UAC Marijuana Special Edition

Utah

The

Special

Edition

Addiction Center

Volume 2 Issue 14

Report

January 2012 Dedicated to research, clinical training, and education in chemical addiction

Contact Us University of Utah Health Sciences Center 410 Chipeta Way, Suite 280 Salt Lake City, Utah 84108 Phone: (801) 581-8216 Fax: (801) 587-7858 E-mail: abbie.paxman@hsc.utah.edu Internet: http://uuhsc.utah.edu/uac/

Utah Addiction Center University of Utah Health Sciences Center 410 Chipeta Way, Suite 280 Salt Lake City, Utah 84108

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Drugs: A Historical Perspective

Marijuana Marijuana, or cannabis, is a substance of dichotomies . There are those who claim that marijuana is the most frequently abused drug of the illegal substances, while others argue it is the least addicting. There are groups who demand that marijuana should be absolutely prohibited and the only way it can be properly controlled is by law enforcement as a Schedule I substance, while others demand that it be made legal like tobacco and alcohol and even classified as legal for routine medical use by clinicians. There are some who claim when used by adolescents, marijuana becomes a gateway drug inevitably leading to addiction to the hardcore potent drugs of abuse such as cocaine, heroin and methamphetamine, while others claim that the vast majority of young people who experiment with this drug typically lose interest as they age and mature into adulthood. Who is right, and what should we know about the “real” marijuana and its associated problems and promises?

The Utah Addiction Center is based in the office of the University of Utah Senior Vice President for Health Sciences INSTITUTIONAL ADVISORY BOARD

A. Lorris Betz, M.D., Ph.D. Louis H. Callister, J.D. Edward B. Clark, M.D. M. David Rudd, PhD, ABPP Patrick Fleming, LSAC, MPA Raymond Gesteland, Ph.D. Jay Graves Ph.D. John R. Hoidal, M.D. Glen W. Hanson Ph.D, D.D.S, Maureen Keefe, RN, Ph.D Jannah Mather, Ph.D. Chris Ireland, Ph.D. John McDonnell, Ph.D. Barbara N. Sullivan, Ph.D. Ross VanVranken, ACSW Kim Wirthlin, MPA

Actually, each of these statements has elements of both truth and deception. That is what makes discussions about marijuana so difficult and often filled with controversy and emotions. Marijuana and its social contexts are very complicated thereby leading to very difficult dilemmas for society, families and individuals. While it is impossible to provide a detailed discussion of everything we know about marijuana, I will briefly touch on three of the most troubling marijuana confusions: (i) is its use bad, with long-term consequences or just a part of normal maturation with no lasting consequences?; (ii) does its use require intensive treatment like many other drugs of abuse, or do the vast majority of users outgrow their inclination to use it without any special intervention? ; and (iii) are the biological targets of the active ingredients in marijuana (e.g.,THC), known as cannabinoid receptors, the basis for potentially harmful illegal substances or do they really have important therapeutic potential. (i) First, relatively speaking, marijuana use, in and of itself, is probably less harmful than use of many of the other drugs of abuse. Smoking marijuana rarely has fatal consequences per se nor is it likely to cause dangerous behavior in the user. However, like all drugs, marijuana use does have potential negative consequences. Research has shown that smoking marijuana can interfere with cognitive functions and proper decision-making. The THC in marijuana alters CNS systems involved in motivation, motor control and coordination thereby creating situations that can be dangerous to the user. Finally, there is evolving evidence suggesting that frequent use of marijuana during adolescence can have long-term consequences on brain development that may cause subtle functional changes even in adulthood. The details of these changes remain to be elucidated by research.

» See Marijuana page 7 1

History and Trends in Marijuana Use

» Marijuana

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From the Book “Drugs and Scoiety” by Dr. Glen R. Hanson

(ii) Second, because of its relatively minor addicting potential, marijuana use typically causes mild dependence with minor withdrawal effects when its use is stopped abruptly. However, because it is so frequently consumed by so many people, there clearly are significant numbers of users who have difficulty setting the habit aside. Often in the more extreme cases of marijuana dependence, there are also issues of polysubstance abuse which can make treatment more complicated. In such situations, it is best to consult with clinicians who are trained to diagnose and treat these behaviors.

ln many societies, marijuana has historically been a valued crop. It is called hemp because the woody fibers of the stem yield a fiber that can be made into cloth and rope. The term cannabis comes from the Greek word for hemp. Initially, the Spaniards brought cannabis to the Western Hemisphere as a source of fiber and seeds. For thousands of years, the seeds have been pressed to extract red oil used for medicinal and euphoriuenic purposes. The plant (both male and female) also produces a resin with active ingredients that affect the central nervous system (CNS). Marijuana contains hundreds of chemical compounds, but only a few found in the resin are responsible for producing the euphoric high. Even the original uses of marijuana remain controversial. Botanists have never been able to trace cannabis to its origins, although some think it originated in Asia. Ancient Chinese documents contain the earliest record name of hemp-ma, meaning fiber producing plant. In the late 1970s, during an archeological dig in Gansu, the seat of Chinese civilization, workers uncovered cannabis seed stored in an earthen jar. Ayurvedic documents from 600 B.C. describe an intoxicating resin from the plant. The fifth-century B.C. Greek historian Herodotus recorded that the Scythians burned the tops of the plant, producing a narcotic smoke. And a first-century Greek physician wrote that hemp was made into intoxicating cakes, perhaps the forerunners of the marijuana brownies of 1960s fame. Other sources report that the first known record of marijuana use is the Book of Drugs written about 2737 B.C. by the Chinese Emperor Shen Nung; he prescribed marijuana for treating gout, malaria, gas pains, and absentmindedness. The Chinese apparently had much respect for the plant. They obtained fiber for clothes and medicine from it for thousands of years. The Chinese named the plant ma (maw), which in the Chinese language can also mean ‘’valuable” or “endearing.” The term ma was still used as late as 1930. The Chinese symbol for marijuana Around 500 B.C., another Chinese book of treatments referred to the medical is two plants under a shelter use of marijuana. Nonetheless, the plant got a bad name from the moralists of the day, who claimed that youngsters became wild and disrespectful from the recreational use of ma. They called it the “liberator of sin” because, under its influence, the youngsters refused to listen to their elders and did other scandalous things. Although the Chinese recognized ma’s medical usefulness, they eventually banned it because of its unpredictable intoxicating effects. Later, because of rampant use, it was legalized again. India also has a long and varied history of marijuana use. It was an essential part of Indian religious ceremonies for thousands of years. The well-known Rig Veda and other chants describe the use of soma, which some believe was marijuana. Early writings describe a ritual in which resin was collected from the plants. After fasting and purification, certain men ran naked through the cannabis fields. The clinging resin was scraped off their bodies, and cakes were made from it and used in feasts. For centuries, missionaries in India tried to ban the use of marijuana, but they were never successful, because its use was too heavily ingrained in the culture. From India, the use of marijuana spread throughout Asia, Africa, Europe, and the Americas-English settlers brought it to the U.S. colonies. Assyrian records dating back to 650 B.C. refer to a drug called azulla that was used for making rope and cloth and was consumed to experience euphoria. The ancient Greeks also knew about marijuana. Galen described the general use of hemp in cakes, which, when eaten in excess, produced narcotic effects. Herodotus described the Scythian custom of burning marijuana seeds and leaves to produce a narcotic smoke in steam baths. It was believed that breathing the smoke from the burning plants would cause frenzied activity. Groups of people stood in the smoke and laughed and danced as it took effect. One legend about cannabis is based on the travels of Marco Polo in the 12th century. Marco Polo told of the legendary Hasan Ibn-Sabbah, who terrorized a part of Arabia in the early 1100s. His The Utah Addiction Center Report

(iii) Third, research has revealed that protein targets in the brain and throughout the body known as cannabinoid receptors are the cause for most of the good and bad effects of using marijuana. We also know that marijuana-related THC is not the only substance that is capable of interacting with these cannabioid systems. In fact, in order to better understand the negative effects of marijuana use as well as determine how to develop medications that have marijuana-related medical benefits without the side effects, scientists have created literally hundreds of substances with the ability to stimulate or block these cannabinoid receptors. This type of research holds Medical marijuana dispensary the very real promise of some day creating novel therapeutic strategies to manage medical problems such as intractable pain, glaucoma, seizures, PTSD, nausea and anorexia, obesity and perhaps even addiction itself. However, while there are legitimate scientists trying to improve treatment of diseases by understanding better the cannabinoid systems, there are also unscrupulous “businesses” trying to take advantage of what science has discovered in order to manufacture “legal” products with marijuana-like effects to make huge profits. The result of these quasi-legal efforts have been products with names such as “Spice”, “Black Mamba” , “K2” and others that are promoted as legal “herbal incense” or synthetic marijuana. Recognizing the potential dangers of these products and their lack of scientific scrutiny, law enforcement and the medical community have taken steps to outlaw these renegade products and keep them from being marketed as legitimate. It is very probable that society will be dealing with these cannabinoid counterfeit products for the foreseeable future as active ingredients are declared illegal by law enforcement and then replaced by other chemically related analogs. In summary, for better and for worse, marijuana continues to be hotly contested by advocates and critics alike. Issues are far from resolved and marijuana is likely to retain its appeal to younger populations for the foreseeable future. The present edition of this Newsletter includes several articles to help readers better appreciate the marijuana dilemma and its personal and social implications.

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a referral to treatment. It is important at this point for physicians to develop a formal relationship with treatment providers to ensure the continued care of the patient. SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders. (SAMHSA, 2010). What is next? An initial overview of SBIRT was presented to physicians and other participants of the Critical Issues Conference on October 3-4, 2011. A more intensive training for physicians and other health care providers will be offered at the upcoming Generations Conference on March 30th, 2012. If you are interested in learning more about SBIRT or being involved in this exciting project, please contact Becky King at the state Division of Substance Abuse and Mental Health at 801-538-4278. 2

The Utah Addiction Center Report

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Committee Assists Legislature in Effort to Control Spice and Bath Salt Products

men were some of the earliest political murderers and he ordered them to kill under the influence of hashish, a strong, unadulterated cannabis derivative. The cult was called the hashishiyya, from which came the word hashish. (The word assassin may be derived from the name of Sheik Hasan, who was a political leader in the 10th century.) It is unlikely, however, that using hashish can turn people into killers. Experience suggests that people tend to become sleepy and indolent rather than violent after eating or smoking hashish or another of the strong cannabis preparations available in Arabia.

Richard J. Oborn,Utah Department of Commerce Dr. David Sundwall,University of Utah School of Medicine.

During the 2010 General Legislative Session, the Utah Legislature passed a bill that created the Controlled Substances Advisory Committee. The Committee serves as a consultative and advisory body to the Legislature regarding: (a) the movement of a controlled substance from one schedule to another; (b) the removal of a controlled substance from any schedule; and (c) the designation of a substance as a controlled substance and the placement of the substance in a designated schedule. The Committee is comprised of 13 members that includes representatives from the law enforcement, addiction medicine, and medical communities. Dr. David Sundwall, primary care physician and Professor at the University of Utah School of Medicine in the Department of Family and Preventive Medicine, acts as chair of the Committee.

Napoleon’s troops brought hashish to France after their campaign in Egypt at the beginning of the 19th century, despite Napoleon’s strict orders to the contrary. By the 1840s, the use of hashish, as well as opium, was widespread in France, and efforts to curb its spread were unsuccessful. In North America, hemp was planted near Jamestown in 1611 for use in making rope. By 1630, half of the winter clothing at this settlement was made from hemp fibers. There is no evidence that hemp was used medicinally at this time. Hemp was also valuable as a source of fiber for clothing and rope for the Pilgrims at Plymouth. To meet the demand for fiber, a law was passed in Massachusetts in 1639 requiring every household to plant hemp seed. However, it took much manual labor to work the hemp fiber into usable form, resulting in a chronic shortage of fiber for fishnets and the like.

Since first meeting in July 2010, the Committee has submitted two written reports to the Legislature. The first, submitted in November 2010, recommended that the Utah Controlled Substances Act (Utah Code 58-37) be amended to include a list of “listed controlled substances” and that synthetic cannabinoid chemicals found in spice products should be added to the new list. The Committee also recommended that chemicals found in bath salt products be listed as controlled substances. The Legislature followed the Committee’s recommendations in the 2011 General Legislative Session when they passed H.B. 23.

George Washington cultivated a field of hemp at Mount Vernon, and there is some indication that it was used for medicine as well as for making rope. In his writings, Washington once mentioned that he forgot to separate the male and female plants, a process usually done because the female plant gave more resin if not pollinated. In the early 1800s, U.S. physicians used marijuana extracts to produce a tonic intended for both medicinal and recreational purposes. This practice changed in 1937 with passage of the Marijuana Tax Act. The Marijuana Tax Act was modeled after the Harrison Act of 1914 in that marijuana was considered a narcotic and subject to the same legal controls as cocaine and the opiates. Like these opiates, marijuana distributors had to register and pay a tax to legally import, buy, or sell this drug. As a result, the Marijuana Tax Act prohibited the use of this drug as an intoxicant and regulated its use as a medicine.

After law enforcement enforced the ban, the Utah Bureau of Forensic Services did testing that confirmed a decrease in the abuse of the controlled substances that were just recently controlled; however, data reported an increase in the abuse of “analogs” of banned substances. Utah Code 5837-5.5 enables prosecution of unlawful possession of analog substances if the chemical structure is substantially similar to that of a controlled substance; however, most local prosecutors do not prosecute unlawful possession of analogs because doing so would likely require expert testimony to prove that the two substances are substantially similar. Local jurisdictions are hesitant to proceed with analog cases due to the extra preparation time required and expert witness testimony needed to prove this charge when they are already overburdened and understaffed.

Most of the abuse of marijuana in the United States during the early part of the 20th century took place near the Mexican border and in the ghetto areas of major cities. Cannabis was mistakenly considered a narcotic, like opium, and legal authorities treated it as such. In 1931, Harry Anslinger, who was the first appointed head of the Bureau of Narcotics and later would become responsible for the enforcement of marijuana laws, believed that the problem was slight. By 1936, however, he claimed that the increase in the use of marijuana was of great national concern. Anslinger set up an informational program that ultimately led to the federal law that banned marijuana. The following sensationalized statement was part of Anslinger’s campaign to outlaw the drug:

In an effort to protect the public from the risk of further abuse of the analog substances, the Committee submitted a second report to the Legislature in October 2011. In the report, the Committee recommended that the Legislature consider listing the analog substances that showed up in tests administered by the Utah Bureau of Forensic Services. Even if the Legislature bans these substances during the 2012 Legislative Session, the Committee anticipates that manufacturers of spice and bath salt products will again create new versions of the product that contain analogs of banned substances. Because the new versions of the products contain only analogs of banned substances, and jurisdictions rarely prosecute analog cases, abuse of spice and bath salt products will continue until the Legislature has a chance to ban the analogs at the next general legislative session. Having identified this problem, the Committee has also recommended that the Legislature consider options of how to enable law enforcement to be more nimble in responding new versions of To obtain more information about the harmful products created by manufacturers. One option would work of the Committee or to obtain be for the Legislature to grant the Controlled Substances Advisory information about an upcoming meeting, please visit the Committee website at Committee the authority to approve temporary placement of http://www.dopl.utah.gov/programs/ substances on the controlled substance list until the next general csac/. If you are interested in providing legislative session when the Legislature would consider whether input to the Committee as they advise to make the placement permanent. There are pros and cons the Legislature regarding the control of substances of concern, you may attend to this proposal and the Committee believes that it warrants a Committee meeting or contact the Legislature’s consideration during the 2012 General Legislative Committee Administrator, Richard Oborn, Session. at 801-530-6767 or roborn@utah.gov. The Utah Addiction Center Report

What about the alleged connection between drugs and sexual pleasure? ... What is the real relationship between drugs and sex? There isn’t any question about marijuana being a sexual stimulant. It has been used throughout the ages for that: in Egypt, for instance. From what we have seen, it is an aphrodisiac, and I believe that the use in colleges today has sexual connotations. In addition, during this time, some usually accurate magazines reported that marijuana was partly responsible for crimes of violence. In 1936, Scientific American reported that “marijuana produces a wide variety of symptoms in the user, including hilarity, swooning, and sexual excitement. Combined with intoxicants, it often makes the smoker vicious, with a desire to fight and kill”. A famous poster of the day, called ‘’The Assassination of Youth,” was effective in molding attitudes against drug use. Largely because of the media’s influence on public opinion, Congress passed the Marijuana Tax Act in 1937. However, as a result of the discussions and debates before the passage of the 1970 Comprehensive

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Taking Another Look at SBIRT (Screening, Brief Intervention, and Referral to Treatment)

Drug Abuse Prevention and Control Act, which replaced or updated all other laws concerning narcotics and dangerous drugs, the Marijuana Tax Act of 1937 was declared unconstitutional in 1969 because it classified marijuana as a narcotic. Marijuana has not been classified as a narcotic since 1971.

Barbara Sullivan, Utah Addiction Center

The State Division of Substance Abuse and Mental Health is currently working with the Utah Addiction Center, local substance abuse authorities, physicians, other health care providers, and local community health clinics to change the conversation about substance abuse and to expand the options for early identification of people with substance abuse problems. At present the substance abuse treatment system is driven by referrals from law enforcement and the criminal justice system. Through SBIRT training, we are hoping to more actively involve physicians, nurses, and other health care professionals in the early identification and referral of patients who may be at risk for substance use 14 disorders.

In the early 1900s, marijuana was brought across the U.S. borders by Mexican laborers who entered the United States seeking jobs. From the border areas of the United States, recreational use of marijuana spread into mainly the southwestern region of the United States. Such use reached major cities in Texas and surrounding states as well as a number of African American communities in these cities. Heavy users of marijuana included a subpopulation of jazz musicians as well as other “bohemian types” who led more of an unstructured existence in unconventional jobs and occupations (artists, entertainers, poets, criminals, and so on). Thus, before the 1960s, marijuana use was largely confined to small segments of African American urban youth, jazz musicians, and particularly artists and writers who belonged to the 1950s Beat Generation. Use rose tremendously in the 1960s, when it was closely associated with the hippie counterculture, in which marijuana was categorized as a psychedelic (consciousness-expanding) sacrament. It spread into other youth categories during the 1970s, until approximately 1978. In each year from 1978 until 1991, marijuana use fell. After 1991, researchers and prevention specialists were astounded to see a rise in usage among youth.

Do We Need SBIRT in Utah?

P E RC EN T

10 According to the Department of Substance Abuse and Mental Health 2010 Annual Report, the Synthetic 8 Estimates of Needs for Utah and the 2009 Student Health Risk Prevention Survey found that 88,251 adults 6 4 and 11,899 youth in the 6th through 12th grades in Utah were classified as needing treatment for alcohol 2 and/or drug dependence or abuse. At present, the 0 majority of the individuals in the public treatment system are referred from criminal justice. However, Age of first use of primary substance - under 18 (fiscal year 2010) SBIRT physicians and other health care professionals may be able to reach a significant portion of these individuals before high end interventions, law enforcement, and criminal justice are needed. SBIRT is designed to identify substance abuse in patients early, and to fill the gap between primary prevention efforts and more intensive treatment for persons with serious substance use disorders. Alcohol Drug

Under 12

Marijuana still grows wild in many American states today. Curiously, one reason for the survival of this supply is that, during World War II, the fiber used to make rope (sisal) was hard to import, so the government paid subsidies to farmers who grew hemp. Much of today’s crop comes from these same plants. Another reason for the spread of the plants is that, until recently, the seeds were used in birdseed. Leftover seed was discarded in the garbage and thus spread to landfill dumps, where it sprouted. Birdseed containing marijuana seeds is still available, but the seeds are sterilized so that they cannot germinate.

TREATMENT NEEDS IN UTAH ADULTS BEAR RIVER CENTRAL DAVIS FOUR CORNERS NORTHEASTERN SALT LAKE

It was found that marijuana in an effective dose impairs intellectual functioning in general.... Marijuana does not change the basic personality structure of the individual. It lessens inhibition and this brings out what is latent in his thoughts and emotions but it does not evoke responses that would otherwise be totally alien to him.... Those who have been smoking marijuana for years showed no mental or physical deterioration that may be attributed to the drug.

SAN JUAN SOUTHWEST SUMMIT TOOELE UTAH COUNTY WASATCH

Much of the early research conducted did not consider the potency of marijuana. As a result, findings from various studies are often conflicting and difficult to compare. Because the quality of marijuana varies so greatly, it is impossible to know the amount of drug taken without analyzing the original material and the leftover stub, or “roach.” Conditions such as type of seed, soil moisture and fertility, amount of sunlight, and temperature all have an effect on the amounts of active ingredients found in the resulting marijuana plant.

WEBER

STATE TOTALS

(under age 18)

5,354 2,110 8,416 1,175 1,577 34,384 524 5,654 1,077 1,616 18,038 573 7,525

375 378 964 234 92 6,499 44 767 204 387 977 117 927

88, 251

11,899

Division of Substance Abuse and Mental Health, 2010 4

The Utah Addiction Center Report

Age 12

Age 13

Age 14

Age 15

Age 16

Age 17

What is SBIRT?

YOUTH

(18+)

The Indian Hemp Drug Commission Report in the 1890s and the 1930 Panama Canal Zone Report on marijuana stressed that available evidence did not prove marijuana to be as dangerous as it was popularly thought; these reports were given little publicity, however, and for the most part were disregarded. In 1944, a report was issued by the LaGuardia Committee on Marijuana, which consisted of 31 qualified physicians, psychiatrists, psychologists, pharmacologists, chemists, and sociologists appointed by the New York Academy of Medicine. They stated in one key summary that marijuana was not the killer many thought it to be:

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Screening: Screening involves universal screening of all patients with a validated tool to assess to “risk level” of substance use and identify individuals who might benefit from intervention. Brief Interventions: In the doctor’s office, a health care professional might use motivational interviewing or other brief techniques to raise awareness of risks and to motivate a patient to be more aware of their use patterns. This may include 1-5 non-judgmental sessions that can be used as teachable moments. Brief Treatment: Upon follow up, a physician may decide that brief treatment is needed. This may include 5-12 sessions of cognitive behavioral treatment. Referral to Treatment: Some patients may need more long term and formal substance abuse treatments. In these cases the physician may make

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