Tuesday Vision Session: Ameritox: Mixing Medicine and Marijuana

1. Mixing Medicine and Marijuana
Scott E Yasko – PRIUM
Rachel Brozina, esq. – Lester, Norton & Brozina
Michael DeGeorge Jr., PharmD – Ameritox
Rx Drug Abuse Summit – April 22, 2014 – Atlanta, GA

2. Quick History of Marijuana in the U.S.
• Cannabis was used legitimately at the turn of
the century
– Primarily used for pain
– Use declined with negative public perception and
the development of aspirin and morphine
• 1925, League of Nations sign a treaty
restricting use to scientific and medical
• Became illegal in 1937 via the Marijuana Tax
Act

3. The Administration of Marijuana
• Smoke
• Oil extract & Butter
– Added to and used to make foods
• Tinctures & Tonics
– Transdermal, sublingual and ingested
• Vaporized
– Heating the plant to inhale the mist
– Alternative to smoking

4. Marijuana in the U.S. Today
• According to CBS News, 51% of Americans
support full legalization
• Indicated for diagnoses such as chronic and
cancer pain, seizure disorders, etc.
– Varies by state
– Physicians do not prescribe; they recommend
• Medical Marijuana has potential
– Charlotte Figi – Dravet Syndrome
– Chaz Moore – myoclonus diaphragmatic flutter

5. What’s Next?
• Reassess drug scheduling
– Schedule I indicates no medicinal use
– 1988, DEA ALJ ruled in favor of reclassification
• More robust studies are needed
– Red tape surrounding U.S. studies
– Leading research coming out of Israel and Spain

6. Federal versus State Law
U.S. Constitution
•Supremacy Clause: generally, federal law
supersedes state law in areas in which Congress
has appropriately exercised its power to legislate
•Commerce Clause: generally, Congress has
express power to regulate commerce among
the states

7. Federal versus State Law
Controlled Substances Act
•Purpose: regulate the manufacture,
importation, possession, use, and
distribution of certain substances
•Execution: five schedules outline the
qualifications for a substance to be
classified
• Schedule 1 substances:
1. High potential for abuse,
2. No currently accepted medical
use in treatment in US, and
3. No accepted safety for use of the
substance under medical
supervision.
• Prescription cannot be written for
substance
U.S. Supreme Court decision:
Gonzales v. Raich
•Situation: a caregiver and a patient
possessing and using marijuana per
California’s Compassionate Use Act
sought an injunction to stop government
from interfering with their activities
•Plaintiffs’ argument: CSA is
unconstitutional as applied to their
conduct
•Government’s argument: CSA preempts
state law; Congress may regulate and
prohibit use and possession of marijuana
under Commerce Clause
•Decision: Congress has authority to
prohibit possession and use of
marijuana, even for medical purposes,
under commerce clause.
•Rationale: marijuana grown for personal
consumption is likely to create high
demand in the interstate market; this
diversion into the interstate market
interferes with federal government’s
interest in eliminating commercial
transactions.

8. USDOJ Memo to U.S. Attorneys
August 29, 2013
• Urges U.S. Attorneys to exercise their discretion in
using federal resources to prosecute individuals using
marijuana for medical purposes
• Emphasizes federal policy of enforcing CSA to prevent:
1. distribution of marijuana to minors
2. revenue falling into hands of dangerous drug cartels
3. diverting medical marijuana from legal states to other states
4. state-authorized marijuana activity from being used as a cover for trafficking other
illegal drugs
5. violence in the cultivation and distribution of marijuana
6. drugged driving and other adverse public health consequences
7. growing marijuana on public or federal lands

9. 21 Jurisdictions Have Legalized
Medical Marijuana
• Alaska
• Arizona
• California
• Colorado*
• Connecticut
• DC
• Delaware
• Hawaii
• Illinois
• Maine
• Michigan
• Montana
• Nevada
• New Hampshire
• New Jersey
• New Mexico
• Oregon
• Rhode Island
• Vermont
• Washington*
* Allows for recreational use

10. Image from Isaac Reese via reason.com

11. Pediatric Exposure to Marijuana in
Decriminalized States
Adapted by CESAR from Wang, G.S., Roosevelt, G., Le Lait, M-C, Martinez, E.M., Bucher-Bartelson, B., Bronstein, A.C., and
Heard, K., “Association of Unintentional Pediatric Exposures with Decriminalization of Marijuana in the United States,” Annals
of Emergency Medicine, In Press, 2014. For more information, please contact Dr. George Wang at
george.wang@childrenscolorado.org.

12. New Illicit Drug Use- 2012
Substance Abuse and Mental Health Services Administration, Results from the 2012 National
Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS
Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services
Administration, 2013.

13. New Illicit Drug Use- 2012
13
Substance Abuse and Mental Health Services Administration, Results from the 2012 National
Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS
Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services
Administration, 2013.

14. Marijuana use increasing
Adapted by CESAR from Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey
on Drug Use and Health: Detailed Tables, 2013. Available online at
http://www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/Index.aspx

15. Perceived risk of marijuana
•University of Michigan, 2013 Monitoring the Future Study

16. Marijuana and poly drug abuse
58% of primary marijuana admissions reported abuse
of additional substances

17. Marijuana and Nonadherence
• Retrospective review of 116,011 urine
samples
• Patients prescribed hydrocodone (excluding
prn)
• May 16, 2011 to May 15, 2012
• Broken into three categories for analysis
– THC positive as only illicit (n=15,153)
– Cocaine positive as only illicit (n=1731)
– No illicit detected (n= 99,115)
An analysis of the association between marijauana use and potential nonadherence in patients prescribed hydrocodone. DeGeorge M, Dawson E, et al.
American Academy of Pain Medicine annual meeting 2013

18. Marijuana and Nonadherence
An analysis of the association between marijauana use and potential nonadherence in patients prescribed hydrocodone. DeGeorge M, Dawson E, et al.
American Academy of Pain Medicine annual meeting 2013

19. An analysis of the association between marijauana use and potential nonadherence in patients prescribed hydrocodone. DeGeorge M, Dawson E, et al.
American Academy of Pain Medicine annual meeting 2013
Marijuana and Nonadherence

20. An analysis of the association between marijauana use and potential nonadherence in patients prescribed hydrocodone. DeGeorge M, Dawson E, et al.
American Academy of Pain Medicine annual meeting 2013
Marijuana and Nonadherence

21. Thank You
Scott E Yasko
PRIUM
National Account Executive
(678) 735-7315
syasko@prium.net
Rachel Brozina, esq.
Lester, Norton & Brozina, p.c.
rachel@lesternortonlaw.com
Michael DeGeorge, PharmD
Ameritox
Associate Director, Medical Affairs
michael.degeorge@ameritox.com