Marijuana use among youth poses significant risks to brain development and mental health. Regular marijuana use is associated with cognitive decline across all domains even after years of abstinence. It can also increase the likelihood of developing psychiatric disorders like depression and psychosis. Prenatal marijuana exposure has been linked to lower birth weight, abnormal development and long term cognitive impairments in offspring. Overall, the evidence shows that marijuana jeopardizes the healthy development of youth.
1. Marijuana Jeopardizing Youth
Eric A. Voth, M.D., F.A.C.P-Eric A. Voth, M.D., F.A.C.P-
ChairmanChairman
The Institute onThe Institute on
Global Drug PolicyGlobal Drug Policy
7. CESAR FAX
U n i v e r s i t y o f M a r y l a n d , C o l l e g e P a r k
A Weekly FAX from the Center for Substance Abuse Research
January 18, 2010
Vol. 19, Issue 2
U.S. High School Seniors’ Perception of Harm from Regular Marijuana Use Decreasing
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
0%
10%
20%
30%
40%
50%
60%
70%
80%
Perceived Risk of Harm
from Regular Use
Used in Past Month
Percentage of U.S. Twelfth Grade Students Reporting Past Month
Marijuana Use and Perceived Risk of Harm from Regular Marijuana Use, 1975-2009
SOURCE: Adapted by CESAR from University of Michigan, “Teen Marijuana Use Tilts Up, While Some
Drugs Decline in Use,” Press Release, 12/14/09. Available online at
http://www.monitoringthefuture.org/data/09data.html#2009data-drugs.
8.
9.
10. Marijuana
Impurity-488 substances, 66 cannabinoidsImpurity-488 substances, 66 cannabinoids
Resembles tobacco in constituents.Resembles tobacco in constituents.
High THC concentrations 2-30%High THC concentrations 2-30%
1/2 life 5-7 days1/2 life 5-7 days
13. Cognitive Changes
AttentionAttention
ConcentrationConcentration
Decision-makingDecision-making
InhibitionInhibition
ImpulsivityImpulsivity
Working memoryWorking memory
Verbal fluencyVerbal fluency
Concept formation and planningConcept formation and planning
J Addict Med 2011;5:1-8J Addict Med 2011;5:1-8
14. Memory
Difficulty sorting information andDifficulty sorting information and
inhibition of memory even after ainhibition of memory even after a
mean two year abstinence.mean two year abstinence.
SOLOWIJ- LIFE SCIENCESSOLOWIJ- LIFE SCIENCES
1995;5:2119-261995;5:2119-26
15. Structural Damage to Brain
59 users 33 controls59 users 33 controls
Ave age 33, Ave use 15 yrs, started 16.7 yoAve age 33, Ave use 15 yrs, started 16.7 yo
Ave joints /mo=147Ave joints /mo=147
Ave life joints 25922Ave life joints 25922
Demonstrated axonal connectivityDemonstrated axonal connectivity
impairment in hippocampus, splenium ofimpairment in hippocampus, splenium of
corpus callosum, commissural fiberscorpus callosum, commissural fibers
Brain 2012:135;2245-2255Brain 2012:135;2245-2255
16. Neuropsychological Decline
1037 individuals1037 individuals
Pot use at 18,21,26,32,38 y/oPot use at 18,21,26,32,38 y/o
Neuropsych testing at 13 before pot and 38Neuropsych testing at 13 before pot and 38
Broad Neuropsychological decline acrossBroad Neuropsychological decline across
all domains even controlling for educationall domains even controlling for education
Greatest decline was adolescent andGreatest decline was adolescent and
persistent use.persistent use.
Proc Natl Acad Sci U S A. 2012 Aug 27Proc Natl Acad Sci U S A. 2012 Aug 27
17. From the horse’s mouth
““I used to smoke this stuff regulerly I quit because II used to smoke this stuff regulerly I quit because I
needed to pass a test to get a job. The reason I am writingneeded to pass a test to get a job. The reason I am writing
is because I never had any of thougs side effects you talkis because I never had any of thougs side effects you talk
about don’t get me wrong its not for every body. But youabout don’t get me wrong its not for every body. But you
don’t need to say untrue things about it coordinationdon’t need to say untrue things about it coordination
imparment that’s bs it allows you to focus better on singleimparment that’s bs it allows you to focus better on single
things its perfect for kids like I was that cant concetrate onthings its perfect for kids like I was that cant concetrate on
ting well you don’t have to reply to this email I am justting well you don’t have to reply to this email I am just
bored and looking at stuff on the net and emailing peoplebored and looking at stuff on the net and emailing people
and going on and on cause I cant sleep well you have aand going on and on cause I cant sleep well you have a
nice day.nice day.
19. Driving Effects
Combining EtOH and Marijuana in FirstCombining EtOH and Marijuana in First
Study Reduced Driving SkillsStudy Reduced Driving Skills
.07 + 100ug = Plain EtOH of 0.09.07 + 100ug = Plain EtOH of 0.09
.07 + 200 ug = Plain EtOH of .14 g/dl.07 + 200 ug = Plain EtOH of .14 g/dl
NHTSA Notes Annals of Emergency MedicineNHTSA Notes Annals of Emergency Medicine
2000;35:3992000;35:399
23. Marijuana and depression
1920 subjects1920 subjects
15 year follow up15 year follow up
Likelyhood of major depression 4 timesLikelyhood of major depression 4 times
greater among users.greater among users.
Am J. Psychiatry
2001;158:2033-2037
25. Marijuana and Psychosis
40454045 psychosis-freepsychosis-free and 59 individualsand 59 individuals
exhibiting psychosis at baseline assessment.exhibiting psychosis at baseline assessment.
Marijuana predictedMarijuana predicted 2.762.76 times greatertimes greater
likelihood oflikelihood of any psychotic symptomsany psychotic symptoms,,
predictedpredicted 24.1724.17 times higher incidence oftimes higher incidence of
severe psychotic symptomssevere psychotic symptoms, and predicted, and predicted
12 times higher need for clinical assessment12 times higher need for clinical assessment
and care for psychotic symptoms.and care for psychotic symptoms.
American Journal of EpidemiologyAmerican Journal of Epidemiology
2002;156:319-272002;156:319-27
26. Persistence of Psychosis
Risk of psychosis -no prior psychosis whoRisk of psychosis -no prior psychosis who
used pot, 1.9 times greater that non-users inused pot, 1.9 times greater that non-users in
ave 3.5 years.ave 3.5 years.
Continued pot use risk of future psychosisContinued pot use risk of future psychosis
was 31% vs 20% in those who did not usewas 31% vs 20% in those who did not use
out to approx 8.5 years.out to approx 8.5 years.
BMJ 2011;342: d738BMJ 2011;342: d738
27. Marijuana and Bipolar Illness
166 first-episode bipolar I disorder patients.166 first-episode bipolar I disorder patients.
Cannabis and alcohol associated with theCannabis and alcohol associated with the
first episode of maniafirst episode of mania
Bipolar Disorder 2008;10:738-741Bipolar Disorder 2008;10:738-741
28. Marijuana and Behavior
Marijuana had a greater effect on degree ofMarijuana had a greater effect on degree of
violent behavior in non-delinquentviolent behavior in non-delinquent
individuals than in delinquent individuals.individuals than in delinquent individuals.
This effect is even more prominent than theThis effect is even more prominent than the
effect of cocaine, amphetamine, oreffect of cocaine, amphetamine, or
tranquilizer/sedative use.tranquilizer/sedative use.
Friedman AS, J Addict Dis. 2003;22:63-78Friedman AS, J Addict Dis. 2003;22:63-78
30. Gateway Effect
Risk spans entire course of adolescent
development.
Young people exposed to other users are at
higher risk for early initiation.
Clear family standards and proactive
family management are important in
delaying alcohol and marijuana use.
Kosterman R, Hawkins JD, Guo J, Catalano RF, Abbott RD.
. American Journal of Public Health 2000;90:360-366.
31. Gateway effects
Risk of other drug use with weekly
marijuana vs nonusers:
14-15 y/o 66.7%
17-18y/o 28.5%
20-21y/o 12.2%
24-25y/o 3.9%
Fergusson DM, et al.
Addiction 2006;101:556-569
32. Marijuana Dependence
Most patients claimed serious problems withMost patients claimed serious problems with
cannabis, and 78.6% met criteria for cannabiscannabis, and 78.6% met criteria for cannabis
dependence.dependence.
Two thirds reported withdrawal. Cannabis is aTwo thirds reported withdrawal. Cannabis is a
reinforcer. produces both dependence andreinforcer. produces both dependence and
withdrawal and reinforces cannabis use.withdrawal and reinforces cannabis use.
Regular cannabis use rapid as tobaccoRegular cannabis use rapid as tobacco
progression, and more rapid than alcoholprogression, and more rapid than alcohol
CrowleyDrug and Alcohol Dependence 1998;50:27-37CrowleyDrug and Alcohol Dependence 1998;50:27-37
33. Marijuana Dependence
20% used before age 16 (20% used before age 16 (New Zealand)New Zealand)
21.7% demonstrated dependence by age 2121.7% demonstrated dependence by age 21
If 5 positive experiences with pot, 28 xIf 5 positive experiences with pot, 28 x
increase risk of dependence.increase risk of dependence.
Fergusson DM, Horwood LJ, Lynskey MT, Madden PAF.
Early reactions to cannabis predict later dependence.
Arch Gen Psychiatry 2003;60:1033-1039
35. Effect on Conception
Women smoking> 90 times in their lifetimeWomen smoking> 90 times in their lifetime
had 27% fewer oocytes retrieved (P=.03)had 27% fewer oocytes retrieved (P=.03)
and 1 fewer embryo transferred (P!.05).and 1 fewer embryo transferred (P!.05).
Women smoking marijuana >10 times inWomen smoking marijuana >10 times in
lifetime infants 17% (P=.01) smallerlifetime infants 17% (P=.01) smaller
Women smoking marijuana 1 year beforeWomen smoking marijuana 1 year before
IVF/ GIFT had25% fewer oocytes retrievedIVF/ GIFT had25% fewer oocytes retrieved
(P=.03)(P=.03)
Am J Ob-Gyn (2006) 194, 369–76Am J Ob-Gyn (2006) 194, 369–76..
36. Effect on Conception (cont)
If men smoked marijuana 11 to 90 times inIf men smoked marijuana 11 to 90 times in
their lifetime, there was a 15% decrease intheir lifetime, there was a 15% decrease in
infant birth weight (P = .03)infant birth weight (P = .03)
more than 90 times, there was a 23%more than 90 times, there was a 23%
decrease (P=.01).decrease (P=.01).
Women and men who smoked in the past 15Women and men who smoked in the past 15
years, had 12%(P=.04) and 16% (P=.03)years, had 12%(P=.04) and 16% (P=.03)
smaller infants, respectively.smaller infants, respectively.
37. Pre-Term Birth
3234 births from healthy women3234 births from healthy women
Use of marijuana (particularly pre-Use of marijuana (particularly pre-
pregnancy) is a strong environment risk forpregnancy) is a strong environment risk for
pre-term birth.pre-term birth.
Dekker GA, Lee SY, North RA, McCowan LM, Simpson NAB, et al.Dekker GA, Lee SY, North RA, McCowan LM, Simpson NAB, et al.
(2012PLoS ONE 7(7): e39154. doi:10.1371/journal.pone.0039154)(2012PLoS ONE 7(7): e39154. doi:10.1371/journal.pone.0039154)
39. Fetal/Infant Effects
Prenatal exposure to marijuana is associated withPrenatal exposure to marijuana is associated with
reduction in birth weight, length, and headreduction in birth weight, length, and head
circumference even when tobacco use factoredcircumference even when tobacco use factored
out.out.
Clinical Chemisty 2010;56:1442-1450Clinical Chemisty 2010;56:1442-1450
40. Fetal Effects: 14 y/o
524 subjects524 subjects
Confounding variables controlledConfounding variables controlled
Greatest effect first Trimester >1joint /dayGreatest effect first Trimester >1joint /day
Fetal exposure= 14 y/o Wechsler compositeFetal exposure= 14 y/o Wechsler composite
Poor Intelligence age 6Poor Intelligence age 6
Attention and Depression age 10Attention and Depression age 10
Neurotoxicology and TeratologyNeurotoxicology and Teratology
Goldschmidt and DayGoldschmidt and Day
34 (2012) 161–16734 (2012) 161–167
42. Respiratory Effects
Cannabis associated with dose-relatedCannabis associated with dose-related
impairment of large airways resulting inimpairment of large airways resulting in
obstruction, wheezing, mucous, andobstruction, wheezing, mucous, and
hyperinflation.hyperinflation.
Dose equivalence 1: 2.5-5 vs tobaccoDose equivalence 1: 2.5-5 vs tobacco
Thorax 2007;0: 1-7Thorax 2007;0: 1-7
43. Lung Damage
Marijuana smoking leads to bullous lungMarijuana smoking leads to bullous lung
disease in normal CXR and lung functiondisease in normal CXR and lung function
20 years earlier than seen with tobacco20 years earlier than seen with tobacco
Respirology 2008;13:122-127Respirology 2008;13:122-127
44. Marijuana and Lung Cancer
The risk of lung cancer increased 8% (95%The risk of lung cancer increased 8% (95%
confidence interval (CI) 2–15) for eachconfidence interval (CI) 2–15) for each
joint-yr of cannabis smoking, 7% (95% CIjoint-yr of cannabis smoking, 7% (95% CI
5–9) for each pack-yr of cigarette smoking,5–9) for each pack-yr of cigarette smoking,
The highest tertile of cannabis use wasThe highest tertile of cannabis use was
associated with an increased risk of lungassociated with an increased risk of lung
cancer relative risk 5.7 (95% CI 1.5–21.6)),cancer relative risk 5.7 (95% CI 1.5–21.6)),
Eur Respir J 2008; 31: 280–286Eur Respir J 2008; 31: 280–286
47. Medical Excuse Marijuana
No compelling evidence that there
is a significant group of untreated
or inadequately treated patients.
Pro-marijuana lobby getting its
“nose under the tent”
48. Marijuana Policy Project
"This is the next step in the evolution of medical
marijuana as a political issue," "We have informed
elected officials about the widespread public
support for the issue, we have lobbied members
of Congress and their staffs directly, and we
have activated our grassroots. Now it is time to
provide financial support to those who are willing
to support medical marijuana.”
Steve Fox
Marijuana Policy Project (MPP) Washington, D.C.
49. Important points to remember
Safe, effective reliable medicines are bestSafe, effective reliable medicines are best
for patients, and they are availablefor patients, and they are available
Marijuana is impure, unreliable, full ofMarijuana is impure, unreliable, full of
contaminants, high side effect rate.contaminants, high side effect rate.
Defense to possession bypasses FDA andDefense to possession bypasses FDA and
jeopardizes consumer protectionjeopardizes consumer protection
Medical excuse marijuana createsMedical excuse marijuana creates
“medicine by popular vote.”“medicine by popular vote.”
50. Proposed Medicinal Uses of
Marijuana
Nausea of ChemotherapyNausea of Chemotherapy
GlaucomaGlaucoma
Appetite StimulationAppetite Stimulation
Multiple SclerosisMultiple Sclerosis
Pain/ MigrainePain/ Migraine
Misc- Cramps, Sleep, DepressionMisc- Cramps, Sleep, Depression
51. Who is Actually Using
Medical Excuse Marijuana?
Under 34 -- 45.4%Under 34 -- 45.4%
Under 54 (most pain age older) 84%Under 54 (most pain age older) 84%
For Pain 82%For Pain 82%
For Anxiety 37%For Anxiety 37%
For Depression 26%For Depression 26%
For Nausea 27%For Nausea 27%
For Appetite 37.7%For Appetite 37.7%
Journal of psychoactive drugsJournal of psychoactive drugs
2011;43:128-1352011;43:128-135
52. Colorado Medical Excuse Pot
Sept 2011 127,444 usersSept 2011 127,444 users
94% pain94% pain
Ave Age 40Ave Age 40
Denver has 400 dispensaries (375 StarbucksDenver has 400 dispensaries (375 Starbucks
state-wide)state-wide)
Denver Dispensary crime up 69% with 75%Denver Dispensary crime up 69% with 75%
increase in burglaries.increase in burglaries. Denver Police June 4, 2012Denver Police June 4, 2012
54. Pain
Healthy volunteers doses 0,2,4,8% THCHealthy volunteers doses 0,2,4,8% THC
Decrease of pain medium dosesDecrease of pain medium doses
Increase of pain higher dosesIncrease of pain higher doses
?Specific substance responsible??Specific substance responsible?
Anesthesiology. 2007;107:785-96Anesthesiology. 2007;107:785-96
55. THC as Opioid Adjunct
THC alone ineffective for the most partTHC alone ineffective for the most part
Literature is contradictory. SomeLiterature is contradictory. Some
demonstrated higher morphine dosesdemonstrated higher morphine doses
May be useful as an adjunct to opiodsMay be useful as an adjunct to opiods
International Review of Psychiatry,International Review of Psychiatry,
April 2009; 21(2): 143–151April 2009; 21(2): 143–151
56. Palliative Care
Studies largely marginalStudies largely marginal
Mostly involve oral or SativexMostly involve oral or Sativex
Not indicated as sole agentNot indicated as sole agent
May be some add-on benefitMay be some add-on benefit
International Journal of Palliative NursingInternational Journal of Palliative Nursing
2010, Vol 16, No 102010, Vol 16, No 10
57. Sativex as add-on for pain
Advanced cancer patients on opioid painAdvanced cancer patients on opioid pain
medsmeds
Low, medium, high dose treatementsLow, medium, high dose treatements
Add on to the opioid medicationAdd on to the opioid medication
Low and medium dose had benefit, not highLow and medium dose had benefit, not high
dosedose
Adverse events dose related and high doseAdverse events dose related and high dose
was unfavorablewas unfavorable
58. Pain in HIV
Trial in HIV-associated neuropathyTrial in HIV-associated neuropathy
No comparison to other medicines norNo comparison to other medicines nor
MarinolMarinol
Benefit in reducing the neuropathic painBenefit in reducing the neuropathic pain
comparable to existing medicationscomparable to existing medications
Difficult to discern “high” vs. medicalDifficult to discern “high” vs. medical
effecteffect
Abrahms Neurology 2007;68 515-521Abrahms Neurology 2007;68 515-521
60. HIV Cognitive Impairment
HIV patients vs controlsHIV patients vs controls
Significantly more depression and anxietySignificantly more depression and anxiety
in marijuana using groupin marijuana using group
More alcohol use if used marijuanaMore alcohol use if used marijuana
Memory impaired even after factoring outMemory impaired even after factoring out
depression, anxiety, and alcoholdepression, anxiety, and alcohol
The Journal of Neuropsychiatry andThe Journal of Neuropsychiatry and
Clinical Neurosciences 2004; 16:330–335Clinical Neurosciences 2004; 16:330–335
61. Pain Summary
Summary of literature on pain/ quality ofSummary of literature on pain/ quality of
studies generally marginalstudies generally marginal
Mostly discussing oral or syntheticMostly discussing oral or synthetic
cannabinoidscannabinoids
May be useful as an adjunct particularly forMay be useful as an adjunct particularly for
neuropathic painneuropathic pain
As solo agent, high doses needed and moreAs solo agent, high doses needed and more
side effectsside effects
Current Opinion in Anaesthesiology 2005, 18:424–427Current Opinion in Anaesthesiology 2005, 18:424–427
62. Cannabinoids in MS
meta-analysis
All studied were non-smokedAll studied were non-smoked
Cannabinoids difficult to work withCannabinoids difficult to work with
Adverse effects not related to doseAdverse effects not related to dose
Little benefit for spasticity-poss as add-onLittle benefit for spasticity-poss as add-on
Evidence on tremor weakEvidence on tremor weak
Evidence on pain moderateEvidence on pain moderate
Problems with psychoactivityProblems with psychoactivity
CNS Drugs 2011:25 ZajicekCNS Drugs 2011:25 Zajicek
63. MS- Cognitive Effects
MS patients using smoked or ingested potMS patients using smoked or ingested pot
Impaired processing speed, memory,Impaired processing speed, memory,
executive function, spatial perceptionexecutive function, spatial perception
Twice as likely as nonusers to beTwice as likely as nonusers to be
classified as globally cognitivelyclassified as globally cognitively
impaired.impaired.
Neurology 2011;76:1153-1160Neurology 2011;76:1153-1160
64. As Paul Harvey would say--
““And now for the rest of the story.”And now for the rest of the story.”
65. Marijuana and Fatal Crashes
California 2008
Five years following medical excuseFive years following medical excuse
marijuana dispensaries 1240 fatal crashesmarijuana dispensaries 1240 fatal crashes
compared to 631 for the five years priorcompared to 631 for the five years prior
8.3% of fatal single vehicle crashes8.3% of fatal single vehicle crashes
5.5% fatal passenger crashes5.5% fatal passenger crashes
Use rate estimated at 16-20%Use rate estimated at 16-20%
Rivals alcohol as top cause of fatalitiesRivals alcohol as top cause of fatalities
Crancer and CrancerCrancer and Crancer
Involvement of marijuana inInvolvement of marijuana in
California Fatal Vehicle CrashesCalifornia Fatal Vehicle Crashes
66. Marijuana treatment episodes
National increaseNational increase
1992 92,5001992 92,500
2008 322,0002008 322,000
California increaseCalifornia increase
1992 73001992 7300
2008 350002008 35000
RAND 2010RAND 2010
Altered State?Altered State?
Assessing How Marijuana LegalizationAssessing How Marijuana Legalization
in California Could Influencein California Could Influence
Marijuana ConsumptionMarijuana Consumption
67. Scientific Status of Medical
Excuse Marijuana
Cannabinoids may be useful and worthCannabinoids may be useful and worth
studyingstudying
Smoking is problematicSmoking is problematic
Legislative processes bypass the FDA andLegislative processes bypass the FDA and
jeopardize the publicjeopardize the public
69. IOM Recommendations
Rec 5-The goal of clinical trials ofRec 5-The goal of clinical trials of
smoked marijuana wouldsmoked marijuana would not be tonot be to
develop marijuana as a licensed drugdevelop marijuana as a licensed drug
Rec 6-Rec 6- must meet the followingmust meet the following
conditions:conditions: failure of all approvedfailure of all approved
medicationsmedications to provide relief has beento provide relief has been
documenteddocumented
70. Practical Issues/Regulation
Has user exhausted all other acceptedHas user exhausted all other accepted
medical interventions?medical interventions?
Is the proposed patient a drug abuser?Is the proposed patient a drug abuser?
Does law allow for drug screening to assureDoes law allow for drug screening to assure
no use of illegal drugs?no use of illegal drugs?
Will patient have medical oversite andWill patient have medical oversite and
monitoring of status and adverse Eventsmonitoring of status and adverse Events
Legal liability and responsibility?Legal liability and responsibility?
71. Practical Issues/ Regulation
What marijuana will be allowed, whatWhat marijuana will be allowed, what
strengths, and who pays for it?strengths, and who pays for it?
Who produces the marijuana?Who produces the marijuana?
Is marijuana purity assured?Is marijuana purity assured?
Is the caregiver licensed and in goodIs the caregiver licensed and in good
standing with regulatory agencies?standing with regulatory agencies?
Does the caregiver demonstrate formalDoes the caregiver demonstrate formal
training or experience in addiction and intraining or experience in addiction and in
the administration of dangerous drugs?the administration of dangerous drugs?
72. Practical Social Issues
Employment drug testsEmployment drug tests
Health insurance medication ridersHealth insurance medication riders
DUI statutes/ accidentsDUI statutes/ accidents
Student/adult athleticsStudent/adult athletics
Side effectsSide effects
Work productivityWork productivity
73. Important points to remember
Safe, effective reliable medicines are bestSafe, effective reliable medicines are best
for patients, and they are availablefor patients, and they are available
Marijuana is impure, unreliable, full ofMarijuana is impure, unreliable, full of
contaminants, high side effect rate.contaminants, high side effect rate.
Defense to possession bypasses FDA andDefense to possession bypasses FDA and
jeopardizes consumer protectionjeopardizes consumer protection
Medical excuse marijuana createsMedical excuse marijuana creates
“medicine by popular vote.”“medicine by popular vote.”