In the first 5 months of this year,  nine children had been treated at the Colorado Children’s Hospital in Aurora for ingesting marijuana.  Seven of these children were in intensive care.    By August, at least 3 more children had been in emergency treatment for marijuana at the same hospital.

The first stores for recreational marijuana opened in January, 2014.  Marijuana overdoses in children began October, 2009, when medical marijuana suddenly exploded in Colorado.  There were no such incidences recorded between 2005 and 2009, according to Dr.George Wang, head of emergency services at Colorado Children’s Hospital.  He explained the problem in a Colorado Public Radio interview last year.   Colorado’s medical marijuana was approved by voters in 2000, but the expansion of medical marijuana in 2009 caused the new problem.  The pace doubled this year, as a commercialized marijuana industry started selling new products.  “Legalizing creates greater promotion…. and also legitimizes the drug,” according to Bob Doyle, who was featured in a video we shared.

In response to two deaths from edible marijuana, the governor signed legislation to regulate marijuana in May.  The laws will go into effect in 2016.  Edible pot will require child-proofing, as is required for pharmaceutical and over-the-the-counter medicine.

Despite labels, many of the children who have been hospitalized were too young to read.

A TV investigation showed that most children can’t tell the difference between the “adult candies” and those that are only for children.  Previously, we published pictures of commercial pot candies available in Colorado, and in California.  Here’s an additional sampling.

Even when parents try to keep it away from them, children go for sweets.  Cartoon-like characters and bright colors will always attract children.   It’s logical that school-age children could be so attracted to the packaging that they would not bother to read.

Both the manufacturing of marijuana sweets and the packaging make them so appealing.  Edible pot processors make products that closely imitate familiar products, like Cap’N Crunch cereal and Pop Tarts. One company’s Pot-tarts are hard to distinguish from Kellogg’s Pop-tarts.

The Hershey Co. has filed a trademark infringement lawsuit against Tincture Belle, a Colorado marijuana edibles company, claiming it makes four pot-infused candies that too closely resemble iconic products of the chocolate maker.

The specific products which mimic the look of Hershey’s candies are: Ganja Joy, like Almond Joy; Hasheath, which looks like Heath Bars; Hashees which resemble Reese’s peanut cups, and Dabby Patty, made to look like York peppermint patties.  The company’s website says its products “diabetic safe and delicious” and helpful with a variety of issues, including pain, headaches and insomnia.

Hershey says the products are packaged in a way that will confuse consumers, including children. The lawsuit alleges that Tincture Belle “creates a genuine safety risk with regard to consumers” who may inadvertently eat them thinking they are ordinary chocolate candy.   Other pot candies that look like Kit Kats, Milky Ways, Nestle’s Crunch and Butterfingers.  Will other candy companies like Nestles or Mars file a lawsuits, also?

Source:  http://www.poppot.org/2014/08/24/new-marijuana-candy-tricks-kids/

Today’s Reality

Even if you smoked pot 20+ years ago without harm, today’s situation is different.  We want our children to avoid marijuana because they care about the risks in marijuana itself.

Here’s the facts for raising your children today:

* Marijuana has been modified since 1994. The THC, which gives the high, is 3-10x stronger in the plants of today.  If a child begins using today’s pot , it’s like to learning to drink with grain alcohol, instead of beer or wine.  Also, youth today frequently use the potent “dabs” “wax” and “budder.”  These are extractions can have 40-80% THC.

* Marijuana is addictive, contrary to a popular myth, particularly with today’s stronger strains of pot.

* In states with medical marijuana, teen usage is much higher than in other states, and many teens who use pot get it from some marijuana cardholders.

* Those who begin in adolescence or their teens, have an addiction rate of 17 percent, as opposed to 9 percent for those who begin using marijuana as an adult. *Emergency Department hospitalizations from marijuana rose from 281,000 to 455,000 between 2004 and 2011, making it 2nd amongst the illegal drugs causing ER treatment.

* Individuals responses to marijuana can be vary greatly, and the potential for paranoia and psychotic reactions are real side effects, omitted in the pot propaganda.

* Marijuana is fat soluble and stays in the body for weeks, which is why some people have flashbacks.

* The  brain, which is 1/3 fat, isn’t fully developed until age 25 or later, and until it is, marijuana can cause irreversible damage.

* Marijuana is not as widely used as alcohol,  6-7% of the adult population, vs.  66% who drink, one reason the comparison doesn’t work. * Marijuana usage causes traffic deaths and it is not safe to combine with driving.

* More teens seek substance abuse treatment for pot than any other legal or illegal substance. * Marijuana is a gateway drug,  because nearly every young person who develops a drug addiction begins with marijuana.  Early pot users such as Robert Downey, Jr. (age 9), and Cameron Douglas  (age 13), prove that the stranglehold of drug addiction lasts for years.

* A multi-year study out of New Zealand, tracking marijuana users and through their mid-30s showed IQs decrease an 6-8 percentage points over time.  Again, we point to the medical studies summarized on this webpage.

* In a recent study, schizophrenics who have used marijuana had an onset of the disease 2-1/2 years earlier than those who did not use marijuana. * Marijuana can trigger psychotic symptoms and/or mental illness, and cognitive decline in youth, more quickly than alcohol, while tobacco does not.

* Since marijuana usage increases the odds of developing a mental illness, expansion of pot will expand mental health treatment needs.

* Efforts to legalize for age 21+  hide the motivation to attract young users and build big profits.  Legal pot mean more young users.

* Marijuana usage is associated with greater risk for testicular cancer in males.

* With universal health care, all of us will pay for the increase in medical care for those needing help from pot abuse.

* The number of pot-related hospitalizations in Colorado accelerated in 2009 and went out of control in the first half of 2014.

* Existing mental health issues, such as ADHD, anxiety and depression, greatly increase the use of drugs for self-medication.

Mental Health, Physical Health Alike

“We cannot promote a comprehensive system of mental health treatment and marijuana legalization, which increases permissiveness for a drug that directly contributes to mental illness,”  states former Congressman Patrick Kennedy, who fought tirelessly on behalf of parity for mental health treatment. Kennedy and policy expert Kevin Sabet promote  Smart Approaches to Marijuana.

* The National Alliance for Mental Illness lists four illegal drugs which cause psychosis: cannabis, LSD, methamphetamine and heroin and two classes of legal drugs, amphetamines and steroids. Pharmaceutical drugs are sold with warnings, while marijuana isn’t.

Sharon Levy, Chairwoman of the American Academy of Paediatrics committee on substance abuse, said “We’re losing the public health battle” and policy is being made by legalization advocates who might be misinformed about marijuana’s dangers.”

Source:  http://www.poppot.org/2016/08/08/latest-child-dangers-marijuana-edibles/

Smart Approaches to Marijuana’s 2017 publication references academic studies which suggest that marijuana primes the brain for other types of drug usage.  Here’s the summary on that subject from page 4, Marijuana and Other Drugs: A Link We Can’t Ignore :

MORE THAN FOUR in 10 people who ever use marijuana will go on to use other illicit drugs, per a large, nationally representative sample of U.S. adults.(1) The CDC also says that marijuana users are three times more likely to become addicted to heroin.(2)

Although 92% of heroin users first used marijuana before going to heroin, less than half used painkillers before going to heroin.

And according to the seminal 2017 National Academy of Sciences report, “There is moderate evidence of a statistical association between cannabis use and the development of substance dependence and/or a substance abuse disorder for substances including alcohol, tobacco, and other illicit drugs.”(3)

RECENT STUDIES WITH animals also indicate that marijuana use is connected to use and abuse of other drugs. A 2007 Journal of Neuropsychopharmacology study found that rats given THC later self -administered heroin as adults, and increased their heroin usage, while those rats that had not been treated with THC maintained a steady level of heroin intake.(4) Another 2014 study found that adolescent THC exposure in rats seemed to change the rodents’ brains, as they subsequently displayed “heroin-seeking” behaviour. Youth marijuana use could thus lead to “increased vulnerability to drug relapse in adulthood.”(5)

National Institutes of Health Report

The National Institutes of Health says that research in this area is “consistent with animal experiments showing THC’s ability to ‘prime’ the brain for enhanced responses to other drugs. For example, rats previously administered THC show heightened behavioral response not only when further exposed to THC, but also when exposed to other drugs such as morphine—a phenomenon called cross-sensitization.”(6)

Suggestions that one addictive substance replaces another ignores the problem of polysubstance abuse, the common addiction of today.

Additionally, the majority of studies find that marijuana users are often polysubstance users, despite a few studies finding limited evidence that some people substitute marijuana for opiate medication. That is, people generally do not substitute marijuana for other drugs. Indeed, the National Academy of Sciences report found that “with regard to opioids, cannabis use predicted continued opioid prescriptions 1 year after injury.  Finally, cannabis use was associated with reduced odds of achieving abstinence from alcohol, cocaine, or polysubstance use after inpatient hospitalization and treatment for substance use disorders” [emphasis added].(7)

Moreover, a three-year 2016 study of adults also found that marijuana compounds problems with alcohol. Those who reported marijuana use during the first wave of the survey were more likely than adults who did not use marijuana to develop an alcohol use disorder within three years.(8) Similarly, alcohol consumption in Colorado has increased slightly since legalization. (9)

Source:   http://www.poppot.org/2017/07/03/replacing-one-addiction-another-will-not-work/

Mass Illness from Marijuana Edibles in San Francisco There’s more potential for overdose from edibles than smoked marijuana, although the teen in Seattle who jumped to his death last December did it after smoking pot for the first time.  Two shocking incidents in California suggest that overdose emergencies will increase if that states vote to legalize marijuana in November.  Here’s a summary of recent cases of toxicity from edibles:

· 19 people were hospitalized in San Francisco on August 7 from THC, after attending a quinceañera party.  The source is believed be marijuana-infused candies, perhaps gummy bears. Several children were among those poisoned, one as young as six.  A 9-year-old had severe difficulty breathing.

· Pot brownies sent a bachelorette party to the emergency room in South Lake Tahoe over the weekend of July 30-31. Eight of the 10 women were admitted to the hospital according to the City of South Lake Tahoe’s website.

· A JAMA Paediatrics article explains the dramatic rise in children’s hospitalizations related to marijuana in Colorado since legalization.  In 10 cases, the product was not in a child-resistant container; in 40 scenarios (34%) there was poor child supervision or product storage.  Edible products were responsible for 51 (52% ) of exposures.  The report claimed that child-resistant packaging has not been as effective in reducing kids’ unintended exposure to pot as hoped.

· The report mentions the death of one child, an 11-month-old baby.  Nine of the children had symptoms so serious that they ended up in the intensive care unit of Colorado Children’s Hospital.  Two children needed breathing tubes.

· The state of Washington has a similar problem with edibles, as reported on the King County Health Department’s website.  From 2013 to May 2015, there were 46 cases of children’s intoxications related to marijuana edibles reported in Washington.  However, reporting is voluntary and the state estimates that number could be much higher.

·  In May, a father plead guilty to deliberately giving his 4-year-old daughter marijuana-laced cake in Vancouver, Washington.  He was sentenced to two years in prison.

· In Hingham, MA, there was a 911 related to teen girl who ingested marijuana edibles.  The candies were in a package labelled Conscious Creations, which didn’t disclose ingredients.   Massachusetts has a medical marijuana program, but it is not clear how or to whom they were sold or dispensed.

 

· July, 2016: Two California teens were hospitalized after eating a marijuana-laced cookie. The teens reported purchasing the cookie from a third teenager who was subsequently arrested.

· July, 2016: A California man was arrested for giving candy laced with marijuana to a 6-year-old boy and an 8-year-old boy; the 6-year-old was hospitalized for marijuana poisoning.

· July, 2016: Police in Arizona arrested a mother for allegedly giving her 11- and 12-year-old children gummy candy infused with marijuana. Police say the marijuana-infused candy was originally purchased by an Arizona medical marijuana user, but was illegally transferred to the mother in question.  (State medical marijuana programs have poor track records of assuring the “medicine” goes to whom it is intended.)

· On April 27, a Georgia woman was arrested after a 5- year-old said he ate a marijuana cake for breakfast.  The child was taken to the hospital for treatment following the incident; according to officials, his pulse was measured at over 200 beats per minute.

· Last year there were more than 4,000 treatments at hospitals and poison center treatments in the US related to marijuana toxicity in children and teens.

Edible marijuana poses a “unique problem,” because “no other drug is infused into a palatable and appetizing form” – such as cookies, brownies and candy.    Many household items cause poisonings, but marijuana edibles are different because they’re made to look appealing and they appeal to children.

 

Source:  http://www.poppot.org/2016/08/08/latest-child-dangers-marijuana-e

A volunteer non-partisan coalition of people from across the US and Canada who have come to understand the negative local-to-global public health and safety implications of an organized, legal, freely-traded, commercialized and industrialized marijuana market. Here’s What’s Coming to Your Back Yard — A tour of a Colorado Commercial Marijuana Operation

Our colleague,  Jo McGuire, in Denver was recently asked to accompany a group of delegates from other states investigating commercial marijuana legalization on a tour of the Colorado marijuana industry. Here’s her account of what they observed:

A delegation from out of state came to Denver in late April to see how the Colorado marijuana industry is working. I was asked to help guide the tour and ask questions of the industry leaders.

This was an all-day experience, so I will give you the highlights that stand out to me.

After the delegation heard a bit about my experience and area of expertise in safe & drug free workplaces, we were given a presentation by two officers of the Marijuana Enforcement Division (MED) in Colorado.

They started off the presentation by repeating how utterly impossible it is to regulate marijuana and keep all the rules and know all the enforcement measures they are supposed to follow (these are the people overseeing enforcement for the whole state.) They bragged that they now have 98 people in their office overseeing regulation but later in the day admitted that only 25% of those do on-site inspections statewide (3,000 facilities), the rest are trying to keep up with paperwork.

They cannot get to every site in the state for inspections (again – impossible) so they respond to complaints, spot-check and rely on other community entities to report anything they may find or see. The largest amount of complainants come from other MJ facilities trying to get their competition shut-down.

The greatest violations are: 1. Using pesticides banned in the U.S. 2. Not using the proper inventory tracking system 3. Waste disposal violations 4. Circumventing the required video-monitoring system

They were asked how potency of marijuana is determined and they said, “It is impossible to determine potency.” When challenged – they were adamant that it is not possible.

When asked how their office is paid for (marijuana money? state coffers?) they did not know. (It’s state coffers – I was on the committee.)

After their presentation, we headed to a marijuana grow facility in downtown Denver. You could smell it from a block away. They grow over 600,000 plants at this one location.

Guards with guns let us into the gate and gave us security badges, telling us that no photos were allowed and we would be on-camera at all times, escorted out if we broke any rules.

First we were shown a tray of baby plants with no tags. There is supposed to be a seed-to-sale tracking system. They said, “Well you can’t track every single one, so we track them in batch numbers when they are less than 8 inches high and then they get individual tags after that.” (More on that later).

This facility does not use “seeds” anyway. They clone their grows from mother plants – so their system is completely different.

They ship dirt over from Sri Lanka because the coconut shells are natural fertilizer for marijuana. So they have a huge room that smells like elephant poo with pallets of dirt “squares” stacked 20 feet high. What else is in it? Is it subject to inspection? No one knew. We were told, “If there were harmful bugs, we would find out eventually.”

Into the first state-of-the-art grow room. There were plants labelled “REC” and “MED”. When asked the difference between recreational and medical marijuana the grower said, “The tags and the tax rates.”

There was an environmental researcher on the tour who asked if the …. 6 gallons of water per plant per day …. is being recycled. The grower said they could not possibly store the massive thousands of gallons it would take to recycle the water. The researcher asked if Denver has any plan in place to test the water for contaminants because many contaminants have been found at both legal and illegal grow sites in northern California and the Enforcement Officers said, “We hadn’t really thought about that.”

When asked if they recycle the dirt, the grower said, “No way. My quality of production ensures every plant has fresh dirt.”

(A side note – the researcher told us later that he expects the contaminants from marijuana will impact our communities for generations on a level similar to DDT exposure.) His research is another story for another day.

Next we passed through the processing area where the trimmers, dryers and baggers were working. Employees are mostly young or people who can’t find jobs elsewhere. They used to have to pass a federal background check (no felonies allowed) but the enforcement guys said, “That was too hard, so we don’t have that requirement anymore.”

An employee perk is “highly discounted product“. They make minimum wage with no benefits, but “everyone is happy”. They discourage Work Comp claims (trimmers get carpal tunnel) because “they would melt the drug cup.” He said they have very high employee turn-over. Some were wearing hazard gear and some were not. Some were wearing protective gear and some were not. This owner also keeps his 11 locations under 11 separate LLC’s so that he can maintain “Eleven separate small businesses” so that he is not to subject to requirements that large employers must meet for employee volume.

I saw rolls of un-printed bags and asked how they determine the potency of their weed. This owner voluntarily sends random samples (of each strain) to a 3rd party lab twice a year. When the lab tells him the approximate potency – correct within 4 nanograms – they print their labels according to that potency until the next random sample is sent in.

GET THIS: He has had product labelled at 18% but the next batch came back at 30%. He said that people know it’s a guessing game and you don’t expect accuracy in

the labelling – just that it’s labelled and it may or may not be close. Also – the product in the package doesn’t necessarily have to be what is printed on the label, as long as he is volunteering for the lab spot checks.

Not all facilities submit to the spot checks that regularly. Remember – we are at this particular place because this business owner is cream-of-the-crop. And by the way, ALL products in the state to include edibles are only subject to random spot checks for quality and potency. That having been said, each brand begins with a lab analysis in order to create the initial labels – but once the creation has been approved – they move full steam ahead with mass production, inspection free (unless it’s voluntary quality checks or complaints are filed).

Also – the labs are not state-owned or run. They are independently owned and operated by “other marijuana industry investors” and they just choose who is cheapest and fastest. For quality checks.

Next we went into the drying room and I asked about how he prevents mould. He doesn’t. It happens. They remove it by hand when they find it. (Pesticides to remove it are illegal and lights are ineffective). At one point he took a few of us down a row to see the dried buds in hundreds of rows of trays … where the labels went from individual plants back to mass batches. Why is this important? Voters believe in “seed-to-sale” tracking but no one knows how much one plant will produce. Will it produce 10 buds or 50 buds? 50 buds cannot have “one” label so this goes in batches. How do you know if buds come up missing from the tracking system? You don’t.

As we were asking these questions and I was curious about some of his branding – he speaks in a very low voice to us while we were rows away from the enforcement team. “Listen, you’re safe in my facility because I am the one that follows the rules – thus why you are here, right? But if you go to any other place, don’t touch anything, don’t go near any equipment and be careful of anything that could contaminate you“. This business is filthy, dirty, scummy, underhanded and full of cheaters, liars and the majority of this industry is shady as hell. Just be careful.”

On to the BIG grow room ….

I thought I had seen and heard everything up to this point.

We walked into one of the rooms where mature “plants” (TREES) are growing and I saw buds that were the length of my entire forearm. He said, “That’s nothing, I’ve got some as big as your whole arm!” And these trees have so many of these HUGE, heavy buds, they are drooping down and propped-up with dozens of bamboo sticks. One bud by itself can bring in hundreds of dollars … and the seed-to-sale tracking system has loopholes bigger than the buds.

One of the enforcement officers shared, “Now these are labelled with THC-A … which is not impairing and has no euphoric effect unless and until it’s smoked.” (I am not sure what comment to place here … but imagine every policy maker outside of our state getting this “sell”.)

I asked a lot of questions to make sure that what I say in my presentations are accurate – I had heard natural marijuana could not grow over 22% – he said he regularly grows it at 33% with no additives. I have been told that I was lying when I said “it is impossible to test every single product that is sold” and this young man laughed and said, “Here is my card, I will go with you and tell them you are right and back you up all the way. If you want them to hear it straight from my mouth – call me.”

Onto the retail store where two ATM’s sit side-by-side in the lobby. This is a cash only business and banking is not allowed, no credit-cards or checks, etc. So the “work-around” is that the Marijuana Facilities take the cash they get from customers and load-up their own ATM’s so electronic transactions go to their separate non-marijuana LLC

and they can deal through the banking system that way. In law enforcement circles this is called money laundering.

The store products ranged from stash devices to pipes and rigs, to intimacy “helpers”, candies, gums, mints and apparel, to a filled syringe and a 90% THC wax product, etc. There are pictures on my FB page … you should check them out.

The store staff are extremely friendly, proud of their work, answer all questions without hesitation and often let slip very damning information without even realizing it’s coming out of their mouth. So interesting.

When we returned to the van, there were people who were stunned to near tears because they truly didn’t believe what they had heard – how it really doesn’t and cannot work successfully, but we are simply doing the best we can at lightning speed. The shock was palpable. Some were extremely angry.

Another interesting tidbit: Colorado just outlawed gummy bears because they are too attractive to children. So we asked what the new rule means for the production of gummy candies. “That’s easy – you can’t use shapes of people, animals or fruit – but vegetables are o.k. because kids hate those and geometric designs are o.k. You know, like Lucky Charms!” They have a year to “sell” all of the candies “attractive to children” before they have to get them off the shelves.

As an aside, I discovered later that evening that I had broken out in hives wherever my skin was exposed and itched terribly for days after this trip.

I know that many other states are “new” to legal pot and if any of your states delegations here for this same tour – PLEASE – make sure I am notified and either I, or one of my colleagues, accompany them. Jo McGuire jo@jomcguire.org

Source:  http://marijuana-policy.org/heres-whats-coming-back-yard-tour-colorado-commercial-marijuana-operation/   2nd July 2017

It is vital that physicians—particularly psychiatrists who are on the frontlines with patients who struggle with cannabis use—are able to identify and characterize cannabis use disorders; provide education; and offer effective, evidence-based treatments. This article provides a brief overview of each of these topics by walking through clinical decision-making with a case vignette that touches on common experiences in treating a patient with cannabis use disorder.

A separate and important issue is screening for emerging drugs of abuse, including synthetic “marijuana” products such as K2 and spice. Although these products are chemically distinct from the psychoactive compounds in the traditional cannabis plant, some cannabis users have tried synthetic “marijuana” products because of their gross physical similarity to cannabis plant matter.

CASE VIGNETTE

Mr. M is a 43-year-old legal clerk who has been working in the same office for 20 years. He presents as a referral from his primary care physician to your outpatient psychiatry office for an initial evaluation regarding “managing some mid-life issues.” He states that while he likes his job, it is the only job he has had since graduating college and he finds the work boring, noting that most of his co-workers have gone on to law school or more senior positions in the firm. When asked what factors have prevented him from seeking different career opportunities, he states that he would “fail a drug test.” Upon further inquiry, Mr. M says he has been smoking 2 or 3 “joints” or taking a few hits off of his “vaping pen” of cannabis daily for many years, for which he spends approximately $70 to $100 a week.

He first used cannabis in college and initially only smoked “a couple hits” in social settings. Over time, he has needed more cannabis to “take the edge off” and has strong cravings to use daily. He reports liking how cannabis decreases his anxiety and helps him fall asleep, although he thinks the cannabis sometimes makes him “paranoid,” which results in his avoidance of family and friends.

More recently, he identifies conflict and regular arguments with his wife over his cannabis use—she feels it prevents him from being present with his family and is a financial burden. He admits missing an important awards ceremony for her work and sporting events for his children, for which he had to “come up with excuses,” but the truth is that he ended up smoking more than he had intended and lost track of the time.

Mr. M reports multiple previous unsuccessful attempts to reduce his use and 2 days when he stopped completely, which resulted in “terrible dreams,” poor sleep, sweating, no appetite, anxiety, irritability, and strong cravings for cannabis. Resumption of his cannabis use relieved these symptoms. He denies tobacco or other drug use, including use of synthetic marijuana products such as K2 or spice, and reports having a glass of wine or champagne once or twice a year for special occasions.

The diagnosis

In the transition from DSM IV-TR to DSM-5, cannabis use disorders, along with all substance use disorders, have been redefined in line with characterizing a spectrum of

pathology and impairment. The criteria to qualify for a cannabis use disorder remain the same except for the following:

1. The criterion for recurrent legal problems has been removed.

2. A new criterion for craving or a strong desire or urge to use cannabis has been added, and the terms abuse and dependence were eliminated.

To qualify as having a cannabis use disorder, a threshold of 2 criteria must be met. Severity of the disorder is characterized as “mild” if 2 or 3 criteria are met, “moderate” if 4 or 5 criteria are met, and “severe” if 6 or more criteria are met. Mr. M demonstrates 3 symptoms of impaired control: using longer than intended, unsuccessful efforts to cut back, and craving; 3 symptoms of social impairment: failure to fulfil home obligations, persistent problems with his wife, and reduced pursuit of occupational opportunities; 1 symptom of risky use: continued use despite paranoia; and 2 symptoms of pharmacological properties: tolerance and withdrawal. As such, he meets 9 criteria, which qualify him for a diagnosis of severe cannabis use disorder.

You summarize Mr. M’s 9 symptoms and counsel him about severe cannabis use disorder. He becomes upset and states that he was not aware one could develop an “addiction” to cannabis. He expresses an interest in treatment and asks what options are available.

Treatment options

Psychotherapeutic treatments, including motivational enhancement treatment (MET), cognitive behavioral therapy (CBT), and contingency management (CM), have demonstrated effectiveness in reducing frequency and quantity of cannabis use, but abstinence rates remain modest and decline after treatment. Generally, MET is effective at engaging individuals who are ambivalent about treatment; CM can lead to longer periods of abstinence during treatment by incentivizing abstinence; and CBT can work to enhance abstinence following treatment (preventing relapse). Longer duration of psychotherapy is associated with better outcomes. However, access to evidence-based psychotherapy is frequently limited, and poor adherence to evidence-based psychotherapy is common.

In conjunction with psychotherapy, medication strategies should be considered. Because there are no FDA-approved pharmacological agents for cannabis use disorder, patients should understand during the informed consent process that all pharmacotherapies used to treat this disorder are off-label. A number of clinical trials provide evidence for the off-label use of medications in the treatment of cannabis use disorder. The current strategies for the off-label treatment of cannabis use disorder target withdrawal symptoms, aim to initiate abstinence and prevent relapse or reduce use depending on the patient’s goals, and treat psychiatric comorbidity and symptoms that may be driving cannabis use. Here we focus on the evidence supporting these key strategies.

Targeting withdrawal and craving

Cannabis withdrawal is defined by DSM-5 as having 3 or more of the following signs and symptoms that develop after the cessation of prolonged cannabis use:

• Irritability, anger, or aggression

• Nervousness or anxiety

• Sleep difficulty

• Decreased appetite or weight loss

• Restlessness

• Depressed mood

• At least one of the following physical symptoms that causes discomfort: abdominal pain, shakiness/tremors, sweating, fever, chills, or headache

Withdrawal symptoms may be present within the first 24 hours. Overall, they peak within the first week and persist up to 1 month following the last use of cannabis. In the case of Mr. M, insomnia, poor appetite, and irritability as well as sweating are identified, which meet DSM-5 criteria for cannabis withdrawal during the 2 days he abstained from use. He also identifies strong craving and vivid dreams, which are additional withdrawal symptoms included on marijuana withdrawal checklists in research studies, although not included in DSM-5 criteria. These and other symptoms should be considered in clinical treatment.

Medication treatment studies for cannabis withdrawal have hypothesized that if withdrawal symptoms can be reduced or alleviated during cessation from regular cannabis use, people will be less likely to resume cannabis use and will have better treatment outcomes. Studies have shown that dronabinol and nabilone improved multiple withdrawal symptoms, including craving; and quetiapine, zolpidem, and mirtazapine help with withdrawal-induced sleep disturbances.1-5

Combining dronabinol and lofexidine (an alpha-2 agonist) was superior to placebo in reducing craving, withdrawal, and self-administration during abstinence in a laboratory model. However, in a subsequent treatment trial, the combined medication treatment was not superior to placebo in reducing cannabis use or promoting abstinence.6

Six double-blind placebo-controlled pharmacotherapy trials in adults with cannabis use disorder have looked at withdrawal as an outcome.7 Of these studies, only dronabinol, bupropion, and gabapentin reduced withdrawal symptoms.8-10 In addition to reducing withdrawal symptoms, nabiximols/Sativex (a combination tetrahydrocannabinol [THC] and cannabidiol nasal spray not available in the US) increased retention (while actively on the medication in an inpatient setting) but did not reduce outpatient cannabis use at follow-up.11

All of the medications available for prescription in the US can be monitored reliably with urine drug screening to assess for illicit cannabis use except dronabinol, which will result in a positive screen for cannabis. When using urine drug screening, remember that for heavy cannabis users the qualitative urine drug screen can be positive for cannabis up to a month following cessation. When selecting a medication, take into account the cost of the medication, particularly since insurance will likely not cover THC agonists such as dronabinol for this indication, and possible misuse or diversion of scheduled substances (eg, dronabinol, nabilone). In addition, monitoring for reductions in substance use and withdrawal symptoms is key.

Abstinence initiation and relapse prevention

Other clinical trials have looked at medications to promote abstinence by reducing stress-induced relapse, craving (not as a component of withdrawal), and the reinforcing aspects of cannabis. Of these trials, the following results show potential promise with positive findings: gabapentin reduced quantitative THC urine levels and improved cognitive functioning (in addition to decreasing withdrawal), and buspirone led to more negative urine drug screens for cannabis (although the difference was not significant compared with placebo).10,12 However, in a follow-up larger study, no differences were seen compared with placebo and women had worse cannabis use outcomes on buspirone.13

N-acetylcysteine resulted in twice the odds of a negative urine drug screen in young adults and adolescents (although there was no difference between adolescent groups in self-report of cannabis use).14 Gray and colleagues15 reported that no differences were seen between N-acetylcysteine and placebo (results of the trial are soon to be published). Topiramate resulted in significantly decreased grams of cannabis used but no difference in percent days used or proportion of positive urine drug screens.16 In a recent small clinical trial, reductions in cannabis use were seen with oxytocin in combination with MET.17 Studies with nabilone and long-term naltrexone administration reduced relapse and cannabis self-administration and subjective effects, respectively, which suggests promising avenues yet to be explored by clinical trials.2,18

Treatment of psychiatric comorbidity

Other studies have looked at the effects of treating common comorbid psychiatric disorders in adults with cannabis use disorder, postulating that if the psychiatric disorder is treated, the individual may be more likely to abstain or reduce his or her cannabis use. For example, if a person is less depressed, he may better engage in CBT for relapse prevention.

Fluoxetine for depression and cannabis use disorder in adolescents decreased cannabis use and depression, although there was no difference compared with placebo.19 A trial of venlafaxine for adults with depression and cannabis use disorder demonstrated less abstinence with greater withdrawal-like symptoms compared with placebo.20,21 These findings suggest that this antidepressant might not be beneficial for treatment-seeking individuals with cannabis use disorder and may actually negatively affect outcomes.

CASE VIGNETTE CONT’D

After discussing and presenting the different psychotherapy and medication treatment options to Mr. M, you and he decide to start CBT to help with abstinence initiation. In addition, you prescribe 20 mg of dronabinol up to 2 times daily in combination with 50 mg of naltrexone daily, to help globally target Mr. M’s withdrawal symptoms and prevent relapse once abstinence is achieved. However, a few days later, Mr. M calls to say that his insurance will not cover the prescription for dronabinol and he cannot afford the high cost. Given his main concerns of cannabis withdrawal symptoms, you select gabapentin up to 400 mg 3 times daily and continue weekly individual CBT.

Mr. M calls back several days later and reports that he has made some improvements in reducing the frequency of his cannabis use, which he attributes to the medication, but he thinks he needs additional assistance. After reviewing the treatment options again, he gives informed consent to start 1200 mg of N-acetylcysteine twice daily. After 10 weeks of this medication, his urine screens are negative.

You continue to provide relapse prevention CBT. He reports to you that his anxiety and insomnia are almost resolved, and you suspect that withdrawal was the cause of these symptoms. He reports significant improvement in his relationship with his family and recently received a promotion at work for “going above and beyond” on a project he was given the lead.

Over the next 6 months, he has 2 relapses that in functional analysis with you are determined to be triggered by unsolicited contact from his former drug dealer. Together, you develop a plan to block any further contact from the drug dealer. After several months, both the gabapentin and N-acetylcysteine are tapered and discontinued. Mr. M continues to see you for biweekly therapy sessions with random drug screens every 4 to 6 weeks.

Conclusion

Based on the available evidence, gabapentin, THC agonists, naltrexone, and possibly N-acetylcysteine show the greatest promise in the off-label treatment of cannabis use disorders. System considerations, such as medication cost, need to be factored into the decision-making as well as combination medication and psychotherapy approaches, which—as demonstrated in the case of Mr. M—may ultimately work best. Until further research elucidates the standard of medication practices for cannabis use disorder, the best off-label medication strategy should target any co-occurring disorders as well as any identified problematic symptoms related to cannabis use and cessation of use. When available, referral for evidence-based psychotherapy should be made.

Source:  (http://www.psychiatrictimes.com)  30th June 201

La Porte, Ind. – Authorities with the La Porte County Sheriff’s Office say 11 teens from Fishers were hospitalized after eating gummy bears laced with THC, an active ingredient found in marijuana.

Police began investigating the incident just before midnight on Thursday after they were dispatched on a medical call to the 5200 N block of CR 325 W.

A 19-year-old male at the scene told a deputy that he became ill after ingesting drugs, and he needed to go to the hospital. He said he was in the area camping with friends, and they also ingested the drugs.

Several more sheriff’s deputies arrived and found 10 other teens that all said they were suffering from a rapid heart rate, pain in their legs, blurred vision, and hallucinations.

According to the sheriff’s office, a deputy determined that they each ate one half of a gummy bear that supposedly contained THC.

Three ambulances arrived at the scene to transport all 11 teens to two local hospitals.

All of the teens were from Fishers, and they are believed to have been staying at a relative’s home. Nine of the teens are 18-years-old and two were 19-years-old; six were males and five were females. Two of the patients were tested and were found to have high levels of THC in their system.

Police are still trying to determine where the teens got the drugs.

Source: http://fox59.com/2017/07/07/police-11-fishers-teens-hospitalized-after-eating-thc-laced-gummy-bears/

In The Lancet Psychiatry, Schoeler and colleagues present a study1 describing the mediating effect of medication adherence on the association between continued cannabis use and relapse risk in patients with first-episode psychosis.

They have previously reported a relapse rate of 36% in this patient group over a 2-year period.2 Acknowledging the potential risk of psychosis relapse related to the high proportion of patients continuing cannabis use after the onset of psychosis, the current study1 investigates the same patient group consisting of 245 patients, obtaining retrospective data on active cannabis use and medication adherence shortly after illness onset, as well as risk of relapse at 2-year follow-up. The authors find that relapse of psychosis associated with continued cannabis use is partly mediated through non-adherence to prescribed antipsychotic medication.

It is well established that cannabis use increases the risk of schizophrenia, not only from the early Swedish conscript studies3 but also from studies on people who use sinsemilla in London, UK, showing that high potency cannabis increases the risk of schizophrenia.4

Twin studies from Norway have shown that cannabis increases the risk of psychosis, even when controlling for genetic factors.5There has been discussion on the direction of the association, as none of these studies can rule out reverse causality, but it seems reasonable to conclude that cannabis is one of many stressors that can precipitate schizophrenia, at least in susceptible individuals.

The association between cannabis use and psychosis continues to interest clinicians and researchers. Cannabis does not precipitate psychosis in most users.3 What are the risk factors in the pathway from cannabis use to psychosis?

The use of cannabis in patients with psychosis can be divided into three groups: those not using cannabis, those using cannabis with few negative consequences, and those in whom cannabis use is followed by relapse and worsening of the disease. Too little effort has been put into studying people with psychosis who can use cannabis without many negative consequences.

Further research should also be put into different variants of cannabis. Strains cultured to produce high content of D-9 tetrahydrocannabinol (THC) are probably associated with higher risk for psychosis than those strains with less THC.4 In healthy participants, cannabidiol has been shown to inhibit THC-elicited paranoid symptoms and hippocampal-dependent memory impairment.6 The use of more balanced forms of cannabis could possibly be less detrimental to mental health.

Genetic predisposition is one factor that is related to the development of psychosis after the use of cannabis.5 However, there is still a long way to go in clarifying the interplay between genes and environmental factors in the cannabis–psychosis association. Therefore, we support the request for doing more studies to investigate the possible interaction between polygenic risk score for schizophrenia and cannabis use in causing psychosis.7

Furthermore, there is a need to examine the use of antipsychotic medication and investigate if some medications are particularly useful for patients with psychotic disorders who intend to continue to use cannabis. In a randomised trial comparing the effects of different antipsychotics,8 clozapine seemed to stand out in reducing craving for cannabis, a finding that is in need of replication.

Previous research has shown that stopping cannabis use after a first episode of psychosis has beneficial outcomes compared with continued use.9 A meta-analysis of observational studies published in 201710 compared adherence to antipsychotic medication between cannabis users and non-users, and found that cannabis use increases the risk of non-adherence to anti-psychotic medication and quitting cannabis may help adherence to antipsychotics. In the current study by Schoeler and colleagues,1 the authors found that adherence to medication was a possible mediator in the association between cannabis use and risk of psychosis relapse when taking potential confounders into account. They found that medication adherence partly mediated the effect of continued cannabis use on outcome, including risk of relapse (proportion mediated=26%, pindirecteffects=0·040, 95% CI 0·004–0·16), number of relapses (36%, pindirect effects=0·040, 0·003–0·14), time to relapse (28%, pindirect effects=0·051, −0·53 to 0·001), and care intensity (20%, pindirect effects=0·035, 0·004–0·11), but not length of relapse (6%, pindirect effects=0·35, −0·030 to 0·09).

Acknowledging the complexity of psychosis relapse prevention, the current findings point to reduction in cannabis use as an intervention target to improve medication adherence, thereby preventing psychosis relapse. The understanding of a triangular association of ongoing cannabis use with medication adherence and psychosis relapse may be a step forward in counteracting further psychotic episodes in some patients.

Source:   DOI: http://dx.doi.org/10.1016/S2215-0366(17)30254-7   Published: 10/7/17

Drinking alcohol during pregnancy could harm not just a woman’s unborn child, but her grandchildren and beyond.

Researchers in the US have found brain abnormalities linked to foetal alcohol spectrum disorder (FASD), at least in mice, can be passed down through the generations.

“Traditionally, prenatal ethanol exposure from maternal consumption of alcohol was thought to solely impact directly exposed offspring, the embryo or foetus in the womb,” says Kelly Huffman from the University of California.

“However, we now have evidence that the effects of prenatal alcohol exposure could persist transgenerationally and negatively impact the next-generations of offspring who were never exposed to alcohol.”

In the experiment, Prof Huffman’s team found the children of mice with FASD also had reduced body weight and brain size, and were more likely to show signs of anxiety and depression. The defects were present in further generations.

“By demonstrating the strong transgenerational effects of prenatal ethanol exposure in a mouse model of FASD, we suggest that FASD may be a heritable condition in humans,” says Prof Huffman.

Babies born with FASD often have intellectual and physical disabilities, behavioural problems and distinct facial features. It is irreversible. A study in 2015 found almost third of Kiwi women continue to drink alcohol during their first trimester, and 11 percent right up until birth. · Concerns over number of women drinking while pregnant

The Ministry of Health says there is no known safe level of drinking, and recommends women abstain from alcohol from the time they decide to have a baby, through conception and the entire pregnancy.

The discovery that FASD affects children who were never exposed to alcohol is a clue to future potential therapies and perhaps even prevention, the researchers say.

The research was published in journal Cerebral Cortex.

Source:  http://www.newshub.co.nz/home/health/2017/07/drinking-alcohol-while-pregnant-harms-kids-for-generations-study.html

Investigating the proposition that cannabis is worth bothering with, this hot topic looks at reports that stronger cannabis on the market is increasing harms to users, prospects of recovery from disorders and dependence, and the emerging response to synthetic forms of cannabis like ‘spice’.

CANNABIS IN THE LAW

A controlled ‘Class B’ substance, cannabis carries legal penalties for possession, supply, and production. Between 2004–2009 cannabis was reclassified as a ‘Class C’ substance, meaning for a brief period of time it carried lesser penalties for possession. In 2009, the Association of Chief Police Officers issued new guidance, advising officers to take an escalating approach to the policing of cannabis possession for personal use: • A warning • A penalty notice for disorder (PND) • Arrest

This three-tiered approach was designed to be “ethical and non-discriminatory”, but also reinforce the “national message that cannabis is harmful and remains illegal”.

In 1990s Britain a common reaction to allocating resources to treating cannabis users was, ‘Why bother? We have more than enough patients with problems with serious drugs like heroin.’ The typically calming use of the drug by adults was seen as preferable to the main alternative – alcohol and its associated violence and disorder. Calls for a treatment response were seen as pathologising what in many societies is both normal and in some ways desirable youth development: trying new experiences, challenging conventions, and exposing the hypocrisy of alcohol-drinking adults. In 1997 the Independent on Sunday launched a campaign to decriminalise cannabis, culminating in a mass ‘roll-up’, and 16,000-strong pro-cannabis march from Hyde Park to Trafalgar Square. Its Editor Rosie Boycott wrote in the paper about her own coming-of-age experience smoking cannabis, telling readers:

“I Rolled my first joint on a hot June day in Hyde Park. Summer of ’68. Just 17. Desperate to be grown-up. … My first smoke, a mildly giggly intoxication, was wholly anti-climatic. The soggy joint fell apart. I didn’t feel changed. But that act turned me – literally – into an outlaw. I was on the other side of the fence from the police – or the fuzz, as we used to call them. So were a great many of my generation.”

The campaign was explosive, but short-lived, apparently subsiding when Boycott left to take up her role as Editor of the Daily Express. A decade later, the Independent issued an apology for the campaign. ‘If only they had known then, what they knew now’, was the message of the article, referring to the reportedly damaging impact of the more potent strains of cannabis and its links to “mental health problems and psychosis for thousands of teenagers”.

Are stronger strains creating more problems?

There has been a long-standing, but controversial, association between cannabis strength and harm. Reading newspaper articles on the subject, it wouldn’t be unusual to see a headline drawing a straight line between ‘super-strength skunk’ and addiction, violence, deaths, or psychosis. In 2008, then Prime Minister Gordon Brown spoke in a similar vein, telling a breakfast-television viewing audience:

I have always been worried about cannabis, with this new skunk, this more lethal part of cannabis.

I don’t think that the previous studies took into account that so much of the cannabis on the streets is now of a lethal quality and we really have got to send out a message to young people – this is not acceptable.

Brown was warning of a dangerous new strain of cannabis on the market, that caused very severe harms to users – contrasting starkly with the common perception of cannabis as a ‘low harm’ or ‘no harm’ drug. The strength or potency of cannabis is determined by the amount of ‘THC’ it contains. THC produces the ‘high’ associated with cannabis, and another major component ‘CBD’ produces the sedative and anti-anxiety effects. As well as potency, the relative amounts of THC and CBD are important for understanding the effects of cannabis – something explored in a University College London study during the programme Drugs Live: Cannabis on Trial. The research team compared two different types of cannabis: the first had high levels of THC (approx. 13%) but virtually no CBD; and the second had a lower level of THC (approx. 6.5%) and substantial amounts of CBD (approx. 8%). They found that CBD had a moderating or protective effect on some of the negative effects of THC, and that “many of the effects that people enjoy are still present in low-potency varieties without some of the harms associated with the high-potency varieties”. At least in the US over the last two decades (between 1995–2014), potency has increased from around 4% to 12%, and the protective CBD content of cannabis has decreased, from around 28% to less than 15%, significantly affecting the ratio of THC to CBD, and with it, the nature and strength of the psychoactive effect of cannabis. Until the 1990s, herbal cannabis sold in the UK was predominantly imported from the Caribbean, West Africa, and Asia. After this time, it was increasingly produced in the UK, being grown indoors using intensive means (artificial lighting, heating, and control of day-length). A study funded by the Home Office analysed samples of cannabis confiscated by 23 police forces in England and Wales in 2008, and found that over 97% of herbal cannabis had been grown by intensive methods; its average potency of 16% compared with just 8% for traditional imported herbal cannabis. This matched other reports of home-grown cannabis being consistently (around 2–3 times) stronger than imported herbal cannabis and cannabis resin.

In 2015, observing a decrease in the use of cannabis in England and Wales, but parallel increase in demand for treatment, a UK study examined whether the trend could be explained by an increase in the availability of higher-potency cannabis. Over 2500 adults were surveyed about their use of different types of cannabis, severity of dependence, and cannabis-related concerns. The researchers found that higher potency cannabis was associated with a greater severity of dependence, especially in young people, and was rated by participants as causing more memory impairment and paranoia than lower potency types. However at the same time, it was reported to produce the best ‘high’, and to be the preferred type.

By definition cannabis is a psychoactive substance, which means it can change people’s perceptions, mood, and behaviour. Higher potency cannabis contains more of the psychoactive component, so it makes sense that higher potency cannabis could increase the risk of temporary or longer-term (adverse) problems with perceptions, mood, and behaviour. However, there is a particular concern that cannabis use could be linked to ‘psychosis’, a term describing a mental illness where a person perceives or interprets reality in a very different way to those around them, which can include hallucinations or delusions.

Whether cannabis causes psychosis, precipitates an existing predisposition, aggravates an existing condition, or has no impact at all on psychotic symptoms, has for decades been hotly contested. With our focus on evaluations of interventions, Drug and Alcohol Findings is in no position to pronounce on this issue, nor on the possibility that the drug might sometimes improve mental health, but some examples of research informing this debate are included below. A 2009 UK study examined whether daily use of high-potency cannabis was linked to an elevated risk of psychosis, comparing 280 patients in London presenting with a first episode of psychosis with a healthy control group. The patients were found to be more likely to smoke cannabis on a daily basis than the control group, and to have smoked for more than five years. Among those who used cannabis, 78% of the patients who had experienced psychosis used higher-potency cannabis, compared with 37% of those in the control group. The findings indicated that the risk of psychosis was indeed greater among the people who were using high potency cannabis on a frequent basis, but couldn’t show that the cannabis use caused the psychosis, or even that the cannabis use made the group more susceptible to psychosis. The wider literature on mental health and substance use would suggest that the association is more complex than this. A recently published paper from the University of York has demonstrated the complications of attributing any association between cannabis use and psychosis to a causal effect of cannabis use rather than other factors or a reverse causal effect. A calculation based on data from England and Wales helped to put this into perspective, indicating that even if cannabis did cause psychosis more than 20,000 people would need to be stopped using cannabis to prevent just one case of psychosis. The apparent steady increase in cannabis potency in the UK since the 1990s is important context for further research. Where higher potency cannabis is increasingly becoming the norm, and is the preference for cannabis users, it would be relevant to generate more evidence of the health-related problems with high potency cannabis, and the treatment and harm reduction solutions based around these health-related problems.

Cannabis accounts for half of all new drug treatment patients

The most widely used illegal drug in Europe, many seemingly enjoy cannabis without it leading to any significant negative social or health effects. However, numbers entering treatment for cannabis use problems have been on the rise (both in the UK, and the rest of Europe), while heroin treatment numbers have fallen  chart. According to Public Health England, this is not because more people are using cannabis, but perhaps because services relieved of some of the recent pressure of opiate user numbers are giving more priority to cannabis, because they are making themselves more amenable to cannabis users, and because of emerging issues with stronger strains of the drug. Whatever the causes, across the UK figures submitted to the European drug misuse monitoring centre show that the proportion of patients starting treatment for drug problems who did so primarily due to their cannabis use rose steadily from 11% in 2003/04 to 22% in 2011/12. With the caveat that data from 2013 onwards is not directly comparabledue to changes in methodology, in 2014 and 2015 the proportion of patients who entered treatment primarily because of a cannabis issue hovered above previous years at 26% (25,278 and 26,295 respectively). Among first ever treatment presentations, the increase from 2003/04 was more pronounced, from 19% to 37%. By 2013, cannabis use had become the main prompt for half the patients who sought treatment for the first time (at 49%), and stayed relatively constant at 47% in 2014, and 48% in 2015.

Showing that more users was not the reason for more starting treatment, over about the same period, in England and Wales the proportion of 16–59-year-olds who in a survey said they had used cannabis in the past year fell from about 11% to 7% in 2013/14, then stayed at that level in 2014/15 and 2015/16. The treatment figures largely reflect trends in England, where in 2013/14 the number of patients starting treatment with cannabis use problems had risen to 30,422, 21% of all treatment starters, up from 23,018 and 19% in 2005/06. Subsequently the number dropped to 27,965 in 2015/16, still around a fifth of all treatment starters. Among the total treatment population – starting or continuing in treatment – cannabis numbers rose from 40,240 in 2005/06 to peak at 64,407 in 2013/14 before falling back to 59,918 in 2015/16; corresponding proportions again hovered around a fifth. As a primary problem substance among under-18s cannabis dominated, accounting for three-quarters of all patients in treatment in 2015/16 and in numbers, 12,863. The dominance of cannabis increased from 2008/09 as numbers primarily in treatment for drinking problems fell.

‘All treatments appear to work’

According to the two main diagnostic manuals used in Europe and the USA, problem cannabis use can develop into a cannabis use disorder or cannabis dependence, identifiable by a cluster of symptoms including: loss of control; inability to cut down or stop; preoccupation with use; neglecting activities unrelated to use; continued use despite experiencing problems; and the development of tolerance and withdrawal. This level of clinical appreciation for cannabis use problems didn’t exist when researcher and writer William L. White entered the addictions field half a century ago:

“When I first entered the rising addiction treatment system in the United States nearly half a century ago, there existed no clinical concept of cannabis dependence and thus no concept of recovery from this condition. In early treatment settings, cannabis was not consider[ed] a “real” drug, the idea of cannabis addiction was scoffed at as remnants of “Reefer Madness,” and casual cannabis use was not uncommon among early staff working in addiction treatment programs of the 1960s. Many in the field remain sceptical of the idea of cannabis dependence, specifically whether problem users at the severe end experience physiological withdrawal. However, reviewing what they believe is mounting evidence, these authors suggest there can be confidence in the existence of a “true withdrawal syndrome” – albeit one that differs qualitatively from the “significant medical or psychiatric problems as observed in some cases of opioid, alcohol, or benzodiazepine withdrawals”. In the case of cannabis, the main symptoms are primarily emotional and behavioural, although appetite change, weight loss, and some physical discomfort are reported. A brief review aimed at practitioners in UK primary care provides guidance on how to manage symptoms of withdrawal among patients trying to stop or reduce their cannabis use.

Research has come a long way, says William L. White, with now “clear data supporting the dependency producing properties of cannabis, a clear conceptualization of cannabis use disorders (CUD) and cannabis dependence (CD)”, but until recently, very little evidence about the prospects of long-term recovery. Yet, key papers – found here and here – indicate that:

• Full remission from cannabis use disorders is not only possible, but probable.

• Stable remission takes time – an average of 33 months.

• Abstinence may not be initially realistic for heavy cannabis users – but those in  remission are usually able to reduce the intensity of their use and its  consequences.

At least in the United States, it seems dependence is more quickly overcome from cannabis than the main legal drugs. A survey of the US general adult population found that within a year of first becoming dependent, 3% each of smokers and drinkers were in remission and remained so until they were surveyed. For cannabis the figure was nearly 5% and for cocaine, nearly 9%. After ten years the proportions in remission had risen to 18% for nicotine, 37% for alcohol, 66% for cannabis and 76% for cocaine. About 26 years after first becoming dependent, half the people at some time dependent on nicotine were in remission, a milestone reached for alcohol after 14 years, for cannabis six years, and for cocaine, five.

Specialised treatment programmes for cannabis users in European countries

Generally for people with cannabis use problems, the European Monitoring Centre for Drugs and Drug Addiction concluded in 2015, and before that in 2008, that “all treatments appear to work”. For adults, effective treatments include motivational interviewing, motivational enhancement therapy and cognitive-behavioural therapy, and for younger people, family-based therapies seem most beneficial. Less important than the type of treatment is the treatment context and the individual’s determination to overcome their problems through treatment. And there is “no firm basis for a conclusion” that cannabis-specific interventions (designed around the risks and harms associated with cannabis) are more effective than general substance use treatment tailored to the individual needs of the cannabis user seeking treatment chart. In some studies brief interventions have been found to work just as well as more intensive treatment, but when the patients are heavily dependent, and the most difficult cases are not filtered out by the research, longer and more individualised therapies can have the advantage. When the World Health Organization trialled its ASSIST substance use screening and brief advice programme in Australia, India, the United States, and Brazil, just over half the identified patients (all had to be at moderate risk of harm but probably not dependent) were primarily problem cannabis users. Among these, risk reduction in relation to this drug was significantly greater among patients allocated to a brief advice session than among those placed on a three-month waiting list for advice. In each country too, risk reduction was greater among intervention patients, except for the USA, where the order was reversed. Suggesting that severity of use was not a barrier to reacting well to brief intervention, only patients at the higher end of the moderate risk spectrum further reduced their cannabis use/risk scores following intervention. The ASSIST study was confined to adults, but young people in secondary schools in the USA whose problem substance use focused mainly on cannabis also reacted well to brief advice.

The relative persistence of opiate use problems versus the transitory nature of those primarily related to cannabis seemed reflected in an analysis of treatment entrants in England from 1 April 2005 to the end of 2013/14, the last time this particular analysis was published. At the end of this period just 7% of primary cannabis users were still in or back in treatment compared to the 30% overall figure and 36% for primary opiate users. The figure peaked at 43% for users of opiates and crack. Over half – 53% – of primary cannabis users had left treatment as planned, apparently having overcome their cannabis problems, compared to 27% of primary opiate users and just 20% with dual opiates and crack use problems. Another 40% of cannabis users had left treatment in an unplanned manner, a slightly higher proportion than among opiate users. The figures tell a tale of relatively high level of success which enables cannabis users to leave treatment, though even in the absence of recorded success, few stay long-term.

However, the forms patients in England complete with their keyworkers while in treatment seem to tell a different story. Compared to how they started treatment, around six months later 45% of primary cannabis users were assessed as using just as often (including a few using more), compared to 30% of opiate users and 42% whose main problem drugs were both opiates and crack, suggesting more rapid and/or more complete remission for opiate users than for cannabis users. One interpretation is that the widespread use of substitute drugs like methadone more reliably reduced the illegal opiate use of opiate users and also helped retain them in treatment, while cannabis users tended quickly to leave treatment, having done well or not. However, these figures relate only to patients who completed the forms at their six-month review, which in practice could have happened anywhere from about one to six months after their assessment for treatment. What proportion of primary cannabis users were still in treatment at that point and available to complete the forms is not clear, but they may have been the patients whose problems were deep seated enough to require extended treatment.

Enjoyable and trouble-free for many, but not without harms Harm reduction – the “set of practical strategies and ideas aimed at reducing negative consequences associated with drug use” – is mostly associated with ‘harder’ drugs like heroin, for which blood-borne viruses and drug-related deaths are clear and severe risks. Yet while “many people experience cannabis as enjoyable and trouble free”, there are also varying degrees of harm with this drug depending on the characteristics of the person using, the type of the cannabis, and the way they consume it. Many formal cannabis harm reduction programmes borrow from the fields of alcohol and tobacco. Advice includes:

• safer modes of administration (eg, on the use of vaporisers, on rolling safer joints, on less risky modes of inhaling) Many people experience cannabis as enjoyable and trouble free … some people require help to reduce or stop

• skills to prevent confrontation with those who disapprove of use

• encouraging users to moderate their use

 

• discouraging mixing cannabis with other drugs

• drug driving prevention and controls

• reducing third-party exposure to second-hand smoke

• education about spotting signs of problematic use

• self-screening for problematic use

In some parts of the UK, National Health Service tobacco smoking cessation services incorporated cannabis into their interventions with adults; and Health Scotland, also addressing the risks of tobacco and cannabis smoking, published a booklet for young people titled Fags ‘n’ Hash: the essential guide to cutting down the risks of using tobacco and cannabis.

Vaporising or swallowing cannabis offers a way to avoid respiratory risks, but only a minority of cannabis do this, most choosing to smoke cannabis joints (or cannabis and tobacco joints). While not all will know about the different health risks, cannabis users may choose against safer consumption methods anyway for a range of reasons (including their own thoughts about safe use):

• Users may find it easier to control the effects (eg, severity, length of effect) of cannabis when inhaling in the form of a joint or spliff

• Preparing and sharing joints can be an enjoyable part of the routine, or part of a person’s social activities

• Alternative methods of smoking (eg, bongs and vaporisers) may be inconvenient to use, or expensive to buy

 

Most harm reduction advice is delivered informally long before users come into contact with drugs professionals – for example through cannabis magazines, websites, and headshops – highlighting the importance of official sources engaging with non-official sources to promote the delivery of accurate, evidence-based harm reduction messages.

A new high

In May 2016 the Psychoactive Substances Act placed a ‘blanket ban’ on new psychoactive substances (previously known as ‘legal highs’), including synthetic cannabinoids (synthetic forms of cannabis). Prior to this, in 2014, there had been 163 reported deaths from new psychoactive substances in the UK, and 204 the year after. The average age was around 28, younger than the average age for other drug misuse deaths of around 38. The fact that these psychoactive substances – which produced similar effects to illicit drugs like cannabis, cocaine, and ecstasy – could be bought so easily online or on the high street, appeared inconsistent; and each fatality prompted “an outcry for something to be done to prevent further tragedies”. This was the context (and arguably the political trigger) for the introduction of the Psychoactive Substances Act. While possession of a psychoactive substance as such wasn’t criminalised;, production, supply, offer to supply, possession with intent to supply, import or export were – with a maximum penalty of seven years’ imprisonment.

Just seven months after the Act came into effect, the Home Office labelled it a success, with a press release stating that nearly 500 people had been arrested, 332 shops around the UK had been stopped from selling the substances, and four people had been sent to prison. But did the Psychoactive Substances Act have the presumably desired effect of limiting access to psychoactive substances (and reducing deaths), or did it just push the drugs the way of dealers? It is perhaps too early to tell, but former chair of the Advisory Council on the Misuse of Drugs Professor Nutt had warned before the Act came into effect that the ‘blanket ban’ would make it harder (not easier) to control drugs. And while Chief executive of DrugWise Harry Shapiro had said the new law would make new psychoactive substances harder to obtain, he also agreed that sale of the drugs would not cease, but merely be diverted to the illicit market: “The same people selling heroin and crack will simply add this to their repertoire.” The paper “From niche to stigma” examined the changing face of the new psychoactive substance user between 2009 and 2016, focusing on people using the synthetic cannabis known as ‘spice’. It looked at the transition of (then) ‘legal highs’ from an “experimental and recreational” scene associated with a “niche middle class demographic”, to “those with degrees of stigma”, especially homeless, prison, and socially vulnerable youth populations (including looked after children, those involved in or at risk of offending, and those excluded or at risk of exclusion from mainstream education). In 2014, the DrugScope Street Drug Survey also observed a problem among these particular groups, recording a “rapid rise in the use of synthetic cannabinoids such as Black Mamba and Exodus Damnation by opiate users, the street homeless, socially excluded teenagers and by people in prison”.

‘SPICE’ AND OTHER SYNTHETICS

Cannabis contains two key components:

• ‘THC’ (tetrahydrocannabinol), which produces the ‘high’

• ‘CBD’ (cannabidiol), which produces the sedative and anti-anxiety effects

Synthetic forms of cannabis contain chemicals that aim to copy the effects of ‘THC’ in cannabis. But the effects of synthetic cannabis can be quite different (and often stronger): firstly, because synthetic production makes it easier to manipulate the amount of the THC-like chemical; and secondly, because of the absence of the moderating equivalent of ‘CBD’. Some synthetics are purposely designed to resemble herbal cannabis, and can be consumed in the same ways (eg, smoked or inhaled). The names also often have deliberate cannabis connotations. The risk of this is that people wishing to take cannabis may be initially unaware that they have been sold the synthetic form, or may believe from the look of it that it will produce similar sought-after effects. The greater intensity of synthetic cannabis at lower dose levels ( box) ensures that it has an appeal in terms of potency and affordability, but may put those with fewer resources at greater harm.

In 2014, the prison inspectorate for England and Wales raised concerns about the rise in the use of psychoactive substances in prisons, in particular synthetic cannabis. A study set in an English adult male prison found that the nature of the market was posing significant challenges to the management of offenders. There, the primary motivation for consumption was being able to take a substance without it being detected. Given this motivation, and the greater likelihood of harms from synthetic versus natural cannabis, the researchers concluded that it was imperative for mandatory drug-testing policies to be revised, and instead rooted in harm reduction – something which would also apply to people on probation subject to mandatory drug-testing.

Cannabis throws up a range of issues rather different from those associated with the drugs treatment in the UK has normally focused on. If current trends continue, understanding the findings will become yet more important to British treatment services.

Source:   http://findings.org.uk/PHP/dl.php?file=cannabis_treat.    Last revised 10 July 2017. 

Legalizing recreational marijuana use in Colorado, Oregon and Washington has resulted in collision claim frequencies that are about three percent higher overall than would have been expected without legalization, a new insurance report has found.

The Highway Loss Data Institute (HLDI) report says that more drivers admit to using marijuana, and the substance is showing up more frequently among people involved in crashes.

The HLDI report authors note that although there is evidence from simulator and on-road studies that marijuana can degrade some aspects of driving performance, researchers haven’t been able to definitively connect marijuana use with more frequent real-world crashes.

Some studies have found that using the drug could more than double crash risk, while others, including a large-scale federal case-control study, have failed to find a link between marijuana use and crashes. Studies on the effects of legalizing marijuana for medical use also have been inconclusive.

Colorado and Washington were the first states to legalize recreational marijuana for adults age 21 and older with voter approval in November 2012. Retail sales began in January 2014 in Colorado and in July 2014 in Washington. Oregon voters approved legalized recreational marijuana in November 2014, and sales started in October 2015.

HLDI conducted a combined analysis using neighbouring states as additional controls to examine the collision claims experience of Colorado, Oregon and Washington before and after law changes. Control states included Idaho, Montana, Nevada, Utah and Wyoming, plus Colorado, Oregon and Washington prior to legalization of recreational use.

During the study period, Nevada and Montana permitted medical use of marijuana, Wyoming and Utah allowed only limited use for medical purposes, and Idaho didn’t permit any use. Oregon and Washington authorized medical marijuana use in 1998, and Colorado authorized it in 2000.

HLDI also looked at loss results for each state individually compared with loss results for adjacent states without legalized recreational marijuana use prior to November 2016.  “The combined-state analysis shows that the first three states to legalize recreational marijuana have experienced more crashes,” says Matt Moore, senior vice president of HLDI. “The individual state analyses suggest that the size of the effect varies by state.”

Colorado saw the biggest estimated increase in claim frequency compared with its control states. After retail marijuana sales began in Colorado, the increase in collision claim frequency was 14 percent higher than in nearby Nebraska, Utah and Wyoming. Washington’s estimated increase in claim frequency was 6 percent higher than in Montana and Idaho, and Oregon’s estimated increase in claim frequency was 4 percent higher than in Idaho, Montana and Nevada.

“The combined effect for the three states was smaller but still significant at 3 percent,” Moore says. “The combined analysis uses a bigger control group and is a good representation of the effect of marijuana legalization overall. The single-state analyses show how the effect differs by state.”

Each of the individual state analyses also showed that the estimated effect of legalizing recreational use of marijuana varies depending on the comparison state examined. For example, results for Colorado vary from a 3 percent increase in claim frequency when compared with Wyoming to a 21 percent increase when compared with Utah.

Data spanned collision claims filed between January 2012 and October 2016 for 1981 to 2017 model vehicles. Analysts controlled for differences in the rated driver population, insured vehicle fleet, the mix of urban versus rural exposure, unemployment, weather and seasonality.

Collision claims are the most frequent kind of claims insurers receive. Collision coverage insures against physical damage to a driver’s vehicle in a crash with an object or other vehicle, generally when the driver is at fault. Collision claim frequency is the number of collision claims divided by the number of insured vehicle years.

HLDI said it will continue to examine insurance claims in states that allow recreational use of marijuana. Meanwhile, IIHS has begun a large-scale case-control study in Oregon to assess how legalized marijuana use may be changing the risk of crashes with injuries. Preliminary results are expected in 2020.

In addition to Colorado, Oregon and Washington, five other states and Washington, D.C., have legalized marijuana for all uses, and 21 states have comprehensive medical marijuana programs as of June. An additional 17 states permit limited access for medical use. Marijuana is still an illegal controlled substance under federal law.

“Worry that legalized marijuana is increasing crash rates isn’t misplaced,” says David Zuby, executive vice president and chief research officer of the Insurance Institute for Highway Safety. “HLDI’s findings on the early experience of Colorado, Oregon and Washington should give other states eyeing legalization pause.”

The Highway Loss Data Institute (HLDI) conducts studies of insurance data on vehicle losses and by publishes insurance loss results by vehicle make and model. Its sister research organization, the Insurance Institute for Highway Safety (IIHS), is focused reducing the losses from motor vehicle crashes. Both organizations are wholly supported by auto insurers and insurance associations.

State Efforts

The Governors Highway Safety Association (GHSA) has urged states to equip themselves with the latest research and recommends that they increase drug testing, bolster laboratory resources, track alcohol (DUI) and drugged (DUID) related driving data separately in state records, use surveys to gauge public attitudes, and evaluate the effects of any law or program changes.

The group has issued a guide, Drug Impaired Driving: A Guide for States, for states. Chief among the report’s recommendations is increased training for law enforcement officers to help them identify and arrest drugged drivers.

“As states across the country continue to struggle with drug-impaired driving, it’s critical that we help them understand the current landscape and provide examples of best practices so they can craft the most effective countermeasures,” said Jonathan Adkins, executive director of GHSA.

GHSA said this year five states are getting grants totalling $100,000 to implement Advanced Roadside Impaired Driving Enforcement (ARIDE) training and Drug Recognition Expert (DRE) programs. The states are Illinois, Montana, Washington, West Virginia and Wisconsin.

Related Research

The HLDI authors cite other research into drugs and driving including a 2016 IIHS survey that found that drivers in Colorado, Oregon and Washington were more likely to view marijuana as a highway safety problem than drivers in states without legalized use (Drivers say alcohol is bigger threat than pot).

A 2016 Columbia University study looked at traffic fatalities in 19 states before and after they enacted legalized medical marijuana laws. On average there was an 11 percent reduction in fatality rates, although the results varied across states. Seven states saw a reduction, while two had an increase, and the other 10 didn’t change.

Researchers using the National Advanced Driving Simulator found that while drivers under the influence of marijuana had trouble maintaining constant lane position, they drove more slowly and with more headway than drivers not under the influence.

About 1 in 5 weekend night-time drivers tested positive for at least one legal or illegal drug in the 2013-14 National Roadside Survey of Alcohol and Drug Use by Drivers conducted by the National Highway Traffic Safety Administration (NHTSA) (More drivers use marijuana, but link to crashes is murky).

A 2016 AAA Foundation study in Washington since legalization estimated that the prevalence of drivers in fatal crashes with marijuana in their blood roughly doubled from 8.3 percent in 2013 to 17 percent in 2014.

The National Highway and Traffic Safety Administration (NHTSA) examined the crash risk associated with driver drug use and found that drivers who tested positive for marijuana were overrepresented in the crash-involved population (More drivers use marijuana, but link to crashes is murky). However, they found no link between marijuana use and driver crash risk. The study, published in 2016, included 2011-12 data on police-reported crashes in Virginia Beach, Virginia, where it is illegal to use marijuana.

Source:  http://www.insurancejournal.com/news/