Marijuana Update

Kevin P. Hill, M.D., M.H.S.

10/2/14, 9
th
Annual Vermont Conference on
Addictive Disorders
McLean Hospital Division of Alcohol and Drug Abuse Treatment
khill@mclean.harvard.edu
Twitter: @DrKevinHill

Supported by NIDA K99/R00 DA029115 (Kevin P. Hill, MD, MHS, PI) and the
Adam Corneel Young Investigator Fellowship from McLean Hospital to Dr. Hill.


Disclosure

I have no financial relationship with a
commercial entity producing health-care
related products and/or services.

Meda Pharmaceuticals has graciously
agreed to provide some of the medications
used in our studies.
Three Areas of Focus
Clinical work: McLean Substance Abuse
consultation service, private practice.
Clinical research: 3 clinical trials (2
marijuana, 1 tobacco cigarettes).
Educational outreach: Science vs. public
perception, official community partner to
Boston Public Schools, book on marijuana
to be released in early 2015.
In The Middle
Marijuana Use:
Scope of the
Problem
Context of Current Laws-
National Statistics
Over 18 million Americans used marijuana
in the past year.
Powerful messages medical marijuana,
legalization, pop culture.
Some messages off the mark, contribute to
gap between science and public perception.
Development of Problems:
About 9% of users may become dependent;
17% (1 in 6) who start use in adolescence

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Estimated Prevalence of Dependence Among Users
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12
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Graders Past Year Marijuana Use
vs. Perceived Risk of Occasional
Marijuana Use
SOURCE: University of Michigan, 2013 Monitoring the Future Study
Why So Complicated?
Cant paint with a broad brush.
Many misguided by their own experiences.
Math can be tricky.

Marijuana Myths
Not harmful
Not addictive
No withdrawal

IT IS HARMFUL!
Early onset poor cognitive function,
IQ decline (Pope 2003, Gruber 2011, Meier 2012)
anxiety (Crippa 2009)
depression (Degenhardt 2003)
risk of psychosis (Kuepper 2011, Large 2011)
Teen Marijuana Use May
Permanently Reduce IQ
Dunedin (NZ) birth cohort- 1037 subjects.
Multiple interviews, neuropsych at 13, 38.
Aimed to test association between
persistent cannabis use and
neuropsychological decline.
Meier et al. 2012

Once You Lose It, You Dont Get It Back
Regular use before 18 associated
with worsening performance.
Your brain is developing until mid-
20s.
Stopping for 1 year did not fully
restore function.
Meier et al. 2012

IT IS ADDICTIVE!
Drugs of abuse increase DA in the
Nucleus Accumbens.triggers the
neuroadaptions that result in
addiction?
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There is Withdrawal!
(Vandrey et al., 2005; Vandrey et al. 2008, Budney et al., 2009)












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Cannabis Tobacco
State of the Science:
Treatment
What does treatment look
like?
Medical detox is not necessary.
30 days of rehab is unlikely.
Get prospective patient to talk to
somebody.
Readiness/alliance work.
Ongoing Treatment
Talk Therapy: individual/group, different
modalities (MI, CBT). (see Bobb and Hill, 2014)
Family support.
Medications in some cases.
No FDA-Approved
Medications
Gabapentin, N-acetylcysteine, Dronabinol.
Nabilone for Cannabis Dependence:
Imaging and Neuropsychological
Performance.
Dronabinol + Clonidine in cannabis-
dependent patients with schizophrenia or
schizoaffective disorder.
State of the Policy
Marijuana in New
England: A Trend
Toward Increased
Access
VT MMJ
By vote in 2004.
Cancer, HIV, MS, cachexia, pain, nausea,
seizures.
9 plants, 2 mature, 7 immature, 2 ounces.
4 dispensaries since 2013.

VT 2013- Decriminalization of
less than an ounce

The Boston Globe Politics


Marijuana advocates
lay groundwork for legalization
in Mass.
Colo., Wash, votes bring push for a 2016 ballot item
on legalization
By Joshua Miller | GLOBE STAFF JANUARY 13, 2014
1 of 5
1/14/2014 11:03 AM
Legalization in 2016?
Easier, Stronger, Cheaper
Already readily available, marijuana easier
to get.
Extremely potent, stronger marijuana is
here to stay with advances in horticulture.
Now around $400/ounce, the price will
likely decrease for marijuana of
comparable potency.

Poor Implementation?
Definitely.
Good ideas? Maybe.

Does the scientific literature support
the use of marijuana as medicine?

Synthetic cannabinoids FDA-approved for
nausea, vomiting associated with
chemotherapy; appetite stimulation; more on
the way.
Data for most other indications is not strong
(outside of chronic pain, neuropathic pain,
and spasticity associated with MS).
Are there better, safer alternatives?

Kleber and DuPont, AJP,
2012
MMJ laws challenge physicians to
recommend use of a schedule I illegal
drug of abuse with no scientific approval,
dosage control, or quality control.
Opposed by all major medical
organizations APA, AMA, ASAM.

3 Reasons You Need to Know
about MMJ
1. Your patients will ask about it.
2. Your colleagues will ask about it.
3. You may be asked to consult on whether
a colleague should certify one of their
patients for MMJ.


Whatever you decide,
make informed decisions.
Journal of Psychiatric Practice

THC and CBD

Major constituents of cannabis.
THC: euphoria.
CBD: analgesic, anti-inflammatory, anti-
anxiety.
Maybe CBD, and cannabis therefore, offer
some things that dronabinol and nabilone
dont.
Policy Ahead of the
Science
Top 3 Issues
Issue #1
MA 60 day supply = 10 ounces
BUT 725.010 A certifying physician may
determine and certify that a qualifying patient
requires an amount of marijuana exceeding ten
ounces as a 60-day supply and shall document
the amount and the rationale in the medical
record and in the written certification. For that
qualifying patient, that amount of marijuana
constitutes a 60-day supply.
My studies: 2.1 oz. per month 3.0 oz.
Issue #2
Debilitating medical condition such as
cancer, glaucoma, HIV or AIDS, Hep C,
Crohns, Parkinsons, MS
Or other conditions as determined in
writing by physician.
Suggestion: other conditions upon
approval by DPH (like medication PAs).

Issue #3
Automatic hardship in MA for MassHealth,
SSI patients.
They are granted hardship to grow their
own.
Will this lead to unintended
consequences?

Hypothetical Scenario
Mr. A, a patient on MassHealth, gets MMJ
card to treat his migraine headaches.
He smokes ounce a week, or 2 ounces
per 60 days.
He recognizes that he can grow another 8
ounces (approximate street value of
$3200, or $19,200 per year).

Legalization
WA, CO, likely on the ballot in MA in 2016.
Addiction vs. Harmless/Personal
Freedom/Taxes
58% of Americans favor legalization.
Once again, the science
suggests we are not ready
Safety - drugged driving.
Need a marijuana equivalent of .08 BAC
AND technology to test for it in the field.
Addiction numbers in WA and CO, but they
did not set up to efficiently track these
outcomes.
These Policies are Feasible
Implementation thus far has not inspired
confidence.
We can work to get answers to inform
choices or we can continue to sling
rhetoric back and forth.
Critical Period
More education needed.
Trends are ominous.
NIDA and NARSAD have invested in these
ideas, but we need more people invested.
Goal is to find effective treatments, but we
also would like to inform the choices
Americans will be making in the next few
years.
Acknowledgments
Scott Lukas
Roger Weiss
Shelly Greenfield
Garrett Fitzmaurice
Staci Gruber
George Trksak
John Rodolico
Dave Penetar
Max Hurley-Welljams-Dorof
Wendy Tartarini
Joe Lewko
Alan Budney
NIDA
NARSAD
McLean
HMS
Meda Pharmaceuticals
McLean IRB
FDA
DEA
Questions?

Recruiting line:
617 855 3823
Synthetics
K2, Spice, and a host of other names.
Synthetic cannabinoids sprayed onto
herbs.
Synthetic Drug Abuse Prevention Act of
2012.
Access and groups who will be tested.
More Dangerous?
Never really sure what you are getting.
Not detectable with standard urine testing.
More likely to precipitate psychosis?