A place where ideas stir the waters of our mind.

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