A place where ideas stir the waters of our mind.

Thursday, March 19, 2015

Is Marijuana HARMFUL to your health?

The push for the legalization of marijuana for medical and recreational use continues to plow ahead.  In the past week, members of Congress as well as members of my State Assembly have joined the pro-pot push. I also noticed an article describing the “useful” tax revenue generated by the legalization of medical marijuana in Colorado.  When money is in the mix, it’s often not long before legislators want a piece of the pie. 

Lost in the move to legalize recreational and medical marijuana are the questions about the health effects of marijuana use. It seems hard for pro and anti-pot proponents to have even a useful conversation to answer health-related questions concerning this drug. Repeating the mantra that “marijuana is safe and no more harmful than alcohol” (including a certain oval office holder), the legalization train keeps chugging ahead and minimizing or ridiculing data concerning harmful health effects.  The anti-marijuana crowd tends towards knee-jerk reactions to these issues, and don’t consider the plight of those struggling with painful and debilitating diseases that don’t respond to conventional treatments.
I wonder what would happen if both sides just took a deep breath (not a long toke) and took a serious look at studies documenting the physical and psychological damage that smokers of marijuana are likely to experience.  Would it then be possible to have an informed dialogue?  Government policies concerning marijuana are too important to be made by those who ignore data in pursuit of a buzz, those on the “Reefer Madness” bandwagon or politicians looking for new revenue to fund pet projects.

Difficult Answers
From the outset, several issues make the marijuana health debate more complicated.
First, the majority of medical marijuana users are those who began using cannabis in adolescence.  That means that those pushing most for legalization also have a long-term history of getting high.  Do we really want the loudest voices influencing this debate to be those looking for a legal high – justified on medical grounds?
Second, it is also clear that some proponents of legal medical marijuana are suffering from long-term intractable conditions or the side effects of cancer treatments. As a person who has a long-term, chronic disease for which there is no cure, I am highly sympathetic to anyone seeking relief from pain or other debilitating conditions. The fact that some potheads are pushing for legal marijuana does not mean that all proponents of legal marijuana are looking for a quick buzz.  There are medical conditions that respond uniquely to cannabis.
Third, there are over 100 cannabinoids marijuana. THC is the cannabinoid that receives the most attention because it is responsible for the “rush” of pleasure when marijuana is used, but is only one of a multitude of the active ingredients in pot. Science is still in the process of trying to better understand and isolate individual cannabinoids to determine their efficacy for medical use.  Is it possible to isolate specific cannabinoids to more effectively treat specific diseases, and deliver the proper dosage in a medium that minimizes or eliminates the health effects of other cannabinoids? This question should be answered, but I’m sure that anything that might eliminate the THC buzz would be quite unpopular with those who see medical marijuana as a quick route to an easy high.
Fourth, the degree to which marijuana users experience harmful marijuana side effects depends on the age of first use, as well as the frequency and duration of use. Studies on the health effects of marijuana must control for these issues, and the good news is that some research already is.
Finally, marijuana does not have uniform concentrations of cannabinoids. What someone smokes in England may be chemically different from what someone smokes in California.  Therefore, it’s important to note that studies of the health effects of marijuana need to control for this and other factors as well as the use of other substances and behaviors.

So, what are studies suggesting about the health effects of marijuana?
For a good overview of current studies about the health effects of cannabis, please check out Dr. Michael Schatman’s article, “Medical Marijuana-the State of the Science” published in Medscape Neurology, February 2015.

Effects on the brain
SPECT scans from Dr. Daniel Amen (Amenclinic.com) show marked decrease in activity in the brain’s prefrontal cortex. The prefrontal cortex is one of the biggest things that separate us from other creatures like lizards. When the prefrontal cortex is impaired, we begin to function like very relaxed lizards and lose a variety of essential brain functions.  The functions impaired include:
  • ·        the ability to effectively regulate emotions
  • ·        maintain effective real-time interactions with others
  • ·        resolve conflicts
  • ·        think creatively or resourcefully
  • ·        impulse control
  • ·        motivation and goal-directed behavior
  • ·        understand the emotional consequences of behavior
  • ·        focus attention

In addition to these problems, a study of over 1000 participants showed that cognitive impairment among adolescent users continued long after they stopped using marijuana. In fact, nobody knows how long these effects will last or if they are permanent.  Proponents of marijuana need to recognize that anything making pot more accessible to teens is dangerous to the brain, including teens or children who use marijuana for medical reasons. Do the health benefits of marijuana outweigh the known long-term cognitive impact of marijuana on the developing brain?
In response, marijuana proponents are quick to point out that only those 21 and older should be able to buy marijuana legally. They argue that the 21-year old age limit will ensure that marijuana legalization will not affect teens. Really?  Really?  How many teens already find access to marijuana now?  Can we really believe that increasing the available supply of available marijuana will somehow magically make it less accessible to kids?

Psychological Effects
Studies report that acute anxiety in marijuana users has risen as THC content has increased and studies that suggest a correlation between marijuana use and anxiety date to 1944. Some studies also suggest that depression, suicidal ideation, and increased risk for suicide are correlated to the use of marijuana. One study by Hadland and Harris found that “frequent marijuana use by teens predicted depression and anxiety later in life”, and a more recent study determined that “use of marijuana among adolescents was associated with adult-onset anxiety.” (Michael Schatman PhD Medical Marijuana-the State of the Science; Medscape Neurology February 2015)
Dr. Schatman also reports a correlation between the use of marijuana and psychotic disorders, schizophrenia and bi-polar disorder. The relationship between marijuana and these mental health issues is complicated. Frequently people with a variety of mental disorders use substances like marijuana to self-medicate, so it’s unclear if marijuana is the causative factor. Risk factors associated with marijuana use and psychosis include: early use of marijuana, childhood abuse, a family history of schizophrenia, as well as a variety of genetic factors. While it would be inaccurate to state that marijuana use leads to these mental health issues, it is equally difficult to unequivocally state that marijuana does not lead to those problems. It would be helpful if proponents of legal marijuana were willing to consider the psychological issues associated with marijuana use of repeating the mantra, “marijuana is safe”. This isn’t about fear it’s about scientifically informed decisions about marijuana use.

Physical Effects
Marijuana is not good for your lungs, and it’s been known for years that cannabis contains carcinogens. A report from The American Lung Association notes that there are 33 cancer causing chemicals in marijuana. In fact, “marijuana deposits four times as much tar into the lungs as cigarettes when equal amounts are smoked”. Add to this other respiratory problems related to marijuana including bronchitis, lung irritation and infection.
Marijuana also affects the heart.  Dr. Schatman notes studies showing a connection between inhaling marijuana and higher rates of heart attack and death. In general people who use marijuana had higher rates of death from lung cancer. They also died more frequently from car accidents. The use of marijuana can also make it more difficult for women to become pregnant. A report in WebMD indicates that marijuana also affects men’s reproductive health. In fact they state, “The smokers weren’t the only ones who got high. The drug effected their sperm too. These stoned sperm party hard and are hyperactive… they’re too fast, too early… and then poop out.” In other words, the sperm of those smoking marijuana tend to swim hyperactively initially, and then to “burn out” and stop moving before they ever reach the egg. I wouldn’t consider marijuana to be an effective form of birth control, but it does effect fertility.
I don’t know about you, but the impact of marijuana on the brain and cognitive functions, along with the psychological and physical effects, strongly suggest that marijuana is not the “harmless drug” that proponents report.

So, what can we make of this information? Is marijuana a safe drug?
It seems best to say that the data is still coming in, but studies definitely indicate there is a dark side to the use of marijuana. We need solid research to study the health effects and benefits of the many cannabinoids in cannabis. Furthermore, we need research to determine the best non-harmful delivery system for medical marijuana.  If a specific cannabinoid can treat a disease effectively, is it possible to deliver it medicinally without the harm caused by smoking marijuana?
Parents opting to use marijuana to treat diseases in children need to carefully weigh the benefits and longer term harm of cannabis prescriptions.  The evidence suggesting long-term damage to the developing brain is compelling. The accompanying psychological effects can also be serious.
Should we deny adults with conditions that tend to respond only to the use of marijuana access to the most effective treatment for their disease because anti-marijuana are afraid? As with any medication, shouldn’t patients become educated about the side effects of their prescriptions, and then be free to make their own informed decisions about usage?

In closing, perhaps it makes sense to look at the health effects of marijuana this way.  When the buzz feels good it’s hard to imagine the harmful effects of marijuana – unless you are a marijuana smoker who is dying of lung disease, stroke, or heart attack. Then it doesn’t seem quite so harmless at all. 

Thursday, February 19, 2015

"Getting high" and Medical Marijuana

The active ingredient in marijuana associated with the rush of euphoria is the cannabinoid, THC. Both medical marijuana legally available from dispensaries as well as cannabis available “on the street” have much higher concentrations of THC than in the past. Users are getting “higher” than ever before. But is marijuana with high THC concentrations really the best use of cannabis for medical reasons?

Patients with chronic pain that is unresponsive to other therapies use marijuana with high concentrations of THC to relieve their pain. Some doctors prescribe it for chemotherapy patients to control nausea and stimulate appetite. Anecdotally, many medical marijuana users report significant improvement in their conditions. With over 100 cannabinoids in marijuana, is euphoria-causing THC responsible for these reported medical benefits? Are high concentrations of THC really the most medically effective cannabinoid in marijuana?

Is the debate over medical marijuana being informed by science - or is it driven by those who use see the medical marijuana debate as an opportunity to legitimize “getting high”?

Another cannabinoid in marijuana that may show more promise than THC for treating a variety of conditions is CBD (Cannabidiol). Research indicates that CBD "mitigates the euphoria associated with THC" (Iverson, The Science of Marijuana). To give marijuana users more “high” for their buck, scientists working for the drug sellers figured out how to boost the amount of THC in the marijuana plants, and subsequently reduced the amount of CBD. So, while THC concentrations increased from around 2% to nearly 10%, the concentration of CBD decreased 300%.

To put it simply, scientists increased THC and reduced CBD content to give users a more intense high. Interestingly, the THC potency in states with legally protected dispensaries is significantly higher than in states without dispensaries (Sevigny, Pacula and Heaton, 2014). This means that medical marijuana will get users very high with low levels of CBD. It also means that harmful side effects associated with THC are maximized in medical marijuana and potential benefits from CBD are minimized.

What are possible medicinal usages for CBD?

In this discussion, I want to be clear. I am NOT arguing for the expansion of medical marijuana or for legalization of marijuana. I am suggesting that more research with CBD is important; I am NOT advocating that “getting high” is the way to solve serious medical problems. I also don’t want to throw the baby out with the bathwater and argue that marijuana has absolutely no medicinal value at all. I want patients suffering from severe, chronic, life-altering medical problems to have the benefit of every effective treatment option supported by data generated from numerous scientific research. As we will see, CBD may be a promising intervention for a long list of medical conditions. If further studies suggest that CBD is an effective treatment modality, I would be much more inclined to support its use, especially if produced synthetically and administered apart from marijuana and its harmful side effects.

Furthermore, it is important to understand that CBD research is still in its infancy. Short-term trials and experiments with animals suggest that CBD may be medically useful, but there isn’t sufficient data from long-term human trials with CBD to draw any final conclusions.

Administration of CBD shows promise when in addressing the following conditions:
·         Epilepsy and seizure disorders - Data suggests that CBD helps reduce seizure frequency including treatment resistant pediatric epilepsy.
·         Parkinson’s Disease – CBD reduced Dystonia and Rapid Eye Movement Sleep Behavior Disorder
·         Pain relief – Patients with MS and spinal cord injury found significant pain relief from CBD without unwanted side effects compared to those receiving the placebo. CBD also seems to have anti-inflammatory and anti-spasmodic benefits.
·         Cancer – In hundreds of human an animal cell studies, CBD interferes with cancer cells’ ability to reproduce themselves.
·         Anxiety & PTSD – While THC tends to increase levels of anxiety in some users, studies show that CBD reduces anxiety and arousal of the autonomic nervous system. CBD also reduced anxiety in patients with generalized social anxiety disorder in a placebo-controlled trial.
·         Psychotic Episodes – CBD has antipsychotic effects and may reduce psychotic symptoms in patients with acute paranoid Schizophrenia and Schizophreniform Psychosis.
·         Addictions – Early research suggests that CBD may be useful in helping smokers reduce cigarette usage compared to those treated with a placebo. CBD may also be useful to reduce opioid seeking behavior; this research is in its infancy.

What conclusions about THC, CBD and medical marijuana can we find?

First, we cannot allow the agenda of those wishing to legitimize their “high” to drive the debate about medical marijuana. A 2014 study found that customers at medical marijuana dispensaries started using marijuana in their teens and 50% had indications of risky alcohol use. 20% had recent histories of prescription or illicit drug abuse. Its unclear form these numbers if these are potheads who have found a new and legal way to continue to get high. However, these numbers do suggest that a significant number of medical marijuana users have a long-term history of using illegal and mind-altering substances. Are these really the people we want driving the movement to legalize and legitimize the use of medical marijuana?

Second, marijuana in its current form at medical dispensaries has higher concentrations of THC than pot sold elsewhere. Furthermore, marijuana available “on the street” has much higher concentrations of THC than was available in the past. Because there is an inverse relationship between THC (which causes euphoria) and CBD (which lessens euphoria) it is virtually impossible to determine the efficacy of CBD from medical marijuana. This also means that serious users experience the maximum health risks associated with the use of marijuana, with minimal potential benefits of CBD.

Third, there is a significant need for more research into the use of CBD for medical purposes. Studies and trials suggest the potential health benefits of CBD for a variety of medical conditions. To understand the benefits and harms associated with CBD, we need more solid data from unbiased scientific research.

Fourth, data suggests that CBD has fewer side effects than marijuana with high levels of THC. As I’ve pointed out in my previous blog, marijuana in its current form has strong addictive potential and is associated with a variety of physical and psychological impairments. We definitely need studies documenting the bio-psycho-social impact and the addictive potential of CBD.

Fifth, clearly there is considerable debate concerning the use of cannabis for the treatment of a variety of physical and psychological conditions. Serious research should inform this debate. We can ill-afford political expediency driven by those hiding out in the purple haze to hijack this necessary medical debate. 

Monday, February 16, 2015

Is Marijuana addictive?

For years, pro-marijuana lobbyists, users, and potheads have vociferously defended marijuana as non-addictive. Arguing that marijuana's non-addictive POTENTIAL made it a safe and relatively harmless substance, marijuana proponents have pushed for legalization and strong liberal protections for the medical use of marijuana.

But is it really non-addictive? 

The new Diagnostic and Statistical Manual of Mental Disorders (DSM-V) disagrees.

The new DSM-V which was released in 2013 includes 5 cannabis-associated disorders. These include:
  •  Cannabis Use Disorder (While the DSM-IV included separate categories for substance abuse and dependence, the DSM-V has included both abuse and dependence in its new cannabis use disorder.)
  •  Cannabis Intoxication
  •  Cannabis Withdrawal
Other cannabis related disorders include, Cannabis Intoxication Delirium, Cannabis Induced Psychotic Disorder, Cannabis Induced Anxiety Disorder and Cannabis Induced Sleep Disorder. From the DSM-V, it appears clear that the use of marijuana can be far from harmless.

How is Cannabis Use Disorder diagnosed?

Cannabis use disorder is defined as the following:
A problematic pattern of cannabis use leading to clinically significant impairment or distress, as manifested by at least 2 of the following, occurring within a 12-month period:

  • Cannabis is often taken in larger amounts or over a longer period than was intended.
  • There is a persistent desire or unsuccessful efforts to cut down or control cannabis use.
  • A great deal of time is spent in activities necessary to obtain cannabis, use cannabis, or recover from its effects.
  • Craving, or a strong desire or urge to use cannabis.
  • Recurrent cannabis use resulting in a failure to fulfill major role obligations at work, school, or home.
  • Continued cannabis use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of cannabis.
  • Important social, occupational, or recreational activities are given up or reduced because of cannabis use.
  • Recurrent cannabis use in situations in which it is physically hazardous.
  • Cannabis use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by cannabis.
  • Tolerance, as defined by either a (1) need for markedly increased cannabis to achieve intoxication or desired effect or (2) markedly diminished effect with continued use of the same amount of the substance.
  • Withdrawal, as manifested by either (1) the characteristic withdrawal syndrome for cannabis or (2) cannabis is taken to relieve or avoid withdrawal symptoms

In my years of working in this field, I've always known that addiction is characterized by tolerance, withdrawal, the disruption of normal psycho-social and relational functioning. These are the kinds of issues that are discussed in typical intake interviews and bio-psycho-social assessments. In looking at the co-occurring issues that must be present in a diagnosis of Cannabis Abuse Disorder, one can clearly see a similarity between harmful use of marijuana and other drugs.  

Notice the presence of cravings, which may often occur despite serious impairment in health, schoolwork, relationships with family and friends, employment, and threats to one’s own health and safety.  These cravings and the urge to “use” which are the subject of some pretty funny stoner movies and stories, are really no laughing matter. The urge to use marijuana is perfectly capable of destroying family, friends, and motivation for school, work, and home.

It is interesting that the DSM-V recognizes the development of tolerance in the use of marijuana. Tolerance means that our body requires increasing amounts of the same substance to achieve the desired effect. In other words, it takes more marijuana to get the same high. For years I heard that it was impossible to develop tolerance for marijuana. It seemed that tolerance was an issue related to heroin or later stage alcoholism – but not use of cannabis. I was wrong!

I also heard that there was no withdrawal associated with the use of marijuana. Proponents of legalized marijuana and potheads argued that the awesome “buzz” had no push back. They could quit anytime they wanted to, but they just didn’t want to. Now it seems clear that one of the factors that drives ongoing use of marijuana is withdrawal. Users are not just chasing the buzz; they are trying to stave off the physical and psychological symptoms of withdrawal. With heavy use of marijuana withdrawal symptoms can include: irritability, anger, or aggression, anxiety, nervousness, decreased appetite, restlessness, and a depressed mood. Physical symptoms can include: significant discomfort, abdominal pain, shakiness/tremors, sweating, fever, chills, or headache. I don’t know about you, but these symptoms describe use of a drug that is far from harmless for serious users.

The debate over legalization and the medical use of marijuana will continue. The pro-marijuana lobby seems committed to a world in which marijuana is readily accessible for all who want it. This is not likely to change anytime soon. As we move forward, it’s important that we consider the full addictive potential of marijuana for already committed stoners as well as casual or curious users. Nobody sets out to become addicted. It is the addictive nature of marijuana that takes the unwary as well as heavy users captive. 

It’s time to stop inhaling the smoke exhaled in our direction by those who simply want to pursue their high, and come to grips with the addictive potential of this supposedly "harmless" drug.

*top photo courtesy of Paul at FreeDigitalPhotos.net