Marijuana Law, Policy & Reform

Editor: Douglas A. Berman
Moritz College of Law

Monday, February 5, 2018

Still more research "suggesting broader access to medical marijuana facilitates substitution of marijuana for powerful and addictive opioids"

S01676296The March 2018 issue of the Journal of Health Economics includes this new research article that provides still further support for a claim that greater access to marijuana may be able to play a role in reducing use and abuse of opioids.  The new article is authored by David Powell, Rosalie Liccardo Pacula and Mireille Jacobson under the title "Do medical marijuana laws reduce addictions and deaths related to pain killers?".  Here is its abstract:

Recent work finds that medical marijuana laws reduce the daily doses filled for opioid analgesics among Medicare Part-D and Medicaid enrollees, as well as population-wide opioid overdose deaths.  We replicate the result for opioid overdose deaths and explore the potential mechanism.  The key feature of a medical marijuana law that facilitates a reduction in overdose death rates is a relatively liberal allowance for dispensaries.  As states have become more stringent in their regulation of dispensaries, the protective value generally has fallen.  These findings suggest that broader access to medical marijuana facilitates substitution of marijuana for powerful and addictive opioids.

Some (of many) prior related posts:

February 5, 2018 in Medical community perspectives, Medical Marijuana Data and Research | Permalink | Comments (0)

Wednesday, December 27, 2017

Some new particulars on what West Virginia physicians think about medical marijuana

In this post last week, I noted the notable data from a survey of West Virginia physicians. The state's Department of Health and Human Resources found that, of "1,455 physicians who took the online survey, 82 percent of them indicated their interest in medical marijuana." Now I see this new local article, headlined "WV State Medical Association drills down on medical marijuana survey," reporting on a smaller survey conducted by the West Virginia State Medical Association. Here are a few details:

Medical Association President Dr. Brad Henry tells MetroNews the organization’s survey of its members show results not nearly as high as the state online survey that showed 82 percent of state doctors “interested” in medical marijuana.

In the WVSMA survey, in which approximately 75 doctors participated, only 31 percent said they were interested in becoming a certified physician for the state’s new medical marijuana law set to take effect in 2019. Henry said the issue continues to be the lack of research associated with the medicinal use of the drug. “Every time I read anything, anything that comes out, there’s some promise but there’s still aren’t good scientific studies to support marijuana use for anything,” Henry said. “There still isn’t that level of scientific information to at least give me confidence in the utility of it as a medicine.”

One thing the doctors are struggling with is the provision in the law that would have a doctor certify someone that has a diagnosis but there’s much else they can tell them because of the lack of research on the drug, Henry said. “You can’t look up (medical marijuana) in a textbook and say, ‘Okay, this is how much you should use. This is the side effects you should expect.’ Even over-the-counter (drugs) you can find what the usual dosages are and what the usual side effects are but with this substance (medical marijuana) that’s just not available,” Henry said....

Four of the questions in the medical association’s survey:

– Do you think there is scientific evidence to support marijuana use as a medical treatment?  Yes 65 percent

– Do you believe the legal access to medical marijuana will help patients?  Yes 64 percent

– Are you interested in becoming a certified physician?  Yes 31 percent

– Are you willing to receive the training required for the certification?  Yes 34 percent

December 27, 2017 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research, Who decides | Permalink | Comments (0)

Thursday, December 21, 2017

Notable coverage of notable marijuana reform public health issues in Nov 2017 issue of Preventive Medicine

1-s2_0-S0091743517X00108-cov150hI have just seen that the November 2017 issue of Preventive Medicine has a series of articles on the "potential health impacts of legalizing recreational marijuana use," and that series is described in an editorial introduction this way:

Legalization of marijuana use has gained considerable momentum in the U.S. with 28 states plus the District of Columbia (DC) legalizing medical marijuana use and 8 states plus DC legalizing recreational marijuana use, with similar liberalization of laws occurring in Canada and other countries (NYTimes, April 13, 2017).  Such actions clearly have tremendous public health implications and it is important that those implications be considered using the best available scientific evidence.

In this Special Issue we invited policy makers from Colorado (Ghosh et al., 2017, in this issue), the first U.S. state to legalize recreational marijuana use, Vermont (Chen and Searles, 2017, in this issue), a state currently considering legalization of recreational use, and the U.S.’s National Institute on Drug Abuse (Weiss and Wargo, 2017, in this issue) to provide a federal perspective on the health implications of legalizing recreational marijuana use.

In addition to policy makers we invited contributions from scientific experts in the health impacts of marijuana use to address the implications of legalizing recreational marijuana use, including potential impacts on the epidemiology of marijuana use and risk perceptions among youth and adults (Carliner et al., 2017, in this issue), emergency medicine (Wang et al., 2017, in this issue), addiction risk (Budney and Borodovsky, 2017, in this issue), adolescent risks and potential interventions (Schuster et al., 2017; Walker, 2017, in this issue), and maternal and child health (Mark and Terplan, 2017, in this issue).

Here are just some of the titles of some of the notable article in the issue:

  • "Lessons learned after three years of legalized, recreational marijuana: The Colorado experience"
  • "Cannabis use, attitudes, and legal status in the U.S.: A review"
  • "Marijuana and acute health care contacts in ColoradoOriginal Research Article" 
  • "The potential impact of cannabis legalization on the development of cannabis use disorders"
  • "Legalization of cannabis: Considerations for intervening with adolescent consumers"

December 21, 2017 in Medical community perspectives, Recreational Marijuana Commentary and Debate, Recreational Marijuana Data and Research, Recreational Marijuana State Laws and Reforms | Permalink | Comments (0)

Monday, December 18, 2017

New data from West Virginia showing strong physician interest in state's developing medical marijuana program

As reported in this local article, headlined "Survey: 82 percent of WV doctors 'interested' in medical marijuana," a notably large percentage of surveyed physicians have expressed an interest in an emerging medical marijuana regime. Here are the basics:

An overwhelming majority of surveyed West Virginia physicians are “interested” in medical cannabis, according to the Department of Health and Human Resources.  Of 1,455 physicians who took the online survey, 82 percent of them indicated their interest in medical marijuana, which will be legal in the state in July 2019 thanks to a law passed during the last legislative session.

Dr. Rahul Gupta, state health officer and commissioner of the state Bureau for Public Health, said the high response volume gives the state a sound outlook on patient and physician views of the looming change.  “We found that to be compelling that there is a certain level of interest, not just from patients, but from the physician community,” he said.

Along with doctors, the bureau analyzed survey results from 6,003 West Virginians, as well as Public Employees Insurance Agency and Medicaid claim data to tease out what tweaks, if any, might be needed for the nascent program.  Of the patients who responded, 2,120 reported suffering from chronic pain, 1,579 reported suffering from post-traumatic stress disorder and another 980 reported suffering from a mental health disorder.

The Medicaid and PEIA data shows crossover between some of the most prevalent conditions in the state and the list of conditions whose victims qualify to obtain medical marijuana....

There is still work to be done and change for the organization to consider.  Among the questions Gupta said the board is considering: Should the state limit how many dispensaries can obtain a permit to sell?  Should the board approve the sale of marijuana in plant form?  Should patients be allowed to grow their own marijuana plants? Should patients be able to purchase any other forms of marijuana?

Marijuana will be available to certified patients in the form of a pill, oil, topical, via vaporization or nebulization, tincture, liquid, or dermal patch.  Gupta said the board is scheduled to meet again in February.

December 18, 2017 in Medical community perspectives, Medical Marijuana Data and Research, Medical Marijuana State Laws and Reforms, Who decides | Permalink | Comments (0)

Saturday, December 9, 2017

"Medical Pot Is Our Best Hope to Fight the Opioid Epidemic"

Images (3)The title of this post is the headline of this new Rolling Stone article. Here are excerpts (with some links from the original preserved):

The pain-relieving properties of cannabis are no longer hypothetical or anecdotal. At the beginning of the year, the National Academies of Science, Medicine and Engineering released a landmark report determining that there is conclusive evidence that cannabis is effective in treating chronic pain.  What's even more promising is that early research indicates that the plant not only could play a role in treating pain, but additionally could be effective in treating addiction itself – meaning marijuana could actually be used as a so-called "exit drug" to help wean people off of pills or heroin.

"We're not just saying opioids make you feel good and so does cannabis, and now you're addicted to cannabis. There are direct reasons why this could actually help people get off of opioids," says Jeff Chen, director of UCLA's new Cannabis Research Initiative.  "If there is a chronic pain component, the cannabis can address the chronic pain component. We also find opioid addicts have a lot of neurological inflammation, which we believe is driving the addictive cycle. We see in preliminary studies that cannabinoids can reduce neurological inflammation, so cannabis could be directly addressing the inflammation in the brain that's leading to opioid dependency."

The theory that cannabinoids could decrease cravings for opioids is further supported by a small 2015 study published in the journal Neurotherapeutics, which found that the non-psychoactive cannabinoid CBD was effective in reducing the desire for heroin among addicts, and remained effective for an entire week after being administered. Similar effects have long been observed in animal studies.

Cannabis, in fact, may be exactly the kind of opioid replacement that politicians and pharmaceutical executives claim to be searching for. "I will be pushing the concept of non-addictive painkillers very, very hard," President Trump said in October, when declaring opioid abuse a national public health emergency.  The CEO of Purdue Pharma, which makes OxyContin, recently referred to the possibility of a drug that helps with pain but isn't physically addictive as the "Holy Grail."...

But already, many Americans seem to be replacing their pills with pot. A survey of pain patients in Michigan, published in 2016 in the journal of the American Pain Society, found medical cannabis use was associated with a 64 percent decrease in opioid use.  A 2016 study published in the health policy journal Health Affairs found that states with medical marijuana saw a drop in Medicare prescriptions and spending for conditions that are commonly treated with cannabis, including chronic pain, glaucoma, seizures and sleep disorders. And a 21-month study of 66 chronic pain patients using prescription opioids in New Mexico found that those enrolled in the state's medical cannabis program were 17 times more likely to quit opioids than those who were not.

At the same time, opioid-related deaths and overdose treatment admissions appear to be declining by nearly 25 percent in states where patients have access to legal marijuana. That number comes primarily from a 2014 study in the Journal of the American Medical Association, and has been supported by additional data from the American Journal of Public Health, the American Academy of Nursing, and the Journal of Drug and Alcohol Dependence.

However, more research is sorely needed. Stanford professor and drug policy expert Keith Humphreys described the studies concerning cannabis legalization and the decrease in opioid-related deaths and hospital admissions as falling victim to a form of logical error known as ecological fallacy. "It's correlation, not causation," he told me, because you cannot use statistical information about entire populations to understand individual behavior.

And researchers are eager for more solid evidence.  The Cannabis Research Initiative at UCLA is working on establishing one of the first studies that will directly administer cannabis to patients addicted to opioids, potentially providing a much more comprehensive understanding of how this all works. Chen, the initiative director, says he has scientists, clinics and a study design all lined up, but funding has been a struggle. "You're forced to go an extra ten miles with zero gas in the tank when it comes to cannabis research," he says. Between the lack of support from the federal government and pharmaceutical companies, Chen says he is "pretty much dependent on philanthropy."

Some (of many) prior related posts:

December 9, 2017 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research, Medical Marijuana State Laws and Reforms | Permalink | Comments (0)

Sunday, November 26, 2017

Taking a close look at "Big Pharma's Anti-Marijuana Campaign"

As mentioned in a prior post, my Marijuana Law, Policy & Reform seminar is hitting its homestretch and the last group of students are delivering presentations on a marijuana-related topic of their choosing. One student for the next class will be looking at what she is calling "Big Pharma's Anti-Marijuana Campaign."  Here is how she has explained her plans, following by links to background information regarding the topic:

My presentation will reveal how Big Pharma contributes to the Opioid Epidemic, how marijuana can be used as a substitute for opioids, how the legalization of medical marijuana threatens the bottom lines of pharmaceutical giants, and how these corporations have subsequently opposed pro-pot legislation.

NIH data on "Overdose Death Rates"

"Can Medical Marijuana Help End the Opioid Epidemic?"

"Patients Are Ditching Opioid Pills for Weed: Can marijuana help solve the opioid epidemic?"

"Is Big Pharma Out to Stop — Or Take Over — Marijuana Legalization?"

"The Real Reason Pot Is Still Illegal: Opponents of marijuana-law reform insist that legalization is dangerous — but the biggest threat is to their own bottom line."

November 26, 2017 in Business laws and regulatory issues, Medical community perspectives, Medical Marijuana Commentary and Debate, Recreational Marijuana Commentary and Debate, Who decides | Permalink | Comments (0)

Sunday, November 19, 2017

Still more talk, from notable conservative outlets, about possible benefits of marijuana reform amidst opioid crisis

Regular readers know that many proponents of marijuana reform have been eager in recent years to talk up the possible benefits of marijuana reform as one useful response to the on-going opioid crisis.   Indeed, since I have blogged many stories and commentaries on this front, it is not really big news to see more new advocacy along these lines.  But that said, this past week I have seen these two notable commentaries in this vein appearing in notable conservative or right-leaning outlets:

From the American Conservative here by Jeffrey Singer, "Can Marijuana Help Addicts Kick Opioids?: Research shows this once maligned 'gateway' drug could be an off-ramp."

From the Wall Street Journal here by Richard Boxer, "Can Marijuana Alleviate the Opioid Crisis?: The federal government should stop blocking research into the drug’s medical potential."

Some (of many) prior related posts:

November 19, 2017 in Medical community perspectives, Medical Marijuana Commentary and Debate | Permalink | Comments (0)

Thursday, November 16, 2017

"Pediatric Death Due to Myocarditis After Exposure to Cannabis"

Advocates of marijuana reform are often quick to assert that nobody dies from an overdose of marijuana.  But this new clinical report from two Colorado doctors, which has the same title as this post, discusses a case of an 11-month child who may have died as a direct result of marijuana exposure.   The paper is authored by Thomas Nappe and Christopher Hoyte, and here is the paper's abstract:

Since marijuana legalization, pediatric exposures to cannabis have increased.  To date, pediatric deaths from cannabis exposure have not been reported.  The authors report an 11-month-old male who, following cannabis exposure, presented with central nervous system depression after seizure, and progressed to cardiac arrest and died.  Myocarditis was diagnosed post-mortem and cannabis exposure was confirmed.  Given the temporal relationship of these two rare occurrences – cannabis exposure and sudden death secondary to myocarditis in an 11-month-old – as well as histological consistency with drug-induced myocarditis without confirmed alternate causes, and prior reported cases of cannabis-associated myocarditis, a possible relationship exists between cannabis exposure in this child and myocarditis leading to death. In areas where marijuana is commercially available or decriminalized, the authors urge clinicians to preventively counsel parents and to include cannabis exposure in the differential diagnosis of patients presenting with myocarditis.

UPDATE: Unsurprisingly, this clinical report links a death to marijuana exposure has created a stir, and this new Washington Post piece headlined "The truth behind the ‘first marijuana overdose death’" provides some context for the controversy.

November 16, 2017 in Medical community perspectives, Medical Marijuana Data and Research, Recreational Marijuana Data and Research | Permalink | Comments (4)

Monday, November 13, 2017

A reasonable accounting of public health realities surrounding marijuana and alcohol

ALCOHOL-VS-MARIJUANA-INFO-CROPThis new Business Insider article, headlined "We took a scientific look at whether weed or alcohol is worse for you — and there appears to be a winner," provides a pretty reasonable review of basic public health research concerning marijuana and alcohol. Here is how the article starts, its main boldheadings, and it conclusion:

Which is worse for you: weed or whiskey? It's a tough call, but based on the science, there appears to be a clear winner.

Keep in mind that there are dozens of factors to account for, including how the substances affect your heart, brain, and behavior, and how likely you are to get hooked. Time is important, too — while some effects are noticeable immediately, others only begin to shape up after months or years of use.

The comparison is slightly unfair for another reason: While scientists have been researching the effects of alcohol for decades, the science of cannabis is a lot murkier due to its mostly illegal status.

30,722 Americans died from alcohol-induced causes in 2014. There have been 0 documented deaths from marijuana use alone. ...

Marijuana appears to be significantly less addictive than alcohol. ...

Marijuana may be harder on your heart; while moderate drinking could be beneficial....

Alcohol is strongly linked with several types of cancer; marijuana is not....

Both drugs may be linked with risks while driving, but alcohol is worse. ...

Several studies link alcohol with violence, particularly at home. That has not been found for cannabis. ...

Both drugs negatively impact your memory, but in different ways. These effects are the most common in heavy, frequent, or binge users. ...

Both drugs are linked with an increased risk of psychiatric disease. For weed users, psychosis and schizophrenia are the main concern; with booze, it's depression and anxiety....

Alcohol appears to be linked more closely with weight gain than marijuana, despite weed's tendency to trigger the munchies. ...

All things considered, alcohol's effects seem markedly more extreme — and risky — than marijuana's.

When it comes to their addiction profile and their risk of death or overdose combined with their ties to cancer, car crashes, violence, and obesity, the research suggests that marijuana may be less of a health risk than alcohol.

Still, because of marijuana's largely illegal status, long-term studies on all of its health effects have been limited — meaning that more research is desperately needed.

November 13, 2017 in Food and Drink, Medical community perspectives, Medical Marijuana Commentary and Debate, Recreational Marijuana Commentary and Debate | Permalink | Comments (0)

Saturday, November 11, 2017

Lots of headlines (and prior posts) about veterans having access to medical marijuana ... but work remains in Trump era

Veterans-day-thank-you-quotesRegular readers know I have, since starting this blog more than four years ago, regularly blogged about a range of issues relating to veterans and their access to marijuana (a dozen of my more recent posts on this topic are linked below).  I feel a genuine and deep debt to anyone and everyone who serves this nation through the armed forces, and I feel  strongly that veterans should be able to have safe and legal access to any and every form of medicine that they and their doctors reasonably believe could help them with any ailments or conditions.

Notably, this White House release from a few days ago touts "President Donald J. Trump is Putting Our Veterans First," and it quotes Prez Trump sating that "we will not rest until all of America’s great veterans can receive the care they so richly deserve."  But current federal law essentially puts veterans last, not first, when it comes to access to medical marijuana because doctors with the Veterans Administration are legally barred from providing the recommendations that patients needs to obtain medical marijuana under state laws.

Perhaps unsurprisingly, on this Veterans Day 2017, issues relating to veterans and their access to marijuana are getting ever more attention.  Here are a few recent press pieces that caught my eye on this topic, followed by a lot of prior posts:

Some recent prior related posts:

November 11, 2017 in Federal Marijuana Laws, Policies and Practices, Medical community perspectives, Medical Marijuana Commentary and Debate, Who decides | Permalink | Comments (0)

Wednesday, October 11, 2017

"The use of cannabis in response to the opioid crisis: A review of the literature"

Cov200hThe title of this post is the title of this notable short literature review on a topic that regular readers know I find very interesting.  The article by multiple authors appears in Nursing Outlook, which is the official journal of the American Academy of Nursing.  Here is its abstract:

Background

A staggering number of Americans are dying from overdoses attributed to prescription opioid medications (POMs).  In response, states are creating policies related to POM harm reduction strategies, overdose prevention, and alternative therapies for pain management, such as cannabis (medical marijuana).  However, little is known about how the use of cannabis for pain management may be associated with POM use.

Purpose

The purpose of this article is to examine state medical cannabis (MC) use laws and policies and their potential association with POM use and related harms.

Methods

A systematic literature review was conducted to explore United States policies related to MC use and the association with POM use and related harms. Medline, PubMed, CINAHL, and Cochrane databases were searched to identify peer-reviewed articles published between 2010 and 2017. Using the search criteria, 11,513 records were identified, with 789 abstracts reviewed, and then 134 full-text articles screened for eligibility.

Findings

Of 134 articles, 10 articles met inclusion criteria. Four articles were cross-sectional online survey studies of MC substitution for POM, six were secondary data analyses exploring state-level POM overdose fatalities, hospitalizations related to MC or POM harms, opioid use disorder admissions, motor vehicle fatalities, and Medicare and Medicaid prescription cost analyses.  The literature suggests MC laws could be associated with decreased POM use, fewer POM-related hospitalizations, lower rates of opioid overdose, and reduced national health care expenditures related to POM overdose and misuse.  However, available literature on the topic is sparse and has notable limitations.

Conclusions

Review of the current literature suggests states that implement MC policies could reduce POM-associated mortality, improve pain management, and significantly reduce health care costs. However, M C research is constrained by federal policy restrictions, and more research related to MC as a potential alternative to POM for pain management, MC harms, and its impact on POM-related harms and health care costs should be a priority of public health, medical, and nursing research.

Some (of many) prior related posts:

October 11, 2017 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research | Permalink | Comments (0)

Tuesday, September 26, 2017

"Seniors Turn To Medical Marijuana For What Ails Them"

The title of this post is the title of this effective 5+ minute segment that aired today on the NPR midday show Here & Now.  Here is how the program's website sets up the segment:

With 29 states allowing medical marijuana, senior citizens have been increasingly seeking its curative powers. But there are many obstacles, ranging from paying for the herb to finding a doctor who is licensed to prescribe.

In New York, considered an especially restrictive medical marijuana state, reporter Karen Michel explores some of the benefits and difficulties for seniors seeking legal pot.

September 26, 2017 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research, Who decides | Permalink | Comments (0)

Monday, September 25, 2017

"Cannabis use among patients at a comprehensive cancer center in a state with legalized medicinal and recreational use"

CoverThe title of this post is the title of this intriguing new research paper in the journal Cancer.  Here is the paper's abstract (with key points emphasized):

BACKGROUND

Cannabis is purported to alleviate symptoms related to cancer treatment, although the patterns of use among cancer patients are not well known.  This study was designed to determine the prevalence and methods of use among cancer patients, the perceived benefits, and the sources of information in a state with legalized cannabis.

METHODS

A cross-sectional, anonymous survey of adult cancer patients was performed at a National Cancer Institute–designated cancer center in Washington State. Random urine samples for tetrahydrocannabinol provided survey validation.

RESULTS

Nine hundred twenty-six of 2737 eligible patients (34%) completed the survey, and the median age was 58 years (interquartile range [IQR], 46-66 years).   Most had a strong interest in learning about cannabis during treatment (6 on a 1-10 scale; IQR, 3-10) and wanted information from cancer providers (677 of 911 [74%]).  Previous use was common (607 of 926 [66%]); 24% (222 of 926) used cannabis in the last year, and 21% (192 of 926) used cannabis in the last month.  Random urine samples found similar percentages of users who reported weekly use (27 of 193 [14%] vs 164 of 926 [18%]).  Active users inhaled (153 of 220 [70%]) or consumed edibles (154 of 220 [70%]); 89 (40%) used both modalities.  Cannabis was used primarily for physical (165 of 219 [75%]) and neuropsychiatric symptoms (139 of 219 [63%]).  Legalization significantly increased the likelihood of use in more than half of the respondents.

CONCLUSIONS

This study of cancer patients in a state with legalized cannabis found high rates of active use across broad subgroups, and legalization was reported to be important in patients' decision to use. Cancer patients desire but are not receiving information about cannabis use during their treatment from oncology providers.

September 25, 2017 in Medical community perspectives, Recreational Marijuana Data and Research, Recreational Marijuana State Laws and Reforms | Permalink | Comments (0)

Monday, September 11, 2017

Spotlighting concerns over increases in heavy marijuana use

In this recent post, I noted that last week the federal Substance Abuse and Mental Health Services Administration (SAMHSA) released here some key data from its 2016 National Survey on Drug Use and Health (NSDUH).  The SAMSHA data showing decreases in teen marijuana use garnered considerable attention, and rightly so because so many are concerned about when marijuana reforms might mean for marijuana activity by those with still developing brains.  

The SAMSHA data covers a lot more than teen usage, and Christopher Ingraham has this new Washington Post piece about a trend in the data concerning adult marijuana use.  His piece is headlined "Here’s one marijuana trend you should actually be worried about," and here are excerpts:

[NSDUH has data on] the number of people who are getting high all the time — heavy users who smoke on a daily or near-daily basis. The federal data shows that those numbers are increasingly precipitously.

In 2016, nearly 19 percent of people who used marijuana that year used it at least 300 days out of the year.  That figure's up by roughly 50 percent from 2002, when 12 percent of marijuana users consumed the drug daily or near-daily.

Again, this on its own is not necessarily cause for concern. It's possible to smoke marijuana moderately on a daily basis — half a joint to wind down after a day of work, akin to the ubiquitous glass of wine with dinner, for instance. But the comparison with alcohol is instructive here. According to the federal survey data, marijuana users are far more likely to use daily than drinkers are to drink daily.... In a given year, lots of people drink — but relatively few of them drink every day. That's not true for marijuana. Marijuana users are nearly three times as likely as drinkers to consume their drug of choice daily.

Some of that daily marijuana use is probably inherently moderate and nothing to be concerned about. But public health researchers worry that much of it is a result of problematic use — drug dependency. "While alcohol is more dangerous in terms of acute overdose risk, and also in terms of promoting violence and chronic organ failure, marijuana — at least as now used in the United States — creates higher rates of behavioral problems, including dependence, among all its users," as Carnegie Mellon University researcher Jonathan Caulkins wrote for the magazine National Affairs earlier this year.

The question, then, becomes how best to address the risks of chronic, heavy marijuana use. Keeping pot illegal is not likely to solve things — after all, the charts above show that daily marijuana use was rising well before the first states legalized the drug in 2014. Legalization advocates say that bringing the drug out in the open and regulating it is the best way to go. They point to tobacco as an example: Tobacco use, including heavy use, has fallen precipitously in the past two decades as a result of public health campaigns and greater stigma around use of the drug — all of which was accomplished without throwing people in jail for using it.

Public-health experts, meanwhile, are increasingly calling for a balance between the extremes of prohibition and commercialization — "grudging toleration," as New York University professor Mark Kleiman puts it. As a Rand Corp. report outlined last year, there are a whole host of options for dealing with the marijuana market, from allowing people to grow marijuana but not sell it, to giving the government a monopoly in marijuana sales, to more esoteric options like allowing nonprofit co-ops to control the supply of the drug.

The good news is that as laws relax around marijuana use, we're running real-world experiments in how some of those options actually work. In the United States, we have a handful of fully commercial markets, like the ones in Colorado and Washington. We also have noncommercial legalization for homegrown marijuana in the District. In Canada, meanwhile, it appears that the province of Ontario will experiment with implementing a government monopoly on the drug starting in July of next year.

September 11, 2017 in Medical community perspectives, Recreational Marijuana Commentary and Debate, Recreational Marijuana Data and Research | Permalink | Comments (1)

Sunday, September 10, 2017

"A Safer Way To Legalize Marijuana"

The title of this post is the headline of this notable extended commentary appearing at the Heath Affairs Blog authored by Rebecca Haffajee, Alex Liber, and Kenneth Warner. Here are excerpts:

Those crafting marijuana laws can draw upon lessons learned about the harms of combusted tobacco and the smoking control policies that followed. Given what we already know about the health hazards of combusted marijuana and the difficulty of controlling the sale of commercially established products, policy makers should capitalize on this opportunity to create a legal marijuana market that mitigates potentially significant harms associated with inhaling combusted marijuana while still facilitating desired benefits of recreational marijuana....

Combustible marijuana likely poses similar risks to those of combustible tobacco, while vaporizing or eating marijuana products offers a “cleaner” delivery mechanism. Why repeat the devastating public health harms of smoking tobacco when policy makers can reasonably mitigate similar consequences of smoking marijuana?...

In a recent comprehensive review of the scientific literature, the National Academies of Sciences, Engineering, and Medicine concluded that “smoked marijuana…is a crude THC delivery system that also delivers harmful substances.” The report and other reviews found strong evidence linking combusted marijuana to increased risk for chronic bronchitis....

Edible and vaporized marijuana products offer the potential to deliver therapeutic and euphoric benefits of marijuana while avoiding cardiopulmonary-related harms of combustion. Although precise estimates of the decreased risks associated with this substitution are not available, by analogy the health risks for smokeless and vaporized tobacco products are estimated to be roughly 90 percent less than those of combusted tobacco.

Valid concerns have been raised about the potential health harms from commercially marketed edibles, especially their attractiveness to, accessibility by, and increasing exposure and overdoses among children. We strongly support prohibitions on the sale of marijuana products — including edibles — to minors, clearly labeling product THC content and requiring child-proof packaging. Additionally, if marijuana is only legally available for sale in forms that do not resemble cigarettes, children may be less likely to cross over between products....

Policy makers in jurisdictions considering legalization are not bound by custom to make available all forms of marijuana for recreational use. Little prior interstate commerce of legal marijuana products exists, and most states have yet to legalize recreational use. The environment is ripe to experiment with different types of markets, and entrepreneurial policy makers could embark on implementing a safer legal marijuana market that omits combustibles, based on our current and developing knowledge.

While uncertainty still exists regarding the relative harms of different marijuana products and robust research is warranted, waiting for perfect scientific consensus about the scope and nature of harms related to marijuana combustion is unwise. The evidence base around marijuana combustion harms is already strong, and growing. Arriving at total consensus will take decades — as it took to link cigarettes to lung cancer — and waiting to embark on an alternative, very likely safer policy regime has real costs, measured in disease and death. Permitting the sale of THC extracts for consumption in edible or vaporized form will neither compromise therapeutic nor euphoric benefits of recreational marijuana use. In addition, creating variation in recreational marijuana policy regimes — between those already enacted that permit marijuana combustion and those enacted in the future that don’t — would create natural experiments ripe to study the differential effects and quantify harms versus benefits. Policy makers in favor of legalization should seize the opportunity to design a new market that permits recreational sale of marijuana only in edible or vaporized form, to minimize the potential for the kind of disease burden associated with smoked tobacco.

September 10, 2017 in History of Marijuana Laws in the United States, Medical community perspectives, Recreational Marijuana Commentary and Debate, Recreational Marijuana Data and Research, Recreational Marijuana State Laws and Reforms | Permalink | Comments (1)

Friday, September 1, 2017

"Make Pot Legal for Veterans With Traumatic Brain Injury"

The title of this post is the headline of this notable op-ed in today's New York Times authored by Thomas James Brennan, a former sergeant in the Marine Corps. Here is much of what he has to say: 

The explosion that wounded me during a Taliban ambush in Afghanistan in 2010 left me with a traumatic brain injury and post-traumatic stress. In 2012 I was medically retired from the Marine Corps because of debilitating migraines, vertigo and crippling depression. After a nine-year career, I sought care from the Department of Veterans Affairs.

At first, I didn’t object to the pills that arrived by mail: antidepressants, sedatives, amphetamines and mood stabilizers. Stuff to wake me up. Stuff to put me down. Stuff to keep me calm. Stuff to rile me up. Stuff to numb me from the effects of my wars as an infantryman in Iraq and Afghanistan. Stuff to numb me from the world all around.  The T.B.I. brings on almost daily migraines, and when they come, it’s as if the blast wave from the explosion in Afghanistan is still reverberating through my brain, shooting fresh bolts of pain through my skull, once again leaving me incapacitated. Initially the prescriptions helped — as they do for many veterans. But when I continued to feel bad, the answers from my doctors were always the same: more pills. And higher dosages. And more pills to counteract the side effects of those higher dosages. Yet none of them quite worked.

One thing did. In 2013, a friend rolled a joint and handed it to me, urging me to smoke it later. It will relieve your symptoms, he promised. That night I anxiously paced around my empty house. I hesitated to light it up because I’d always bought into the theory of weed as a “gateway drug.” But after a few tokes, I stretched out and fell asleep. I slept 10 hours instead of my usual five or six. I woke up feeling energized and well rested. I didn’t have nightmares or remember tossing or turning throughout the night, as I usually did. I was, as the comedian Katt Williams puts it, “hungry, happy, sleepy.”

With the help of my civilian psychiatrist, I began trading my pill bottles for pipes and papers. I also began to feel less numb. I started to smile more often. I thought I had found a miracle drug. There was just one problem: That drug was illegal. In 21 states, including North Carolina, where I live, any use of marijuana is forbidden under state law. The current punishments for those who possess or cultivate cannabis — even for medical purposes — may include a felony conviction and imprisonment, loss of child custody and permanent damage to their livelihood. The V.A. encourages veterans to discuss their cannabis use with their doctors, but because cannabis is also prohibited under federal law, the V.A. cannot prescribe it in any form — thereby denying countless veterans relief to many mental health symptoms and other service-connected disabilities.

The medical benefits of marijuana for the more than 360,000 post-Sept. 11 veterans who have brain injuries are not universally recognized. (As many as one in five veterans are thought to have post-traumatic stress.) But medical experts like Dr. Frank Ochberg, a psychiatrist and former associate director of the National Institute of Mental Health, believe that “medical marijuana absolutely belongs in the pharmacy for post-traumatic stress and brain injury treatment.” The V.A., Dr. Ochberg said, “is failing veterans by not making cannabis a treatment option.”...

Most of the major veterans groups, including the American Legion, Iraq and Afghanistan Veterans of America, Veterans of Foreign Wars and Disabled American Veterans, support regulated research into the medical uses of cannabis. But the research is slow in coming: Since 1968, the University of Mississippi has been home to the only licensed facility to produce cannabis for clinical research. In March it was reported that the university’s cannabis was contaminated with lead, yeast and mold — substances that jeopardize research efficacy and patient safety.

What I know is that it works for me. If I hadn’t begun self-medicating with it, I would have killed myself. The relief isn’t immediate. It doesn’t make the pain disappear. But it’s the only thing that takes the sharpest edges off my symptoms. Because of cannabis, I’m more hopeful, less woeful. My relationship with my wife is improving. My daughter and I are growing closer. My past is easier to remember and talk about. My mind is less clouded. More than anything, it feels good to feel again. My migraines and depression don’t control my life. Neither do pills.

But I live in fear that I will be arrested purchasing an illegal drug. I want safe, regulated medical cannabis to be a treatment option. Just like the sedatives and amphetamines the V.A. used to send me by mail. And the opioids they still send to my friends.

September 1, 2017 in Federal Marijuana Laws, Policies and Practices, Medical community perspectives, Medical Marijuana Commentary and Debate, Who decides | Permalink | Comments (1)

Tuesday, August 15, 2017

US Justice Department reportedly blocking marijuana research requests supported by DEA

The Washington Post has this notable new article reporting that "The Justice Department under Attorney General Jeff Sessions has effectively blocked the Drug Enforcement Administration from taking action on more than two dozen requests to grow marijuana to use in research." Here is more:

A year ago, the DEA began accepting applications to grow more marijuana for research, and as of this month, had 25 proposals to consider.  But DEA officials said they need the Justice Department’s sign-off to move forward, and so far, the department has not been willing to provide it.  “They’re sitting on it,” said one law enforcement official familiar with the matter. “They just will not act on these things.”

As a result, said one senior DEA official, “the Justice Department has effectively shut down this program to increase research registrations.’’  DEA spokesman Rusty Payne said the agency “has always been in favor of enhanced research for controlled substances such as marijuana.’’  Lauren Ehrsam, a Justice Department spokeswoman, declined to comment....

[Attorney General Jeff] Sessions frequently speaks harshly about marijuana use, and Justice Department officials have been reviewing the policy of his predecessor when it comes to enforcing federal laws on marijuana in states where the drug is legal.  Sessions, too, has called medical marijuana “hyped, maybe too much,” and signaled that he is skeptical about benefits of smoking it.  “Dosages can be constructed in a way that might be beneficial, I acknowledge that, but if you smoke marijuana, for example, where you have no idea how much THC you’re getting, it’s probably not a good way to administer a medicinal amount.  So forgive me if I’m a bit dubious about that,” Sessions said earlier this year.

The DEA is no shrinking violet when it comes to marijuana enforcement.  Last year, Rosenberg declined to lessen restrictions on its use, maintaining its classification as a Schedule 1 controlled substance — which means it has no accepted medical use and a high potential for abuse.  But Rosenberg wrote at the time that the DEA would “support and promote legitimate research regarding marijuana and its constituent parts.”  The DEA, he wrote, already had approved such research, registering 354 people and institutions to study marijuana and related components, including the effects of smoked marijuana on humans.

The DEA indicated at the time it was willing to see those studies expand, asking for applications from people who wanted to grow marijuana to be used for research.  The only source of marijuana for researchers then was — and is — the University of Mississippi, which has permission to grow and distribute the drug for research.

One still-waiting applicant is Lyle Craker, a professor at the University of Massachusetts at Amherst.  Craker has spent years seeking approval to do research into whether other parts of marijuana plants have medicinal value.  “I’ve filled out the forms, but I haven’t heard back from them. I assume they don’t want to answer,’’ said Craker. “They need to think about why they are holding this up when there are products that could be used to improve people’s health . I think marijuana has some bad effects, but there can be some good and without investigation we really don’t know.’’  Craker submitted his latest application Feb. 14, and after getting additional questions from the DEA in March, supplied additional information in April.

Brad Burge, spokesman for the Multidisciplinary Association for Psychedelic Studies, said the federal government for years has prevented important research into marijuana.  “That’s a sad state of affairs,’’ he said, adding, “if the DEA is now asking for permission to say yes, then the resistance is now further up the chain of command.’’

Rosenberg indicated in a call with The Washington Post that he still would support more marijuana research.  “I stand by what I wrote,” he said.  Tension between Rosenberg and Trump is perhaps unsurprising.  Rosenberg was appointed during the Obama administration, and he had served as chief of staff and senior counselor to James B. Comey, who was the FBI director until Trump fired him earlier this year.

The Justice Department has not rejected any of the 25 people whose applications to grow marijuana the DEA is considering. Rather, the department is not taking any action at all, officials said.  Before approving such applications, DEA officials have to assess each applicant and determine whether their facility is secure and whether they had previously been complying with federal law.

August 15, 2017 in Federal Marijuana Laws, Policies and Practices, Medical community perspectives, Medical Marijuana Commentary and Debate, Who decides | Permalink | Comments (0)

Sunday, July 9, 2017

"Is marijuana a secret weapon against the opioid epidemic?"

Regular readers may already be tired of posts here exploring whether marijuana reform may be an important element of modern responses to the modern opioid epidemic.  But until that epidemic is over, I am going to keep posting on this topic.  And the title of this post is the headline of this PRI article is based on an interview that aired on PRI's Science Friday. Here are excerpts:

“Really, if we stopped medical marijuana programs that are now in place in 29 states and Washington, DC … the science suggests we would worsen the opioid epidemic,” says Dina Fine Maron, a medicine and health editor at Scientific American, who wrote a recent story on the subject.

She explains that states with medical marijuana programs have fewer opioid overdose-related deaths than states without medical marijuana — 25 percent fewer, according to a 2014 study cited in her article. “The reality is that the literature right now suggests that if anyone is using an opioid — whether it be a prescription painkiller or something like heroin — a prescription painkiller is more likely [than marijuana] to lead to drug abuse,” she says, “because it’s more addictive and obviously can be more lethal.”...

University of Georgia public policy professor W. David Bradford has studied how legal medical marijuana impacts prescription use by enrollees of Medicare, the federal health insurance program for seniors and the disabled. “What we found … was significant reductions in prescription use, most notably among pain medications, and the largest plurality of those would be opiates,” he says.

Then he researched the effect on enrollees in Medicaid, the federal-state program that helps the poor and people with disabilities pay for health care. “We redid the study for Medicaid just this past month in Health Affairs and, again, found large reductions in the use of prescription pain medications when states turned on medical cannabis laws.”...

Legal medical marijuana isn’t a silver bullet for the complex US opiate crisis, Bradford says. But while dozens of people in the US die each day from opioids, there has never been a fatal overdose documented from marijuana alone. “The National [Academies] of Sciences, Engineering, and Medicine just this past January issued a comprehensive report where they said there is conclusive evidence that cannabis can be effective at managing pain,” he says. “So, to the extent we can divert people from initially starting on opiates through legitimate prescriptions, we divert them from the path of abuse and then the path of death,” he adds. “And it does seem that cannabis could be one tool in the arsenal to do that.”

Some prior related posts:

July 9, 2017 in Medical community perspectives, Medical Marijuana Data and Research | Permalink | Comments (1)

Friday, July 7, 2017

University of Maryland pharmacy school partnering with Americans for Safe Access on medical marijuana instruction

Download (2)As an academic working at a large state university believing in the importance of training students about marijuana law, policy and reform, I am always extra interested hearing about academics at other large state universities working in this space.  One such story is covered in this new AP article with the sub-headline "The University of Maryland School of Pharmacy will begin offering training to prepare prospective workers for the medical marijuana industry." Here are some of the notable details:

The University of Maryland School of Pharmacy will begin offering training to prepare prospective workers for the medical marijuana industry. The move puts the Baltimore school in league with few other established universities and colleges, including the University of Vermont College of Medicine's Department of Pharmacology, seeking to bring educational standards to a growing national industry that grapples with evolving science and uncertain legal standing.

"We wanted to be there as a resource," said Magaly Rodriguez de Bittner, a pharmacy professor and executive director of the school's Center for Innovative Pharmacy Solutions, which began signing up potential workers for training June 29.  "If you're going to be dispensing," she said, "let's make sure your staff in trained in best practices to do it safely and effectively."

The pharmacy school will offer classes through its online platform toward certifications required under the state's medical marijuana law for those involved in the business.  It's partnering with the advocacy group Americans for Safe Access on the certification program. That organization will provide the instructors and the curriculum, which the school vetted and adjusted.

Training doesn't mean an endorsement of using marijuana by the school, a well-regarded institution founded in 1841, Rodriguez de Bittner said.  Medical marijuana is not approved by the U.S. Food and Drug Administration. The school had an online platform to offer the training and a mission to provide education to health care providers, even if the science and government regulation has yet to catch up with demand, she said.

Few universities even support research into medical uses for cannabis, largely because accessing the plant is restricted by federal law that categorizes it the same as heroin and LSD.  And though Maryland, 28 other states and the District of Columbia have made medical marijuana legal, the administration of President Donald Trump has signaled it could increase enforcement efforts.

Some large health systems in Maryland are concerned enough to ask their doctors not to recommend the drug, including LifeBridge Health and MedStar Health.  Johns Hopkins Medicine and the University of Maryland Medical System still are formulating policies.  Maryland's medical marijuana rules don't obligate doctors to get specific training before prescribing cannabis, but like other states it does require growers, processors, dispensaries and laboratories to be "certified," said Patrick Jameson, executive director of the Maryland Medical Cannabis Commission....

The pharmacy school's partnership with Americans for Safe Access gives the nonprofit advocacy group "immediate legitimacy" for its courses, said Shad Ewart, a professor at Anne Arundel Community College, who teaches a course about the marijuana industry for credit but not yet industry certification.  He said the school also benefits because officials there had to do little legwork in developing a curriculum that could have taken months or years to produce on their own. (University officials said they reviewed the content and made it conform to educational norms.)

Still, Ewart understands many colleges and universities don't want to jeopardize federal funding for research, student loans or other programs by wading into the medical marijuana arena.  He said there was a need, and in his case, demand particularly from students who wanted to launch their own businesses.  He said he steers students to focus on ancillary operations such as security, marketing, accounting and retail. "If the legislation says you must have fencing with video surveillance, well, that's good for the fencing and video industries," he said.

Jahan Marcu, chief science officer for Americans for Safe Access, said the group has been offering training since 2002 when there were approximately 11 dispensaries around the country. Instruction initially focused only on "survival," which meant how to handle law enforcement.  Now that there are several thousand businesses, the training has evolved to match what's required by states that allow medical marijuana for each type of operation from growing and processing to retailing and laboratory testing, he said.  Courses offer instruction about laws and regulations; the latest evidence on uses for medical marijuana; plant and product consistency; pesticides; sanitation; operating procedures; labeling, inventory control and record keeping; and other relevant information....

Marcu said his group is not the largest marijuana educator, though it's not clear anyone is keeping track. Among others offering instruction are Cannabis Training Institute, THC University and Green Cultured. In addition to such new "universities" dedicated to medical marijuana certification, there are some medical societies and health departments offering training. The university affiliation, Marcu hopes, will bring some accountability and possibly standards that others could adopt.

Rodriguez de Bittner said since launch of the training site, there has been interest from potential workers in Maryland, West Virginia, California and the District of Columbia. "There is so much out there," she said. "We're trying to partner and provide courses based on the best evidence — as it develops."

July 7, 2017 in Business laws and regulatory issues, Medical community perspectives, Who decides | Permalink | Comments (0)

Wednesday, July 5, 2017

"Cannabis use and psychotic-like experiences trajectories during early adolescence: the coevolution and potential mediators"

OlalertbannerThe title of this post is the title of this notable new article appearing in the Journal of Child Psychology and Psychiatry authored by Josiane Bourque, Mohammad H. Afzali, Maeve O'Leary-Barrett, and Patricia Conrod. Here is the abstract:

Background

The authors sought to model the different trajectories of psychotic-like experiences (PLE) during adolescence and to examine whether the longitudinal relationship between cannabis use and PLE is mediated by changes in cognitive development and/or change in anxiety or depression symptoms.

Methods

A total of 2,566 youths were assessed every year for 4-years (from 13- to 16-years of age) on clinical, substance use and cognitive development outcomes. Latent class growth models identified three trajectories of PLE: low decreasing (83.9%), high decreasing (7.9%), and moderate increasing class (8.2%). We conducted logistic regressions to investigate whether baseline levels and growth in cannabis use were associated with PLE trajectory membership. Then, we examined the effects of potential mediators (growth in cognition and anxiety/depression) on the relationship between growth in cannabis use and PLE trajectory.

Results

A steeper growth in cannabis use from 13- to 16-years was associated with a higher likelihood of being assigned to the moderate increasing trajectory of PLE [odds ratio, 2.59; 95% confidence interval (CI), 1.11–6.03], when controlling for cumulative cigarette use. Growth in depression symptoms, not anxiety or change in cognitive functioning, mediated the relationship between growth in cannabis use and the PLE moderate increasing group (indirect effect: 0.07; 95% CI, 0.03–0.11).

Conclusions

Depression symptoms partially mediated the longitudinal link between cannabis use and PLE in adolescents, suggesting that there may be a preventative effect to be gained from targeting depression symptoms, in addition to attempting to prevent cannabis use in youth presenting increasing psychotic experiences.

July 5, 2017 in Medical community perspectives, Medical Marijuana Data and Research, Recreational Marijuana Data and Research | Permalink | Comments (3)