencephalograms (EEGs), the gold standard monitoring test for people with epilepsy.

Additionally, in 20% of cases reviewed seizures worsened with use of cannabis and in some patients there were significant adverse events. These are not the stories that you have likely heard in your public hearings, but they are the reality of practitioners at Children’s Hospital Colorado who have cared for the largest number of cases of children with epilepsy treated with cannabis in the U.S.

The families and children coming to Colorado are receiving unregulated, highly variable artisanal preparations of cannabis oil prescribed, in most cases, by physicians with no training in pediatrics, neurology or epilepsy. As a result, the epilepsy specialists in Colorado have been at the bedside of children having severe dystonic reactions and other movement disorders, developmental regression, intractable vomiting and worsening seizures that can be so severe they have to put the child into a coma to get the seizures to stop. Because these products are unregulated, it is impossible to know if these dangerous adverse reactions are due to the CBD or because of contaminants found in these artisanal preparations. The Colorado team has also seen families who have gone into significant debt, paying hundreds of dollars a month for oils that do not appear to work for the vast majority. For all these reasons not a single pediatric neurologist in Colorado recommends the use of artisanal cannabis preparations. Possibly of most concern is that some families are now opting out of proven treatments, such as surgery or the ketogenic diet, or newer antiseizure medications because they have put all their hope in CBD oils.

AES is sympathetic to the desperation parents of children with severe, treatment-resistant epilepsy feel, and understand the need for compassionate or promising new therapies in in appropriate and controlled circumstances. We are however opposed to the use of artisanal preparations of unregulated compounds of cannabis that contain unverified content and are produced by people with no experience in pharmaceutical production. That is what is currently happening in Colorado and may soon be happening in multiple states across the county as they legalize the use of medical marijuana products.

The products currently provided in Colorado do not meet the FDA definition of expanded or compassionate use. The FDA requires compassionate use therapies to meet the same criteria as an investigational new drug which require standard purity, content and content uniformity testing of the product. None of these criteria are met in the products being given to people with epilepsy in Colorado and we are seeing the distressing results noted above. And yet, these and other similar products are being considered for use in Pennsylvania.

It is also worth noting that in late February 2015, the FDA issued several warning letters to firms that claim that their products contain CBD. The FDA has tested those products and, in some of them, did not detect any CBD as claimed on the label. Because there is no standard for these products, the market is increasingly flooded with a wide variation of products and states which approve access to these preparations will bear the burden of monitoring for quality and controlling for the continuity of supply.

In sum, there simply is no clinical, controlled research to support the adoption of new CBD legislation for epilepsy such as your state is considering. The anecdotal results of a few families in Colorado, shared in the media, should not be the basis for law making. The rush by states to pass CBD legislation has created an unusual situation where people with epilepsy and their families are demanding access to a highly variable homegrown substance that may or may not be beneficial and the medical and scientific community lacks the necessary efficacy and safety data to make good treatment decisions regarding cannabis for people with epilepsy, especially in children.

The new legislation in most states places epilepsy practitioners in an untenable situation where they are expected, or in some states directed by law, to respond to requests for these highly variable artisanal products with no protocols, no research and no clinical guidelines regarding dosing or side-effects, and no assurance that the cannabis products that are to be recommended are pure, safe or uniform, making it nearly impossible to know if we are truly “Doing No Harm.”

We need to accelerate the clinical research and wait to act until we have results to support decisions. If there are components of cannabis with specific therapeutic values we need to know this and we need to develop pharmacy grade compounds that utilize these components to help the nearly one million people living with drug resistant epilepsy. And if the harmful aspects of cannabis outweigh the therapeutic benefits, we need to find out now, before more medically fragile children have been exposed to cannabis products that are not effective and may risk damage to vital organs, brain development, or worse.

We urge you and your fellow committee members to delay adoption of new cannabis legislation and to continue to support and encourage new research. If we can be of additional help please contact our Executive Director, Eileen Murray, at emurray@aesnet.org.

Thank you for your consideration of our position.

Sincerely,

Amy Brooks-Kayal, MD,  President, American Epilepsy Society.  Chief and Ponzio Family Chair, Children’s Hospital Colorado,  Professor of Pediatrics and Neurology, University of Colorado School of Medicine

The Food and Drug Administration recently announced it intends to require warning labels and child-resistant packaging on liquid nicotine products such as those used in e-cigarettes.

The Centers for Disease Control and Prevention said the popularity of e-cigarettes has resulted in a number of cases of nicotine poisoning in recent years.

Jonathan Foulds, professor of public health sciences at  Penn State College of Medicine, says nicotine poisoning is not a new problem. “There is a long history of very young children getting a hold of their parents’ tobacco,” he says. “The most common scenario is that a toddler consumes something, and the parents don’t know how much. Then they call the poison control center or end up in the emergency room.”  In the best case that leads to anxiety, and possibly unpleasant investigations for the families, and in the worst case it could lead to loss of consciousness or death for the child, Foulds says.

He adds any substance that could be harmful to children should come in a childproof container. “There are hundreds of cases of poisoning from cigarettes every year, and so all nicotine products, including cigarettes, should be in childproof packages.”  Nicotine replacement lozenges and other novelty smokeless tobacco products that resemble candy can also be dangerous.

The liquid used in e-cigarettes is often flavored – anything from strawberry to cookies’n’cream – and may therefore smell appealing to children who come across it.

“All nicotine is a poison as are all tobacco products containing nicotine, so people using any of them should take great care to keep them out of reach of kids,” Foulds says.

A nicotine overdose usually makes a person sweaty, clammy, dizzy and nauseous. It proceeds to vomiting and loss of consciousness. It can also lead to death.  Luckily for most children, nicotine doesn’t taste good, so most do not continue to consume it once they have had a taste. But with the highly concentrated liquid nicotine, a child who drinks even a small amount could end up with a lethal dose.

Foulds says the proposed measures alone won’t solve the problem. He adds consumers need to be vigilant about using provided childproofing measures and making sure that any substances that could be harmful to children stay out of reach: “Simply put, nicotine is a poison and consumers need to take responsibility for keeping it away from children, whether it is in a childproof container or not.”

Source:  Newsroom:  Penn State Milton S. Hershey Medical Center   23-Jul-2015

Firm Smith Johnson Research released poll today finding that 51% of Coloradans would oppose Amendment 64 today. Survey finds Colorado’s marijuana legalization law does not do a good job to prevent children from using marijuana or keep our roads safe.

DENVER, CO- Smith Johnson Research, a polling firm who has worked with Democrats and Republicans, today released a poll finding that a majority (51%) of likely Coloradan voters would oppose Amendment 64 today. Only about a quarter of voters thought the Amendment had done a good job at preventing marijuana-impaired driving and workplace accident, preventing child poisonings from marijuana candies, and preventing marijuana use from increasing among youth.  “After two years of increased marijuana use a growing proliferation of marijuana candies aimed at children, more arrests in schools for pot, a jump in the number of people publicly using marijuana, and an increase in marijuana-related driving citations, we shouldn’t be surprised that Coloradans are coming around to opposing legalization,” said Kevin A. Sabet, Ph.D., an assistant professor at the University of Florida and President of SAM. ” The special interest marijuana industry has too firm a grip on regulations in Colorado, and voters don’t like what they’re getting.”

“It’s time for a renewed conversation about marijuana in Colorado,” said Ben Cort, Colorado SAM Member and an addiction treatment professional.

Bob Doyle, chair of Colorado SAM said, “We intend to kick-start those conversations so that Coloradans – rather than the marijuana industry – can determine the future of their own state.”

Forty-five percent said they would strongly oppose the measure. Only 36% said they would be strongly for the measure if it were on a ballot now. The telephone poll queried 600 likely voters, yielding a sampling error of +/- 4%. The top-cited concerns of voters were edible marijuana products and driving under the influence of marijuana.

###

About SAM (Smart Approaches to Marijuana)

SAM is a nonpartisan alliance of lawmakers, scientists and other concerned citizens who want to move beyond simplistic discussions of “incarceration versus legalization” when discussing marijuana use and instead focus on practical changes in marijuana policy that neither demonizes users nor legalizes the drug. SAM supports a treatment, health-first marijuana policy.

_______________________

iNational Survey on Drug Use and Health, Colorado State Estimates (2014).

iiDenver Police Department Versadex and OSI database (2014).

iiiDenver Police Department, 2014

ivDenver Police Department, Data from Aurora and Denver through Dec 1, 2014.

Source:  PRESS RELEASE  August 25 2015   will@learnaboutsam.org 5                                                            

June 23, 2015

Using the most sophisticated driving simulator of its kind to mirror real-life situations, new research shows that marijuana use impairs one measure of driving performance. People driving with blood concentrations of 13.1 µg/L THC – the main psychoactive ingredient in marijuana – showed increased weaving within the lane, similar to those with 0.08 breath alcohol, the threshold for impaired driving in many states. Drinking alcohol and smoking marijuana had an additive effect, so that drivers using both substances weaved within lanes even if their blood THC and alcohol concentrations were below the impairment thresholds for each substance alone. Alcohol, but not marijuana, increased the number of times the car actually left the lane and the speed of weaving. The National Institute on Drug Abuse, the Office on National Drug Control Policy, and the National Highway Traffic Safety Administration funded the study.

THC concentrations drop rapidly during the time required to collect a blood specimen in the U.S., generally within two to four hours. Oral fluid (saliva) tests for THC can be performed roadside without this long wait. However, oral fluid THC showed a two to five fold greater variability than blood tests. This indicates that while oral fluid may be an effective screening tool for detecting recent marijuana use by a driver, it may not be a precise measure of the level of impairment.

In the study, more than 50 percent of participants controlled their marijuana inhalations (called titration) so they had consistent blood THC peak concentrations, regardless of the percentage of THC in the marijuana (2.9% vs. 6.7%). This shows that past driving studies based on cannabis dose rather than blood THC may have missed the importance of dose titration. In addition, it was found that low amounts of alcohol significantly increased peak THC concentrations.

Source:http://www.sciencedirect.com/science/article/pii/S0376871615003142. 23.06.15   

To learn more about drugged driving, go to: www.drugabuse.gov/publications/drugfacts/drugged-driving. For more information, contact the NIDA press office at media@nida.nih.gov or 301-443-6245.

Colorado, March 2014. Hancock-Allen JB, Barker L, VanDyke M, Holmes DB.

Abstract

In March 2014, the Colorado Department of Public Health and Environment (CDPHE) learned of the death of a man aged 19 years after consuming an edible marijuana product.   CDPHE reviewed autopsy and police reports to assess factors associated with his death and to guide prevention efforts.

The decedent’s friend, aged 23 years, had purchased marijuana cookies and provided one to the decedent. A police report indicated that initially the decedent ate only a single piece of his cookie, as directed by the sales clerk. Approximately 30-60 minutes later, not feeling any effects, he consumed the remainder of the cookie.

During the next 2 hours, he reportedly exhibited erratic speech and hostile behaviors.   Approximately 3.5 hours after initial ingestion, and 2.5 hours after consuming the remainder of the cookie, he jumped off a fourth floor balcony and died from trauma.

The autopsy, performed 29 hours after time of death, found marijuana intoxication as a chief contributing factor. Quantitative toxicologic analyses for drugs of abuse, synthetic cannabinoid, and cathinones (“bath salts”) were performed on chest cavity blood by gas chromatography and mass spectrometry. The only confirmed findings were cannabinoids (7.2 ng/mL delta-9 tetrahydrocannabinol [THC] and 49 ng/mL delta-9 carboxy-THC, an inactive marijuana metabolite). The legal whole blood limit of delta-9 THC for driving a vehicle in Colorado is 5.0 ng/mL.

This was the first reported death in Colorado linked to marijuana consumption without evidence of polysubstance use since the state approved recreational use of marijuana in 2012.

Source: MMWR Morb Mortal Wkly Rep. 2015 Jul 24;64(28):771-2.

Abstract

BACKGROUND:

In Brazil, crack cocaine use remains a healthcare challenge due to the rapid onset of its pleasurable effects, its ability to induce craving and addiction, and the fact that it is easily accessible. Delayed action on the part of the Brazilian Government in addressing the drug problem has led users to develop their own strategies for surviving the effects of crack cocaine use, particularly the drug craving and psychosis. In this context, users have sought the benefits of combining crack cocaine with marijuana. Our aim was to identify the reasons why users combine crack cocaine with marijuana and the health implications of doing so.

METHODS:

The present study is a qualitative study, using in-depth interviews and criteria-based sampling, following 27 crack cocaine users who combined its use with marijuana. Participants were recruited using the snowball sampling technique, and the point of theoretical saturation was used to define the sample size. Data were analyzed using the content analysis technique.

RESULTS:

The interviewees reported that the combination of crack cocaine use with marijuana provided “protection” (reduced undesirable effects, improved sleep and appetite, reduced craving for crack cocaine, and allowed the patients to recover some quality of life).

CONCLUSIONS:

Combined use of cannabis as a strategy to reduce the effects of crack exhibited several significant advantages, particularly an improved quality of life, which “protected” users from the violence typical of the crack culture. Crack use is considered a serious public health problem in Brazil, and there are few solution strategies. Within that limited context, the combination of cannabis and crack deserves more thorough clinical investigation to assess its potential use as a strategy to reduce the damage associated with crack use.

Source:  http://www.ncbi.nlm.nih.gov/pubmed/26209238  BMC Public Health. 2015 Jul 25;15(1):706. doi: 10.1186/s12889-015-2063-0.

Abstract

BACKGROUND:

Cannabis use is decreasing in England and Wales, while demand for cannabis treatment in addiction services continues to rise. This could be partly due to an increased availability of high-potency cannabis.

METHOD:

Adults residing in the UK were questioned about their drug use, including three types of cannabis (high potency: skunk; low potency: other grass, resin). Cannabis types were profiled and examined for possible associations between frequency of use and (i) cannabis dependence, (ii) cannabis-related concerns.

RESULTS:

Frequent use of high-potency cannabis predicted a greater severity of dependence [days of skunk use per month: b = 0.254, 95% confidence interval (CI) 0.161-0.357, p < 0.001] and this effect became stronger as age decreased (b = -0.006, 95% CI -0.010 to -0.002, p = 0.004). By contrast, use of low-potency cannabis was not associated with dependence (days of other grass use per month: b = 0.020, 95% CI -0.029 to 0.070, p = 0.436; days of resin use per month: b = 0.025, 95% CI -0.019 to 0.067, p = 0.245). Frequency of cannabis use (all types) did not predict severity of cannabis-related concerns. High-potency cannabis was clearly distinct from low-potency varieties by its marked effects on memory and paranoia. It also produced the best high, was preferred, and most available.

CONCLUSIONS:

High-potency cannabis use is associated with an increased severity of dependence, especially in young people. Its profile is strongly defined by negative effects (memory, paranoia), but also positive characteristics (best high, preferred type), which may be important when considering clinical or public health interventions focusing on cannabis potency.

Source:  http://www.ncbi.nlm.nih.gov/PMID: 26213314   July 27th 2015

NDPA would thoroughly recommend you to read this excellent article – backed up with references.  Adolescent users of cannabis need to know that research 

has shown:

‘…….structural changes within the brain of adolescent patients using marijuana….’

‘….The cannabis users were noted to have striatal, globus pallidus, and thalamus changes showing these brain regions appearing to shrink and collapse inward.’

Thus using marijuana to get high can actually result in real brain damage.

 

Abstract 

With the recent legalization of recreational marijuana in Colorado, Washington, Alaska, the District of Columbia and legislation pending for both medical and recreational marijuana in several other states, it is important for the facts regarding its potential for serious mental health consequences to be known. Little has been said about the psychiatric risks of this substance, particularly in youth. Several studies have shown increased rates of depression, anxiety and schizophrenia among those who use marijuana on a regular basis. In addition, permanent loss of IQ and structural changes in the brain have been demonstrated with habitual use. Legalization of marijuana for recreational use can influence an adolescent’s perception of this substance as “safe.” In states that have legalized marijuana for medical purposes, there is the very real problem of “diversion.” As many as 34 percent of 12th-graders who use marijuana in states with legalized marijuana had obtained it from a person who had received it through a prescription.

Introduction

With the recent legalization of recreational marijuana in Colorado and Washington and the legal use of medical marijuana in 23 states, South Dakota will likely face another concerted effort to legalize marijuana for both medical and recreational purposes. Proponents of marijuana legalization state that marijuana is no different than alcohol and would increase tax revenues and lower the expense of prosecuting users. However, there are significant deleterious effects to the use of this substance that weigh heavily in favor of keeping the laws in South Dakota as they are. Background While known by a variety of different names (cannabis, pot, Mary Jane, weed, etc.) marijuana is a drug that is familiar to most people.

Research into the use of this drug is bringing to light a number of very serious concerns, especially within the adolescent population, that many familiar with the drug have failed to recognize in the past. The legalization of marijuana, compounded with the continued illegal use of cannabis, continues to have a major impact on the lives of the youth that we treat in our medical practices and interact with in our communities. Many users of the drug consider it to be a “safe” alternative to “hard core” drugs or alcohol; however, this belief is in stark contrast to the reputable research findings being published on this topic.

Review 

According to data published by the Centers for Disease Control and Prevention’s (CDC) Youth Risk Behaviour Surveillance (YRBS) survey in 2013 which surveyed ninth through 12th grade students in public and private schools throughout the U.S., 40.7 percent of ninth through 12th grade students reported that they had used marijuana one or more times during their lifetime – 8.6 percent of which indicated that they had tried marijuana for the first time prior to age 13. These percentages were noted to be slightly lower in South Dakota’s adolescent population with 29.6 percent of ninth through 12th grade students reporting having used cannabis one or more times in their life, and 7.2 percent of those indicating that they had first used marijuana prior to age 13. 1

One of the leading arguments of proponents for legalized marijuana is that the regulated, legal use of cannabis obtained through legal channels will result in a decrease in the overall amount of marijuana being used due to the disruption of the underground market by which people currently obtain the drug. One study, published between 2002 and 2008, which looked at adolescent marijuana use, showed that the use was lower and the perception of its riskiness was higher in states where medical marijuana was not legal. On the other hand, adolescent marijuana use was noted to be “higher and perception of its riskiness lower” in states where medical marijuana was legal. 2

Gil Kerlikowske, director of the White House Office of National Drug Control Policy stated, “Today…there is evidence suggesting that regulation schemes that have been promoted by the marijuana legalization lobby are not succeeding in preventing the diversion of marijuana into the hands of young people, as was promised to the voters.” Of interest, it should be noted that “34 percent of the 12th-graders who used marijuana and lived in states with medical marijuana laws reported that they obtained the drug through someone else’s prescription – and 6 percent said they had their own prescription”. 3

Not only are there a growing number of adolescents reporting cannabis use, but the perceived dangers of this drug are shifting as well. According to a Feb. 6, 2013 article in JAMA, adolescent attitudes toward marijuana use seem to be changing. When looking at adolescent attitudes towards marijuana use, this article indicated that only 41.7 percent of eighth-graders felt that occasional marijuana use was dangerous. 4

One of the greatest misconceptions surrounding marijuana safety is a false belief that the marijuana of the boomer generation is the same marijuana that is being used by our youth today. According to a report by the National Institute on Drug Abuse, “The amount of tetrahydrocannabinol (THC) in marijuana samples confiscated by police has been increasing steadily over the past few decades. In 2012, THC concentrations in marijuana averaged close to 15 percent, compared to around 4 percent in the 1980s.”5

Marijuana, or cannabis, is a derivative of the plant cannabis sativa. 6

Cannabis exists in many forms and levels of potency with herbal cannabis being the most commonly used form. 7   The active ingredient in cannabis is tetrahydrocannabinol. 7

Research has demonstrated that the effects of cannabis on the human body are related to the agonistic effects at the cannabinoid receptors (CB1 and CB2). 8 The CB1 receptor is a pre-synaptic receptor that is found in large quantities in the striatum, hippocampus and cerebellum and also in lesser amounts in peripheral tissues, liver adipocytes, the pancreas, the gastrointestinal tract, skeletal muscle and in immune cells. 8   In contrast, CB2 receptors are located mainly in the immune cells in tissues such as the spleen and liver. 8   Cannabinoid receptors found in neurons are activated by the neurotransmitter anandamide. 7

It is the endocannabinoid system that has been identified as one of the key components “for cortical development, neuronal migration, connectivity and synaptogenesis. During adolescence, many brain regions undergo dramatic levels of growth and synaptic remodeling,” particularly in the prefrontal cortex. 9

THC, the active ingredient in cannabis, acts like anandamide and leads to activation of the neuron. It is activation of the CB1 receptor that leads to the psychoactive effects of cannabis. 7   One theory that explains how this occurs is that by stimulating the cannabinoid receptors, the glutamate and gammaaminobutryic acid functioning is altered. This in turn leads to structural changes within the brain of adolescent patients using marijuana. 10

It is these changes in neuronal structure that may account for many of the very serious neurological effects that can accompany adolescent marijuana use. It is also the large number of CB receptors in the striatum, amygdale, hippocampus, cerebellum, and prefrontal cortex that give rise to the brain’s pleasure and reward centers, contributing to the addictive potential of the drug. 7

It is worth noting that there exists an abundance of cannabinoid receptors in the prefrontal cortex, a region of the brain that has been identified in the development of schizophrenia. 9 Research looking at the effects of marijuana use on the developing brain support the theory noted above. In a recent study at Northwestern University, it was reported that teens who smoked marijuana daily for a three year period had abnormal changes in the structure of their brain compared to teens in the control group. Brain abnormalities and memory problems were observed in these individuals in their early twenties, two years after they had stopped using marijuana. The cannabis users were noted to have striatal, globus pallidus, and thalamus changes showing these brain regions appearing to shrink and collapse inward. These individuals also had poorer working memory. The earlier the age of cannabis use, the more dramatic the brain changes and memory deficits were noted to be. 11

Although many proponents of cannabis legalization have refuted the claim that cannabis is a “gateway drug” to using even more dangerous and addictive substances of abuse, studies that have looked at substance use trends among cannabis users seem to support the “gateway drug” theory. Not only does it appear that cannabis use itself is a potential precursor to future drug use, but the age of first use of cannabis and the frequency of cannabis use seem to also be predictors of future substance abuse issues. Studies have shown that over two-thirds of those under the age of 18 who have been admitted to a drug treatment program identify cannabis as their substance of choice. It is estimated that the “risk for illicit drug initiation appeared 21 times higher among cannabis experimenters and 124 times higher among daily cannabis users than among non-users.”7

Data from the Treatment Episode Data Set (TEDS), which is a national data base of annual admissions to substance abuse treatment facilities in the U.S., shows that among adults who first used marijuana at the age of 14 or younger, 13.2 percent went on to develop drug dependence or abuse. This rate was noted to be six times higher than that of adults who first used marijuana starting after the age of 18. A 2011 review of demographic data looking at age showed that 74 percent of those surveyed in drug treatment facilities across the U.S. reported that they had first started to use substances of abuse at the age of 17 or younger, with 34.1 percent reporting they had first used substances of abuse between that ages of 15-17 and 29.7 percent reporting their first use between the ages of 12-14. Another 10.2 percent reported that they had first begun using substances of abuse before they were 11 years of age.

Of those surveyed, only 26 percent reported that they began using substances of abuse at the age of 18 or older. 12   Another claim that is often made by those in favour of marijuana legalization is that cannabis is not an addictive drug. Popular belief is that cannabis use is safe and does not carry any long term addictive potential. Credible research contradicts this belief. According to The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the current criteria for a substance use disorder is a “cluster of cognitive, behavioural, and physiological symptoms indicating that the individual continues using the substance despite significant substance related problems.” One important characteristic that defines a substance use disorder is “an underlying change in brain circuits that may persist beyond detoxification, particularly in individuals with severe disorder.” These brain changes may be demonstrated by “the repeated relapses and intense drug craving when the individuals are exposed to drug-related stimuli.” As indicated earlier in this article, the activation by THC of the CB receptors in the striatum, amygdale, hippocamupus, cerebellum and prefrontal cortex areas, which are known to give rise to the brain’s pleasure and reward center, contribute to the addictive potential of the drug. 13   DSM-5 has defined cannabis-related disorders by the following diagnostic criteria:

A problematic pattern of cannabis use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

1. Cannabis is often taken in larger amounts or over a longer period than was intended

2. There is a persistent desire or unsuccessful efforts to cut down or control cannabis use.

3. A great deal of time is spent in activities necessary to obtain cannabis, use cannabis, or recover from its effects.

4. Craving, or a strong desire or urge to use cannabis.

5. Recurrent cannabis use resulting in a failure to fulfill major role obligations at work, school or home.

6. Continued cannabis use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of cannabis.

7. Important social, occupational, or recreational activities are given up or reduced because of cannabis use

8. Recurrent cannabis use in situations in which it is physically hazardous.

9. Cannabis use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by cannabis.

10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of cannabis to achieve intoxication or desired effect. b. Markedly diminished effect with continued use of the same amount of cannabis.

11. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome from cannabis. b. Cannabis is taken to relieve or avoid withdrawal.

12 . While many of the acute effects of cannabis tend to be reversible (increased heart rate, blood shot eyes, euphoria and relaxation) proponents and opponents of marijuana legalization tend to disagree on cannabis’s ability to cause withdrawal symptoms once the drug has been discontinued. Research has identified a number of symptoms related to cannabis withdrawal such as irritability, anger, aggression, anxiety, depressed mood, restlessness, sleep difficulty and decreased appetite or weight loss. These withdrawal symptoms typically begin within 24-48 hours after discontinuation of the drug and typically last between one and three weeks. These symptoms may cause the user of the drug significant distress and contribute to relapse among those trying to abstain. 7

13.  For those who do choose to use cannabis, the use of this drug does not come without the potential for serious health risks. Research has shown that there is nearly a five time increased risk of myocardial infarction in the hour after one uses marijuana. Cannabis smokers are also exposed to many of the same harmful chemicals that cigarette smokers are exposed to. This exposure to chemicals puts one at a greater risk for developing cancer, bronchitis and recurrent lung infections. 7  Marijuana has also been shown to affect one’s level of cognition and motivation. Consider for a moment the image that comes to mind when you think of the term “pot head,” a slang term often used to describe someone that frequently smokes marijuana. This phrase, often used as a comedic portrayal of a marijuana user, depicts these frequent users of the drug as being extremely laid back, unmotivated, lazy, excessively hungry and as having poor memory.

14   Research shows that there is a connection between marijuana use and one’s motivation. Many experts agree that excessive use of marijuana, as well as a number of other “psychoactive” drugs, can lead to amotivational syndrome, a term used to describe the “variety of changes in personality, emotions and cognitive functions such as lack of activity, inward-turning, avolition, apathy, incoherence, blunted affect, inability to concentrate and memory disturbance” that is noted in chronic users of these drugs.

15.   Not only does marijuana affect one’s motivation, but also one’s cognitive ability. Marijuana use has been shown to affect adolescent academic performance. Results from the U.S. National Survey on Drug Use and Health showed that “youth with poor academic results were more than four times likely to have used cannabis in the past year than youth with average or higher grades.”

Cannabis use has also been shown to lead to decreased attention span, slower reaction times and motor/coordination deficits. Studies have also demonstrated that the use of cannabis may result in a decrease in adolescent IQ. It has also been shown that adolescents who are heavy users of marijuana have “poorer complex attention functioning, as well as poor sequencing ability, slower psychomotor speed, and difficulties in verbal story memory.”7   The motivation and cognitive affects of cannabis are also seen in adults who use marijuana. Studies indicate that a strong correlation exists between chronic cannabis use and unemployment, increased dependency on social welfare programs, and a decrease in life satisfaction rates. 7

The National Institute on Drug Abuse has also released studies showing that employees who used cannabis were more likely to have increased absences, accidents, worker’s compensation claims and job turnover when compared to non-cannabis users. 7   In recent years there has been more research into the role that marijuana plays in the development of mood disorders, anxiety disorders and psychosis. In one study of over 50,000 Swedish patients published by Zammit et al., a link was identified between marijuana use and the development of schizophrenia, a risk that was notably greater with increased marijuana use.

16.   In fact, in one published article, it was noted that of the research subjects who used cannabis over 50 times, there was a sevenfold increase in the risk for developing schizophrenia. 16   In another study, performed by Arseneault et al., it was demonstrated that in those subjects who used marijuana prior to the age of 15, there was a four times increased risk of developing schizophrenia by age 26. 16 .

Not only has marijuana been linked to increased rates of psychosis and schizophrenia, but more evidence is being reported on the link between cannabis and other mental health conditions. A study in Australia demonstrated that there was a relationship that existed in adolescent males and females with regard to the daily use of marijuana and the development of depression. 8.   This relationship was found to be the most profound in adolescent girls. In fact, in girls under the age of 15, it was found that there was a significant increase in suicidal ideation or attempts over the course of the next 15 years of their life. 8   Another research study performed in Australia found that in teens ages 13-17 who had used marijuana, there was a three times increased risk of developing depression when compared to those teenagers who had never used the drug. 8.   Increased levels of anxiety have also been linked to marijuana use. For those adolescents who used cannabis on a weekly basis and who continued to use until the age of 29, there was a significantly increased likelihood of developing an anxiety disorder. 7.

From a cognition standpoint, cannabis is known to slow a person’s ability to react, decrease their motor coordination, and decrease one’s ability to concentrate and focus. This increased level of distractibility, along with slower reaction times, has been shown to be a contributing factor in motor vehicle accidents when users of the drug attempted to drive while under the influence of cannabis. In a laboratory setting, cannabis and THC where noted to “produce dose-related deficits in reaction time, attention, motor performance and coordination, and information processing that can last up to 28 days after abstinence from the drugs.”7.

There are over 60 pharmacologically active cannabinoids in marijuana. One such chemical, cannabidiol (CBD), is a compound that may have anti-anxiety, anti-inflammatory and antispasmodic actions. It has been reported that CBD does not cause cognitive deficits or the perception of feeling “stoned.” The level of THC in medically dispensed marijuana is extremely high while CBD is low. THC is the chemical responsible for euphoria, or the “high” in marijuana. Indications for legally available marijuana for medicinal use vary from State to State and include cancer, glaucoma, AIDS, hepatitis, ALS, seizure disorders, Crohn’s disease, Parkinson’s disease and multiple sclerosis. Data collected in states where marijuana is legal for medicinal purposes suggests that the majority of those who possess medical marijuana user cards do not have one of these conditions.

Conclusion

There is a significant amount of evidence to support that the long-term use of marijuana is harmful to individuals and society, especially to adolescents. Research has shown that marijuana use can lead to an increased risk of chronic mental illnesses such as schizophrenia, depression, and anxiety by causing structural changes in a young, maturing brain. Adolescent use of marijuana can also lead to decreased intelligence levels and poor working memory which can interfere with educational attainment and create psychosocial and financial problems that no amount of increased tax revenue can offset. Although there are many in society who will lobby for legalization of this drug due to its “safety” profile, the evidence on this topic refutes this claim and we in South Dakota would be wise to continue to defeat any attempt at legalization of this harmful substance.

REFERENCES

1. Centers for Disease Control and Prevention. Youth risk behavior surveillance – United States, 2013. Morbidity and Mortality Weekly Report. 2014;63(4): 1- 170.

2. Wall MM, Poh E, Cerda A, Keyes KM, Galea S, Hasin DS. Adolescent Marijuana Use from 2002 to 2008: Higher in States with Medical Marijuana Laws, Cause Still Unclear. AEP. 2011; 21(9): 714-716.

3. Brauser D. Regular marijuana use in teens on the rise.Medscape. December 18, 2013; 1-3

4. Kuehn B M. Teen perceptions of marijuana risks shift: Use of alcohol, illicit drugs, and tobacco declines. JAMA. 2013;309(5): 429-430.

5. National Institute on Drug Abuse. Drug facts: Marijuana. January 2014;1-6.

6. Cohen M, Rasser PE, Peck G, Carr VJ, Ward PB, Thomson PM, Johnston P, Baker A, Schall U. Cerebellar grey-matter deficits, cannabis use and firstepisode schizophrenia in adolescents and young adults. International Journal of Neuropsychopharmacology. 2012;15: 297-307.

7. Douaihy A. Cannabis revisited. UPMC Synergies. 2013;1-11.

8. Rubino T, Zamberletti E, Parolaro D. Adolescent exposure to cannabis as a risk factor for psychiatric disorders. Journal of Psychopharmacology. 2012;26(1): 177-188.

9. Hill MN. Clearing the smoke: What do we know about adolescent cannabis use and schizophrenia? Journal of Psychiatry Neuroscience. 2014;133: 75-76.

10. Hilt RJ. Cannabis and the adolescent brain. Pediatric Annals. 2014;43(3): 89-90.

11. Smith MJ, Cobia DJ, Wang L, et al. Cannabis-related working memory deficits and associated subcortical morphological differences in healthy individuals and schizophrenia subjects. Schizophrenia Bulletin. 2013;40(2): 287-299.

12. SAMHSA. The TEDS report: Age of substance use initiation among treatment admissions aged 18 to 30. 2014;1-8.

13. Diagnostic and statistical manual of mental disorders. American Psychiatric Publishing; 5th edition. 2013.

14. Merriam-Webster online dictionary. http://www.merriam-webster.com. 2014.

15. Ozaki S, Wada K. Amotivational syndrome in organic solvent abusers. Nihon Yakurigaku Zasshi. 2001;117 (1): 42-48.

16. Shapiro GK, Buckley-Hunter L. What every adolescent needs to know: Cannabis can cause psychosis. Journal of Psychosomatic Research. 2010;69: 533-539.

About the Authors: Shawn Van Gerpen, MD, Assistant Professor and Residency Director, Department of Psychiatry, University of South Dakota Sanford School of Medicine. Tamara Vik, MD, Assistant Professor and Child and Adolescent Residency Director, Department of Psychiatry, University of South Dakota Sanford School of Medicine. Timothy Soundy, MD, Professor and Chair, Department of Psychiatry, University of South Dakota Sanford School of Medicine.

Source:  https://www.sdsma.org  2015

By Howard Weissman

The Post-Dispatch editorial “Descriminalização” (July 26) advocated the broad decriminalization of drugs in America, including heroin and cocaine. It emphasized the experience of Portugal, where a shift to decriminalization that began in 2001 appears to have been positive. The editorial noted that “public policy based on myths doesn’t work,” which is clearly true. But reporting the “success” of Portugal is a bit of myth, too. For example, the paper quoted misleading references in a 2009 report on Portugal by the libertarian Cato Institute. The Cato report concluded that “drug usage in many categories has actually decreased when measured in absolute terms, whereas usage in other categories has increased only slightly or mildly.” The implication: Eliminating criminal penalties for drug use did not produce the increased drug use predicted by opponents of decriminalization. However, a more rigorous analysis published last year in Law and Social Inquiry, the journal of the American Bar Foundation, found no evidence that Portugal actually changed its enforcement approach after the “radical decriminalization,” as Cato put it, of 2001. Examining the eight-year period prior to decriminalization, the Bar Foundation’s journal reported that the average number of people in Portuguese prisons for simple drug possession was about 21. Not 21 percent, but 21 people out of 10 million. That’s 0.00021 percent — effectively zero. In other words, when Portugal eliminated incarceration as a penalty, it didn’t change anything; it merely formalized the criminal justice policy it already had. I agree with the editorial’s view that we must shift our emphasis from incarceration to treatment and prevention. As young people across the St. Louis region die at the rate of one per day from heroin and the illegal use of prescription opioids, law enforcement agencies are recognizing that they cannot arrest their way out of the drug problems plaguing our communities. That said, we must, as the editorial noted, “try something different.” The United States, with 5 percent of the world’s population, consumes 80 percent of the drugs — 90 percent of all opiates. We are a country consumed with consumption, and until we begin to treat substance use disorders as a public health emergency equal to or greater than, say, the obesity epidemic, overdoses will continue to kill more of our young people than automobile accidents, and addiction will continue to be America’s most expensive problem. The Post-Dispatch editorial observes, accurately, that Richard Nixon’s 1971 War on Drugs has been a failure. But it’s worth remembering that Nixon declared two wars in 1971: the war on drugs and the war on cancer. We have not prevailed in either, but we have learned that prevention is the most effective way to address both problems, medically and economically. If we are going to seriously address the drug problem in our region and in our country, we must get serious about substance abuse prevention programming. For the cost of housing 175 inmates in one prison for one year, we could provide research-informed, effective, multi-week programming for every student in every grade in every classroom in every school in the entire St. Louis region. In a single generation, this shift in spending would drastically reduce the demand for illegal drugs and alcohol. Yes, instead of incarcerating drug users, we need to offer treatment, more and better and sustained treatment. And current drug laws are applied disproportionally to people of color, which also must change, along with mandatory minimum sentences. But we also need to initiate a massive public education/awareness campaign that generates the necessary political will to allocate the resources necessary to get serious about preventing addiction before it takes hold. Until we address our seemingly insatiable desire to drink and get high, decriminalization of all drugs is just spitting in the wind. Howard Weissman is executive director of the National Council on Alcoholism and Drug Abuse — St. Louis Area.

Source: http://www.stltoday.com/news/opinion/the-myth-of-portugal-s-drug-policy 05/08/2015

Today, NFIA, in partnership with SAM, is publishing a preliminary list of more than 800 nonprofit organizations that are working to build marijuana-free and drug-free communities. The list can be accessed at The Marijuana Report.Org website on the Links page.

Organized by state, the list provides the name, location, phone number, and link to the website or Facebook page of each organization.

“No one had any idea how many organizations are concerned about the impact of marijuana legalization on our kids until we began putting this list together, not even us,” notes William F. Carter, NFIA’s Chairman of the Board.

Adds NFIA’s Senior Advisor, Kent “Oz” Nelson, retired Chairman and CEO of United Parcel Service, “The overwhelming misinformation about marijuana that legalization proponents are putting out there is influencing young people negatively,” he says. “Just last week we learned that daily marijuana use among the nation’s college students is the highest it has ever been since surveys began. It’s encouraging to learn there are so many groups dedicated to educating the public about marijuana’s effects.”

“Like the tobacco industry, which lied to Americans about the harmful effects of cigarettes for more than 50 years, the emerging marijuana industry is telling the same kinds of lies about marijuana,” said NFIA’s President and CEO, Sue Rusche.

Added Kevin Sabet, co-founder and director of SAM, “The public deserves to hear about the substantial science that defines marijuana’s harmful effects. We are delighted to discover how many groups are out there to counteract the marijuana industry’s lies.”

Explore list here.

Source: National Families in Action September 2015

Rocky Mountain High Intensity Drug Trafficking Area (RMHIDTA) report shows significant increases in traffic fatalities, child poison control exposures, hospitalizations, youth use, amongst other alarming data, detailing how Colorado’s experiment with retail marijuana regulation is a public health and safety failure.

DENVER, CO – The Rocky Mountain High Intensity Drug Trafficking Area (RMHIDTA) has released its updated report, The Legalization of Marijuana in Colorado, The Impact, Volume 3,which outlines the most alarming data to date, demonstrating how Colorado marijuana legalization policies have harmed public safety and health.

 Highlights from the report show serious changes since 2014, when retail marijuana businesses began operating in Colorado, including:

·      Traffic deaths:  A 32 percent increase in marijuana-related traffic deaths in just one year from 2013

·      Driving under the influence:  Toxicology reports with positive marijuana results of active THC for primarily driving under the influence have increased 45 percent

·      Marijuana use by children:  Colorado youth usage (ages 12 to 17) ranks 56 percent higher than the national average

·      ER visits:  A 29 percent increase in the number of marijuana-related emergency room visits

·      Hospitalizations:  A 38 percent increase in the number of marijuana-related hospitalizations

·       Poison control: Marijuana-only related exposures increased 72 percent in only one year

·       More marijuana trafficking: The yearly average interdiction seizures of Colorado marijuana increased another 34 percent

“This report serves as a wake-up call for all Coloradans,” said Bob Doyle, chair of Colorado SAM. “It is time to stop yielding to Big Marijuana special interests and put health and safety ahead of marijuana commercialization.”

“For too long, the marijuana industry has been telling Americans that ‘everything’s fine’ in Colorado. This data-driven report tells a very different story,” said Kevin Sabet, President of SAM and an assistant professor at the University of Florida.

Jo McGuire, co-chair of Colorado SAM added, “We are prepared to engage Colorado community members in conversations that will send strong messages to our state leaders that these outcomes are unacceptable and legalization clearly does not work.”

In August 2015, poll results showed that popularity for marijuana legalization amongst Coloradans is losing support over concerns of traffic problems, youth usage, child exposures and the proliferation of edible products.

Source: Press Release 15^th September 2015 www.learnaboutsam.org

A new study has caused quite a stir among would-be marijuana cognoscenti because it contradicts major research about the impact of marijuana on physical and mental health. The Marijuana Report asked neuroscientist, Bertha K. Madras of Harvard Medical School, to look briefly at the study. Dr. Madras served as Deputy Director for Demand Reduction at ONDCP.

Bertha K. Madras, PhD

A recent manuscript by Bechtold et al,¹ describes a longitudinal assessment of a population of marijuana users which, after data collection, were divided into four user groups: (1) nonusers to low use (48%, n=186); (2) limited to adolescent use (10%, n=38); (3) late initiators and increasing (20%, n=76); and (4) early onset with chronic use (22%, n=86). Marijuana use was monitored from adolescence (age 15) into young adulthood (age 26). Ten years later, and ten years after the last determination of marijuana use, study authors asked the subjects, now at an average age of 35.8 years, to report their health status. Each of the four groups self-reported no differences in physical or mental health problems in their mid-thirties. The authors concluded that regardless of how much and how long marijuana was used, and regardless of race, the physical and mental health problems of these four groups were similar. That is, high marijuana use for prolonged periods was not associated with any physical or mental health problems. They also claimed that this is a definitive study because it was longitudinal and superior to other published reports on long-term health consequences of marijuana.

A critical evaluation of the validity of the findings and sweeping conclusions is essential, lest they are interpreted inappropriately. A perusal of the study and the authors’ stated caveats in the manuscript reveal significant weaknesses, with the use of an unrepresentative, possible archaic population, inadequate sample size, inadequate methodologies to assess mental health and physical problems, (self-reports, evaluation of psychiatric status without considering the “spectrum” nature of psychiatric conditions, and absence of addiction evaluation). The findings conflict with other well designed longitudinal studies that assess long-term consequences of marijuana use with early age of initiation of marijuana.

This type of study would not approach or fulfill rigorous criteria for longitudinal research, as exemplified by the 2014 NIDA funding opportunity with similar goals (see “An example of a well-designed study,” last section). The conclusions conceivably are compromised by the following perceived shortcomings of the study.

Population Concerns

1. The sample size, 386 people, was too small to detect a marijuana effect on psychotic disorders or on other health conditions. NIDA recommends a sample size of 10,000 to detect differences (see final paragraphs). About 50% of the subjects – age 14 – were selected on the basis of their high scores on anti-social behaviors 1 (conduct problems) and the remainder from adolescents without high anti-social behavior scores, but it is not clear whether the drop-out rate from the study was equally represented by both categories. Did more people with early onset anti-social behaviors drop out and does this skew the conclusions? Was there under-sampling of a population at highest risk? There is strong and accumulating evidence that marijuana use is associated with psychosis, with earlier age of onset of schizophrenia, and with worsening of psychotic/schizophrenic symptoms. These association studies were gleaned from thousands of people, not from fewer than 400 subjects, especially when only 100 people are in the high risk group. The small sample size would also make it difficult to detect other serious marijuana-associated medical problems. Reporting of cardiovascular complications related to marijuana and the extreme seriousness of these events (death rate of 25.6%) is increasing, but this occurs in a small number of users (one estimate is 1.8%).

Marijuana is a possible risk factor for cardiovascular disease in young adults,⁶ with a temporal association between marijuana use and heart attacks, sudden cardiac death, and for stroke, transient ischemic attack, and marijuana-induced arteritis.⁷ Pulmonary symptoms attributable to marijuana use, even with less intense use, include chronic bronchitis, daily cough, and phlegm production (four quality studies document these findings). No power analysis indicates adequacy of sample size.

Think about this: The prevalence of schizophrenia is 1 in 100. If you sample only 86 subjects of the riskiest group, “early onset chronic users” category, it is unlikely that you can detect a significant increase in prevalence of psychosis or schizophrenia. Another example: a recent study found the incidence of serious cardiac effects of marijuana in 1.8% of heavy users. Was the sample of early onset chronic users (86 people) large enough to detect serous cardiac effects, especially from self-reports?

2. The study does not have a drug-naïve population for comparative measures of outcomes. The authors report that the amount of marijuana used during adolescence and early adulthood had no effect on the occurrence of a range of health problems.

Think about this: The study has no group that controls for a general, representative population, a non-drug using population. Some other studies have shown different outcomes among youth or young adults who choose not to use, those who use occasionally, or heavy users. What populations are these groups compared to? Are the group sizes large enough to detect differences?

3. The populations and use patterns investigated in this study are anachronistic and conceivably irrelevant for 2015. Subjects were initially screened in 1987-1988, with a majority of users recruited that did not fall into the heavy use range (daily or near daily use), a use pattern increasingly observed at the present time. The majority of subjects used marijuana during the 1990’s when the psychoactive THC content of marijuana was relatively low, compared with current concentrations.

Think about this: The most serious health outcomes associated with marijuana use, including addiction, occur in heavy users (daily or near daily use) using for long periods of time. Currently, marijuana access has risen rapidly as its legal status changes, its perception of harm has plummeted among youth, along with a rising perception that as a medicine it is safe and can be used daily. Daily use of high potency 2 marijuana among adolescents and young adults is near or at its highest level in nearly three decades. The populations of this study may be irrelevant to current trends, especially since 2009, as marijuana potency is at its highest level ever, availability is greater because of reduced federal and state oversight, as daily use increases, and perception of harm declines. These factors conceivably influence self-reporting of effects and their magnitude. Are the outcomes of this study relevant to current use patterns and marijuana potency?

4. The population is not representative of the general population: (a) the prevalence of concussions (27.7%) is inordinately high. (b) Death by gunfire is inordinately high. No explanations are offered for the abnormally high prevalence of concussions or death by gunfire, and whether this population has a higher than average prevalence of cognitive impairment. Was there a relationship between concussions and marijuana use or self-reporting of adverse health problems?

Think about this: The overall rate of traumatic brain injury (concussions) presenting in emergency departments in the United States (recent CDC statistics) is 19 per 100,000 persons; for males in this age group, it is about 470 per 100,000 persons (or 4.7 for each 1,000 persons). A concussion rate of 27% of this population (270 per 1000 persons) is about 60 times higher than the general population within this age range. Some rigorous research criteria exclude subjects with traumatic brain injury because of the potential for cognitive impairment. The high numbers of concussions and deaths due to gunfire are anomalous if compared to statistics within the general population. Is this sample representative?

5. Self-reported medical health problems by these subjects differ from population statistics, on the basis of occurrence by race. According to CDC statistics in 2010, the prevalence of diseases in the general population among African American (AA) adults compared to white (W) adults is different than reported in this study. The CDC ratios (AA:W) for the general population are: Diabetes, CDC = 1.6:1; this study = 4:0. Chronic kidney disease, CDC = 1.14:1, this study = 0:0.6. Sexually transmitted diseases, CDC = 4:1; this study = 0.5:1.1.

Think about this: The health problems self-reported by the African-Americans and white subjects may or may not be accurate, but they differ from the CDC prevalence data for the general population. Differences highlight the need for recruiting sufficiently large numbers of subjects to be representative of the population as a whole. Do differences reflect the unusual populations of this study, which may not generalize to the entire population?

Methodological Concerns: Outcome measures

6. The purpose of the study was to determine whether different patterns of marijuana use among youth affected mental and physical health. All findings are based on an inadequate method for measuring outcomes – self reports, because of potential bias, recall errors, and reliance on self-knowledge of medical conditions. The authors did not investigate medical records, did not confirm marijuana and other drug use with biometric tests, did not interrogate contacts, and did not inquire about sequence of use of other drugs.

Think about this: More than 75% of people harbouring a substance use disorder (SUD), based on objective DSM-IV criteria (Diagnostic and Statistical Manual-IV), do not think they have a SUD and do not seek treatment.² To rely solely on self-reporting of mental or physical health problems with a questionnaire, raises doubts about the overall study design and conclusions. Other examples: Fifty percent of men who died of heart disease had no obvious symptoms. A diagnosis of diabetes or high blood pressure is made by biometric testing, not by self-reports. Without confirmation from medical records or physician-initiated tests, is it possible to know high blood pressure or diabetes with certainty?

7. Following from #6 above, there is no evidence that subjects reported health outcomes based on their medical records. Authors did not question whether study participants had visited a physician during the past year, past five years or ten years since the last contact. Confirmation of medical conditions by a medical record would strengthen the conclusions. The core outcomes of this study are mental and physical health. Knowing whether the mental and physical health of subjects in this study had been objectively diagnosed by a physician or specialist (psychiatrist, addiction medicine) is critical. The unknown medical record, combined with an assumption that subjects’ self-reports were accurate, diminish the convictions of the authors’ conclusions.

Think about this: Many health problems are not apparent to individuals until they are referred to, or measured by a professional; addiction, high blood pressure, diabetes, cancer, and cognitive impairment. Were all subjects reporting results from a recent annual check-up? Unless this information and results are provided, can one assume that self-reports are accurate?

8. Following from #6, #7 above, mental health diagnoses were based on questionnaires, not on biometric testing or long-term assessment (mental health diagnosis requires more than a single session and long-term evaluation). The diagnosis of psychosis, mood disorders, and anxiety disorders, does not rely solely on a person’s response to a single oral or written questionnaire or impressions of their own health. Definitive diagnosis for a serious mental health problem such as schizophrenia, requires systematic questioning, and over a significant period of time to determine whether symptoms persist and are not temporary aberrations. Moreover, mental health problems including substance use disorders (addiction), occur along a continuum of mild to severe. It is possible that the focus on a diagnosis of a psychotic disorder in the current study limited their ability to detect subtle effects of marijuana use on brain function, thought processes, or early psychotic symptoms. Scores were not generated that reflect this continuum. Authors arbitrarily selected a cut-off point to rate the presence or absence of a diagnosis.

Think about this: It is simple to detect one’s own asthma or headache but, for many mental health problems, self-diagnosis may be inaccurate. Can one know if they are developing subtle signs of a mental problem or cognitive impairment unless measured objectively? Can one know if an early stage of cancer is present unless discovered by imaging, by biopsy, or gene expression profiling? Can one know if 4 asymptomatic heart disease is present without ECG testing? Is self-diagnosis of an early stage of mental illness reliable?

Methodological concerns: Marijuana use

9. The investigators divided marijuana users over time into four groups, using model fit statistics. The chart showing marijuana use over time for these four groups provides no error bars indicating whether these groups are significantly different at each age during the study.

Think about this: One would assume the groups were different, based on the four-group solution that was selected on the basis of model fit statistics, substantive interpretation, face validity of classes, parsimony, and consistency of findings with prior research. But, it would be helpful if error bars representing range of use at each age were included to assure the reader that the group divisions based on subjective criteria (interpretation, face validity of classes, parsimony, and consistency of findings with prior research) are transparently clear at each age.

Some data of the marijuana use component are missing: 46% of the subjects had voids in data. Almost half of the subjects did not report marijuana use at various times during the 10 years of survey. This partial set of data is problematic, even though authors claim missing data were from people similar to those who yielded full data sets, and it is possible to interpolate missing data. Reasons for these data gaps should be provided.

Think about this: If a segment of data is not available, does it invalidate or skew the chart showing trends of the four groups? Uncertain.

10. Marijuana use was not questioned at the end of the study (age 36 years). Strong longitudinal studies have shown that early onset and heavy use of marijuana is associated with or is a causative agent in long-term adverse effects on educational achievement, employment, welfare dependency, use of other illicit drugs, psychotic symptoms, I.Q. reduction, and others.^3-5 This study provides marijuana use rates until age 26, measures life outcomes at age 36 but doesn’t ask subjects whether they used marijuana from age 26-36 and at age 36. Most users apparently were not consuming daily or nearly daily and three of the four groups had largely stopped using by the age of 26. Why was marijuana use not measured at the end of the study?

Think about this: It is critical to know whether the people using marijuana from age 15-26 years, were still using at age 36, at the time the health outcomes were questioned. If you are studying whether marijuana has interfered with the mental and physical health of subjects at the present time, is it not logical to interrogate whether they are currently using, or if they stopped and when they stopped? If they stopped 10 years before the study, then long-term consequences may be less likely.

11. Marijuana potency was far lower (1980’s to 1990’s) during the period of marijuana consumption of this population. This conceivably affects outcomes and consequences.^5.

12 Quantity, frequency, and potency of marijuana use is a critical measure. Frequency and potency were not questioned. The main outcome measure was the number of times marijuana was used during the year. The patterns of use, number of times used each day, and potency, were not interrogated during each annual survey.

Methodological concerns: Outcomes not measured

13. Marijuana addiction (cannabis use disorder or CUD), among the most significant of the adverse effects of marijuana, was not interrogated. The prevalence of CUD is related to age of onset, quantity and frequency of use and is closely linked to other life outcomes.

Think about this: Addiction is among the most prominent effects of chronic marijuana use, and yet the study did not ask about addiction.

14. Life outcomes were not measured (employment, educational achievement) at the

end of the study. Other strong longitudinal studies have interrogated life outcomes and concluded that marijuana has adverse long-term effects on employment and educational achievement, and other social consequences, as a function of age of onset and quantity used.^3-5

Think about this: Longitudinal studies indicate that heavy continuous marijuana use leads to lower socioeconomic status and achievement (e.g. college education, employment) than infrequent or no use. When an individual is using marijuana very frequently for a number of years, are they more or less likely to maintain a job, complete high school or college, or be on welfare?

15. Cognitive testing was not measured. Cognitive impairment is one of the hallmarks of acute and possibly long-term marijuana use. It is also associated with other adverse life outcomes.

Think about this: If you were designing a study to learn whether an intoxicant that is known to interfere with learning, memory, and executive function, would you omit evaluating learning and memory from the study?

16. A number of health problems questioned (e.g. cancer, high blood pressure, heart attacks, strokes) arise later than the average age of the subjects (mid- 30’s). The health questionnaire was filled out by marijuana users in their mid-30’s, an age at which most significant health problems are not yet manifest.

17. Acute effects of marijuana were not asked: intoxication, accidents, emergency department mentions, unplanned pregnancies, and HIV-AIDS. For example, a recent European study collected Emergency Department data from 14 European centers for six months to determine acute toxicity of marijuana. Of the sample, 356 (16.2 %) involved marijuana alone or together with other drugs/alcohol and 1.6 % with marijuana alone. Of the 35 non-fatal lone marijuana presentations, the most commonly reported features were agitation/aggression (22.9 %), psychosis (20.0 %), anxiety (20.0 %), and vomiting (17.1 %). There was one fatality due to prolonged cardiac arrest, with no other drugs detected.⁶

Think about this: Acute marijuana toxicity can lead to emergencies requiring medical attention. Does omission of this from the questionnaire achieve a comprehensive view of medical consequences of marijuana?

Citations and Comparison with other Studies

18. Authors omit mention of important recent longitudinal studies that show different outcomes than their own study. Other carefully controlled and longitudinal studies have shown that early age of onset of marijuana use is associated with a number of mental and physical consequences, including addiction, cognitive deficits, mental health problems, educational and employment outcomes, and others. Citations 3 and 4 are not mentioned, others are dismissed with a list of weaknesses, even though the current study is fraught with significant weaknesses.

19. The authors attempt to support their conclusions by dismissing well designed reports by others. In the introduction, they do not discuss severe limitations of their own study: (e.g. daily use of high potency marijuana is currently at its highest level in 30 years of surveys, in contrast with their subjects; weaknesses of self-reported medical and psychiatric conditions, and others as stated above). Instead, the introduction curiously offers a critique, entitled Limitations in Prior Research. In it they conclude that “prior research has produced mixed findings regarding the associations between chronic marijuana use and indicators of physical and mental health, …and that individuals who begin using marijuana frequently during early adolescence and those who use at high frequencies throughout adolescence and young adulthood tend to develop more health problems (i.e., psychotic symptoms, respiratory problems) than infrequent/nonusers, in contradistinction to their own findings.

Think about this: In their critique:

(1) The authors claim this study is among a “handful of studies that have been able to prospectively delineate subgroups of individuals with varying developmental patterns of marijuana use from adolescence into young adulthood.” The strength of the present study was to document marijuana use, but not in depth and not confirmed by biometric testing, annually for the decade of life encompassing adolescence and early adulthood. Yet, other research has interrogated key variables, age of onset, frequency and quantity of marijuana use (confirmed with biometric testing), some in prospective, longitudinal studies, others in cross-sectional studies. The medical record at the study’s inception is of limited value because it is neither comprehensive nor independently verified. The initial assessment of 15-year-old boys was inadequate and was not followed by a longitudinal assessment, except for marijuana use. The 10 year hiatus in data collection is a weakness. Self-reports of mental and physical health are inappropriate.

(2) They claim that “few longitudinal studies have examined whether young men who exhibit early and chronic developmental patterns of marijuana use are more likely to exhibit both physical and mental health problems in their mid-30s.” Unfortunately, this study does not answer this question because of the quality of the outcome measures, no marijuana use patterns recorded for 10 years, and the only medical and 7 mental health outcomes are reported by mothers of the subjects around age 15 and by the subjects themselves at ~ age 36.

(3) They claim that “Many studies have failed to control for important confounding factors, such as health problems that predated the onset of regular marijuana use and co-occurring use of tobacco, alcohol, and hard drug.” Yet, the documented and age appropriate deficits associated with marijuana use, in-depth psychiatric status, cognitive impairment, declining academic performance, school drop-out rates, accidents, and others were not interrogated in this survey.

Limited references

1. Bechtold, J., Simpson, T., White, H. R., & Pardini, D. Chronic Adolescent Marijuana Use as a Risk Factor for Physical and Mental Health Problems in Young Adult Men Online First Publication, August 3, 2015. http://dx.doi.org/10.1037/adb0000103 Psychology of Addictive Behaviors.

2. Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

3. Fergusson DM, Boden JM, Horwood LJ. Psychosocial sequelae of cannabis use and implications for policy: findings from the Christchurch Health and Development Study. Soc Psychiatry Psychiatr Epidemiol. 2015 May 26. [Epub ahead of print]

4. Fergusson DM, Boden JM. Cannabis use and later life outcomes. Addiction. 2008 Jun;103(6):969-76; discussion 977-8.

5. Meier MH, Caspi A, Ambler A, Harrington H, Houts R, Keefe RS, McDonald K, Ward A, Poulton R, Moffitt TE. Persistent cannabis users show neuropsychological decline from childhood to midlife. Proc Natl Acad Sci U S A. 2012 Oct 2;109(40):E2657-64.

6. Dines AM, Wood DM, Galicia M, Yates CM, Heyerdahl F, Hovda KE, Giraudon I, Sedefov R; Euro-DEN Research Group, Dargan PI. Presentations to the Emergency Department Following Cannabis use-a Multi-Centre Case Series from Ten European Countries. J Med Toxicol. 2015 Feb 5. [Epub ahead of print]

7. Jouanjus E, Lapeyre-Mestre M, Micallef J; French Association of the Regional Abuse and Dependence Monitoring Centres (CEIP-A) Working Group on Cannabis Complications*. Cannabis use: signal of increasing risk of serious cardiovascular disorders. J Am Heart Assoc. 2014 Apr 23;3(2):e000638. doi:10.1161/JAHA.113.000638.

8. Thomas G, Kloner RA, Rezkalla S. Adverse cardiovascular, cerebrovascular, and peripheral vascular effects of marijuana inhalation: what cardiologists need to know. Am J Cardiol. 2014 Jan 1;113(1):187-90.

An example of a well-designed longitudinal study

NIDA Funding Opportunity http://grants.nih.gov/grants/guide/rfa-files/RFA-DA-15-015.html

Research Design and sample should describe the following:

• A longitudinal single-cohort design to prospectively examine the neurodevelopmental and behavioral effects of substance use from early adolescence through the period of risk for substance use and substance use disorders.

• Participants, approximately ages 9-10 at baseline, who are largely naïve to substance use at the time of study enrollment; the focus on a largely asymptomatic population at baseline provides the opportunity to define brain and behavioral risk factors and trajectories before the onset of substance use;

• A design with a sample size that is sufficiently large to achieve the study goals; preliminary estimates indicate a sample size of approximately 10,000 participants (combined across sites) at the end of the 5-year funding cycle would be needed, though a smaller sample can be proposed if justified by feasibility and statistical-power analyses;

• A sampling strategy designed to establish a community-based sample that is broadly representative of and generalizable to the U.S. general population as a whole, including males and females, as well as major racial, ethnic, and sociodemographic subgroups of the population; it is recognized that the level of precision achieved for various subgroups may vary, and that probability-based sampling and oversampling of certain demographic subgroups or geographical regions may be required;

• A sampling design that considers oversampling of population subgroups at greater risk for uptake of substance use during adolescence (e.g., positive family history of substance use disorders, externalizing psychopathology, disinhibitory traits, prenatal exposure to substances);

• A research approach that considers incorporating genetically informative designs (e.g., family based) or subjects (e.g., twins, siblings);

• A sampling design to produce geographical variation of macro-level factors associated with substance use (e.g., state-level policies concerning the permissiveness of marijuana, alcohol, and tobacco use; regional variation in prevalence of marijuana, alcohol, and tobacco use; rural, urban and suburban populations);

• State-of-the-art data-collection procedures (e.g., computer-administered/assisted interviews), practices (e.g., cultural matching) and quality-control processes (e.g., random verification, logic-checking);

• Standardized measures that, where possible, are compatible with data-harmonization efforts (e.g., PhenX Toolkit) and ongoing studies of substance use and neurodevelopment;

• Comprehensive multi-informant (e.g., respondent, parent/guardian, sibling, etc. as appropriate) assessment of substance use to permit estimates of prevalence, incidence, and change in use patterns (e.g., quantity, frequency) by specific substances (e.g., nicotine, alcohol, marijuana), products and product types (cigarettes, e-cigarettes, snuff, beer, liquor, joints, blunts), and modes of administration (e.g., inhalation, oral, drinking, nasal); measures of change should be sensitive enough to detect dynamic patterns among adolescents as they enter and pass through the period of risk for substance use;

Behavioral Measures and Biospecimens should describe the following:

• Comprehensive and multi-level assessment of predictors, mediators, moderators, and outcomes associated with substance use (e.g., demographics, pubertal status, personality traits, parental monitoring, peer group deviance, family structure, parent-child relationships, prosocial behaviors, romantic relationships, stressful events, availability of substances, state and local policies related to marijuana, alcohol, and tobacco use, educational attainment, learning 9 disability designation or receipt of services, crime, unemployment, experience and/or witnessing of trauma or violence);

• Assessment of concurrent and historical participation in interventions that may prevent or mitigate substance use and its consequences (e.g., pre- and post-natal prevention programs; Head Start; receipt of counseling, psychotherapy and other behavioral health interventions or services; family or classroom-based prevention interventions);

• Comprehensive measurement of confounders and other risk factors (e.g., prenatal exposure, abuse or trauma, drug availability, exposure to environmental risk factors, sport injuries especially to the head, etc.);

• Rigorous quantitative and categorical assessment of symptomatology and psychiatric disorders, including severity;

• Family history assessment of substance use disorders and other psychopathology;

• Age-appropriate assessment of HIV-risk knowledge and behaviors;

• Neuropsychological battery of tests that is developmentally sensitive and that allows for the assessment of major neurobehavioral dimensions associated with substance use (e.g., attention, information processing, learning and memory, cognitive control, motivation, emotional regulation, disinhibition, risk taking);

• Screening for drug intoxication prior to behavioral, cognitive, or functional imaging sessions and neuropsychological assessment, with delineated thresholds for inclusion/exclusion;

• Clear and justified inclusion/exclusion criteria to identify individuals unable to complete the assessment protocol for various reasons (e.g., use of certain prescribed medications, language/reading impairments, brain injury, severe mental illness, etc.);

• Detailed plans and procedures to collect, process, analyze, and store biospecimens (e.g., urine, blood, saliva, hair) indicative of substance exposure; • Additional biospecimens should be collected for subsequent research on genetic/epigenetic factors influencing or affected by substance use, with accompanying plans for analyses.

The Rocky Mountain High Intensity Drug Trafficking Area released its third annual report this week. The organization has been tracking the impact of marijuana legalization in Colorado since the state first legalized the drug for medical use in 2000, passed legislation to allow dispensaries beginning in 2009–which spawned a commercial marijuana industry–and legalized pot for recreational use in 2012. The 2015 report shows that by 2013, Colorado marijuana use was nearly double the national usage rate. The state ranked 3rd in the nation for youth use in 2013, up from 14th in 2006; 2nd in the nation for young adult use in 2013, up from 8th in 2006; and 5th in the nation for adults, up from 8th in 2006.

Drug-related school expulsions, most of which are marijuana-related, far exceed school expulsions for alcohol use. Note the sudden jump in drug expulsions that began in 2009 when Colorado allowed a commercial marijuana industry to emerge. Total school suspensions and expulsions rose from 3,736 by the end of the 2008-2009 school year to 5,249 by the end of the 2013-2014 school year.

Marijuana-related traffic fatalities in Colorado also began rising with the introduction and growth of the commercial marijuana industry in 2009. While total State wide fatalities decreased between 2006 and 2014, marijuana-related fatalities increased over that time.

Colorado marijuana-related emergency room visits increased to 18,255 in in 2014.

Marijuana-related hospitalizations have nearly quintupled since Colorado first legalized marijuana for medical use. Again, note the surge starting in 2009 when growers, processors, and dispensaries were first authorized, and a commercial industry began developing extensive marijuana products such as edibles, vape pens, and butane hash oils (BHO) to attract new customers. BHO has elevated THC levels to the highest seen in the nation; some contain 75 percent to 100 percent THC.

Although there is no data to document whether the increase in homelessness in Denver and other Colorado cities is marijuana-related, those who provide services to the homeless report that many say they relocated to Colorado because of marijuana’s legality.

In Colorado, marijuana is not available in about three-fourths of the state. Of a total 321 local jurisdictions, 228 (71 percent) ban all forms of marijuana businesses; 67 (21 percent) allow both medical and recreational marijuana businesses; and 26 (8 percent) allow only medical or recreational marijuana businesses.

Read report here.

This wonderful book tells much of the story about cannabis that we are not allowed to hear.

I strongly commend it to you all. It does the neuroscience very well, and reviews much of the brain and neuroscience nicely and in a sensible and balanced way, and also indicates how the crazy side skews their presentation of evidence to aid and abet their grossly dishonest agenda. It actually gives a list of 21 social harms directly related to drug addiction – and then says that there are several dozen more which have not been mentioned!!!!

It is written by a senior practising psychiatrist majoring in addiction medicine, who was also a cannabis addict from 17-19 years of age. So he has known both sides of the fence.

Source: Book reviewed by Stuart Reece sreece@bigpond.net.au  Sept 2015

https://books.google.co.uk/