Medical Marijuana:The “Need for Weed” Movement

Might Like Getting High OnSome Science

Medical Marijuana:The “Need for Weed” Movement

Might Like Getting High OnSome Science

Donald R. Vereen, M.D., M.P.H.Director

Community Academic EngagementPrevention Research Center of Michigan

School of Public HealthUniversity of Michigan

Former Medical Officer and Special AssistantNational Institutes of Health Former “Deputy Drug Czar”

White House Office of National Drug Control Policy

Donald R. Vereen, M.D., M.P.H.Director

Community Academic EngagementPrevention Research Center of Michigan

School of Public HealthUniversity of Michigan

Former Medical Officer and Special AssistantNational Institutes of Health Former “Deputy Drug Czar”

White House Office of National Drug Control Policy

University of Michigan Substance Abuse CenterMember SymposiumSeptember 16, 2011

California Proposition 215

November 1996

Washington State Ballot Initiative 692

November 1998

Oregon Measure 67 December 1998

Alaska Ballot Measure 8

March 1999

Maine Citizen Initiative Question 2

December 1999

Hawaii Senate Bill 862 December 2000

Colorado General Election Amendment 20

June 2001

Nevada Referendum Question 9 –

October 2001

Vermont Senate Bill 76

July 2004

Montana Initiative 148

November 2004

Rhode Island Senate Bill 70

January 2006

New Mexico Senate Bill 523

July 2007

TIMELINE OF MEDICAL MARIJUANA LEGISLATION

Michigan Medical Marihuana Act

The Law• Approved by Michigan voters on November 4, 2008 by

ballot initiative• The Michigan Medical Marihuana Program (MMMP) is a

state registry program within the Bureau of Health Professions at the Michigan Department of Licensing and Regulatory Affairs.

Michigan Medical Marihuana ActThe Law

• Program Statistics: – 181,303 original and renewal applications received since April 6, 2009.

– 105,458 patient registrations issued. Sept 2, 2011

– The number of caregivers will be posted as soon as an accurate number can be obtained.

– 19,705 applications denied -- most due to incomplete application or missing documentation.

Michigan Medical Marihuana ActThe Law

• Responsibilities of the MMMP – Review applications submitted by patients and caregivers wishing to

participate in the MMMP and issue medical marihuana registration identification cards to those individuals whose applications are approved.

– Maintain the confidentiality of program records in accordance with applicable

state and federal confidentiality laws.– Collect and disseminate statistics about participation in the MMMP including,

but not limited to:• Number of applications filed and approved.

• Nature of the debilitating medical conditions of qualified patients.

• Number of registration identification cards revoked.

• Number of physicians providing written certifications for qualifying patients.

Michigan Medical Marihuana ActThe Law

• The people of the State of Michigan find and declare that:– National Academy of Sciences’ Institute of Medicine (IOM) report of 1999

has “found” / “discovered” beneficial uses of marihuana.– FBI’s Uniform Crime Reports show that nearly 99 out of 100 marihuana

arrests occur under “state” law rather than “federal” law. Consequently, changing state law will have the practical effect of protecting from arrest the vast majority of seriously ill people who have a medical need for marihuana.

– States are not required to enforce federal law which prohibits the use of marihuana except under very limited circumstances. Michigan joins 12 other states which do not penalize the medical use and cultivation of marihuana.

Michigan Medical Marihuana ActThe Law

• Protections:– A qualifying patient (diagnosed by a licensed physician as having a

debilitating medical condition) who has been issued and possesses a registry identification card (a document issued by the MDCH that identifies a person as a registered qualifying patient or registered primary caregiver (a person at least 21 years old who has agreed to assist with a patient’s medical use of marihuana and who has never been convicted of a felony involving illegal drugs)) shall not be subject to arrest, prosecution, or penalty...for the medical use of marihuana in accordance with this act…may possess up to 2.5 ounces of usable marihuana, 12 marihuana plants kept in an enclosed, locked facility, and any incidental amount of seeds, stalks, and unusable roots.

Michigan Medical Marihuana ActThe Law

• Certification:– To be eligible for the Registry Identification Card one must: Complete an application Complete information about a ‘primary caregiver” – if applicable Patient’s physician must complete and sign the Physician Certification Form

and indicate the appropriate medical condition(s):Cancer Glaucoma Cachexia/

WastingHepatitis C ALS Severe/Chronic

PainAgitation of Alzheimer’s Nail Patella Severe nausea

HIV/AIDS+ Crohn’s Disease Seizures

Severe Muscle Spasms

Institute for Behavior and Health (IBH) – March 18, 2011-based on American Society of Addiction

Medicine

1. Only seriously-ill patients who have exhausted other treatment options are permitted access 2. These patients receive high quality care and supervision from their treating physicians3. Marijuana products are tested for quality and potency in licensed labs by qualified individuals4. Strict procedures are implemented from physician’s office to point of distribution and use by the intended patient to detect and deter marijuana abuse and diversion to thers in the community

CANNABIS KINETICS

• Oral use– Psychoactive effects slowed to about one hour– Absorption is erratic– High is less intense, but lasts longer than if smoked

• IV use– Water insoluble so cannot be injected

CANNABIS KINETICS

• SMOKING three cannabis joints will cause you to inhale the same amount of toxic chemicals as one pack of cigarettes.– The French Consumer Institute tested regular Marlboro cigarettes

alongside 280 specially rolled joints of cannabis leaves and resin in an artificial smoking machine.

– The tests examined the content of the smoke for tar and carbon monoxide, as well as for the toxic chemicals nicotine, benzene and toluene.

– Cannabis smoke contains seven times more tar and carbon monoxide.

– Someone smoking a joint of cannabis resin rolled with tobacco will inhale twice the amount of benzene and three times as much toluene as if they were smoking a regular cigarette, the study said.

Overall problems of use

Mode of administrationNo smoking in hospitalsNo standard dose of smoked marijuanaSmoke is hazardous in and of itselfSmoking may impair immune system responseDifficulty concentrating on complex tasksSlowed reaction timesTolerance develops quicklyEffect is 4 - 6 hrs

CANNABINOIDS• There are two main receptors for cannabinoids in

humans– CB1(in brain) if stimulated produces

• Euphoria• Impaired short term memory and sense of time

– CB2 (in spleen, peripheral sites) if stimulated produces• Immunosuppressant activity• Not psychoactive

Cannabinoid Receptors:

Cerebellum – body movement and coordinationCortex – higher cognitive functionsNucleus accumbens – reward, feeding and other appetitive behaviorsBasal ganglia – movement controlHypothalamus – body temperature, salt and water balance, reproductive functions, analgesia, feeding behaviorAmygdala – emotional responses, fearHippocampus – learning and memory

Endocannabinoids (e.g. anandamide)

constitute one of the first lines of defense against pain, the anatomical locus and the precise receptor mechanisms underlying cannabinergic modulation of pain are uncertain. Clinical exploitation of the system is severely hindered by the cognitive deficits, memory impairment, motor disturbances and psychotropic effects resulting from the central actions of cannabinoids.

Agarwa, N., et al, Neurosci. 2007 Jul;10(7):870-9. Epub 2007 Jun 10.

R. Mechoulam et al. 2003. Cannabidiol: an overview of some pharmacological aspects.

Neuroscience Letters 346: 61-64;

Cannabidiol (CBD) non-psychoactive cannabinoid

clinically demonstrated to have analgesic, antispasmodic, anxiolytic, antipsychotic, antinausea, and anti-rheumatoid arthritic properties.

The U.S. Food and Drug Administration (FDA) has given the green light to Valeant Pharmaceuticals International to bring the synthetic cannabinoid nabilone (Cesamet) back to market after 17 years. Nabilone, sold in Canada is similar to Marinol - was originally marketed by Eli Lilly and Co. but withdrawn from the market in 1989. It is now approved by the FDA for treatment of vomiting and nausea caused by chemotherapy and is listed as a Schedule II controlled substance.

SativexWhole plant medicinal cannabis extractProduced by Bayer and GW pharmaceuticals and approved for use in Canada for multiple sclerosis and neuropathic pain (2005)Contains THC and nabidiolex, not delta - THCPhase 3 trials in multiple sclerosis patients showed that sublingual spray was safe and effective for symptom relief

nucleusaccumbens

hippocampusstriatum

frontalcortex

substantianigra/VTA

Dopamine PathwaysPrincipal “Pleasure” System of the Brain

Dopamine PathwaysPrincipal “Pleasure” System of the Brain

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Effects of Drugs on Dopamine LevelsEffects of Drugs on Dopamine LevelsEffects of Drugs on Dopamine LevelsEffects of Drugs on Dopamine Levels

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LEARNING

Circuits Involved In Drug Abuse and Addiction

Circuits Involved In Drug Abuse and Addiction

All of These Must Be ConsideredIn Developing Strategies to

Most Effectively Treat Addiction

All of These Must Be ConsideredIn Developing Strategies to

Most Effectively Treat Addiction

Marijuana brain changes

DriveOFCDriveOFC

Saliency NAcSaliency NAc

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Non-Addicted BrainNon-Addicted Brain

AddictedBrainAddictedBrain

STOP STOP

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Saliency Saliency

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Saliency Saliency

Adapted from: Volkow et al., J Clin Invest 111(10):1444-1451, 2003. Adapted from: Volkow et al., J Clin Invest 111(10):1444-1451, 2003.

ADDICTION IS A DEVELOPMENTAL DISEASE starts in adolescence and childhood

ADDICTION IS A DEVELOPMENTAL DISEASE starts in adolescence and childhood

NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003

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Age at cannabis use disorder as per DSM IV

Brain areas where volumes are smaller in adolescents than young adults.

Sowell, E.R. et al., Nature Neuroscience, 2: 859-861, 1999Sowell, E.R. et al., Nature Neuroscience, 2: 859-861, 1999