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Marijuana in Colorado Scott Humphreys, MD Associate Medical Director Colorado Physician Health Program April 10, 2015 8TH ANNUAL NEUROMEDICINE CONFERENCE The Medical Center of Aurora © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Cannabis • Complex alkaloid mixture of more than 400 compounds derived from the Cannabis sativa plant • 60 different compounds described with activity on the cannabinergic system • Most abundant cannabinoids are – Delta-9 tetrahydrocannabinol (most psychoactive) – Cannabidiol – Cannabinol © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP History of Marijuana © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP History of Marijuana • 6000 BC – Cannabis seeds used as food in China • 4000 BC – Textiles made of hemp in China • 2727 BC – first recorded medicinal use in Chinese Pharmacopoeia © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP History of Marijuana • 1400 BC to AD – trade moves product through India, Mediterranean countries, Europe – numerous medicinal uses reported © Colorado Physician Health Program 2014 All Rights Reserved Please do not reproduce or use without written permission of CPHP History of Marijuana • 3rd century Rome – Used for sails and ropes © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP History of Marijuana • 1378 – Emir of the Ottoman Empire makes the first edict against eating hashish or smoking cannabis – 1st “War on Drugs” • 1798 – Napoleon declared total prohibition on marijuana after realizing much of the Egyptian lower class were habitual smokers • 1868 – Egypt – 1st modern country to outlaw cannabis ingestion • 1890 – Hashish made illegal in Turkey © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP History of Marijuana • Introduced to North America in 1600s by Puritans – Hemp for ropes, sails, clothing; cannabis a common ingredient in medicines, sold openly in pharmacies…..lucrative © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP History of Marijuana • 1937 – Marijuana Tax Act (MTA) – transfer of cannabis illegal throughout US except for medicinal and industrial use, expensive excise tax and detailed logs required • 1969 – MTA found to be unconstitutional since it violated 5th Amendment privilege against self-recrimination © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP History continued • 1970 – Controlled Substance Act – classified cannabis as having: – – – – – High abuse potential No medical use Not safe to use under medical supervision All use proscribed by law (i.e. a Schedule I drug) • 1975 – FDA establishes Compassionate Use Program: – Glaucoma – Multiple Sclerosis – Cancer (Cachexia, Nausea) • 1986 – Dronabinol placed into Schedule II by DEA • 2003 – Canada – 1st country in world to offer medical marijuana to patients © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Epidemiology • By 2001 more than 12 million Americans (about 5% of the population) were using marijuana on a monthly basis (average of 18.7 joints) (SAMHSA, 2002) • 39% of adult male arrestees and 26% of adult female arrestees tested positive for marijuana, as did 53% of the juvenile male and 38% of the juvenile female arrestees (DEA, DAWN, ADAM, 2003) © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP High Rates of Past Year Dependence or Abuse on Marijuana (Comparison to other Drugs Among Persons 12 or older, 2010) Source: SAMHSA, 2010 NSDUH © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP In 2009, Reports of Past Month Use of Marijuana Among 12th Graders Exceeded that of Cigarette for the First Time in the Survey’s History SOURCE: University of Michigan, 2011 Monitoring the Future Study © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Changes in Attitude Lead to Changes in Use: Marijuana Use and Perceived Risk in 12th Graders, (1975 to 2010) Past PastYear YearUse use Perceived Perceived Risk Risk 60 50 30 20 10 09 07 05 03 01 99 97 95 93 91 89 87 85 83 81 79 77 0 75 Percent Percent 40 Source: The Monitoring the Future study, the University of Michigan © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Proportion of sample dropping out between ages 16 and 18 Early Marijuana (and other drug) Use Linked to Dropping Out of School Source: Bray et al. Health Economics, 9(1), pp. 9-18, 2000. © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Cannabis Use and Later Life Outcomes are Dose Dependent % welfare dependent (ages 21-25) 400+ 300 to 399 200 to 299 % Unemployed (ages 21-25) 100 to 199 1 to 99 Mean personal income In thousands of NZ dollars at age 25 % gained university degree by age 25 Never Number of occasions using Cannabis ages 14-21 Source: Fergusson and Boden. Addiction, 103, pp. 969-976, 2008. Addiction: About 9% of cannabis users may become dependent Percent of users who Become addicted Comparative Prevalence of Dependence Among Different Drug Users * * Nonmedical Use pp.244-268 (1994) * Source: Anthony et al. Exp. Clin. Psychopharmacol. 2(3), © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP PHARMACOLOGY OF MARIJUANA THC CONCENTRATIONS • - ordinary; average of 3 percent THC • - sinsemilla; average of 7.5 percent THC, can be 24 percent • - hashish; averages 2 to 8 percent THC, can be 20 percent • - hash oil; averages 15 to 50 percent THC, but can be 70 percent+ Source: 2006 NIDA Report © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Blasting – Dabs (90%) © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Butane (Infused) Hashish Oil - BHO © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Butane cans and mind altering substance; what could go wrong? © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Metabolism of Marijuana • Massive first pass metabolism via the oral route – only 10-20% reaches systemic circulation unchanged – takes 30 – 60 minutes to achieve an effect – key side effect on CNS can be dysphoria rather than euphoria • Via the lungs – onset of action within seconds – “high” experienced with serum concentration of 3 ng/ml, produced by as little as 2-3 mg D9-THC, average “joint” contains 0.5 – 1.0 g of cannabis © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Drugs Can be Chemical Imposters (THC mimics a natural brain chemical) Brain’s Chemical Drug Anandamide THC © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP COGNITIVE EFFECTS OF MARIJUANA © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Marijuana and Cognitive Impairment Messinis et al. Neurology 2006;66:737 Use of 4 joints or more per week resulted in a decrease in mental test performance, subjects who smoked regularly for a decade or more did the worst Long-term marijuana users were impaired 70% of the time on a decision making test, compared to 55% for short-term users and 8% for non-users © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Marijuana and Cognitive Impairment Pope et al. JAMA 1996;275:521 Heavy marijuana use (daily for at least one month) is associated with residual neuropsychological effects even after a day of supervised abstinence from the drug Unknown whether this is due to residue of drug in the brain, withdrawal effects or frank neurotoxic effect of the drug © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP 5 years later… Pope et al, Arch of Gen Psych • • • • Heavy users (5000+ lifetime uses) Control group 28 day washout Cognitive differences 1 week out but these resolved by 1 month cessation © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Microcog and Habituated MJ Users Hart et al; 2001 Neuropsychopharmacology 18 MJ users – avg 24 joints/wk Within participant double-blind design Prior to testing 1 joint (0%, 1.8% or 3.9% THC) Subjective feelings of being “high” correlated with THC concentration • Premature responses were increased and time to finish • But, no sig difference in cognitive flexibility, mental calculation or reasoning. • • • • © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Cog decline childhood to mid-life (Meier et al, PNAS 2012) • • • • • • Prospective study (n-1037) Followed from birth to age 38 Neuropsych testing 13yo and 38yo Controlled for years of education 6pt decline in IQ in heavy users! Finding further suggest most of the damage is likely done in adolescence and not fully restorable © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Marijuana and Driving • • • • • • • - impairment dose related - 60% failed field sobriety test 2 1/2 hours after moderate smoking - impairment documented 3-8 hours later (Hollister, 1986) - low amounts, diminished ability to perceive and respond to changes on the road - did not make appropriate speed adjustments -induces drowsiness and impairs judgment (Mathias, 1996) - with alcohol, performance worse ) (SAMHSA/NHTSA © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP The Lower Baseline Cerebellar Metabolism in Marijuana Abusers is likely to Result in Motor Deficits Control Marijuana Abuser Cerebellum/Whole Brain 1.2 1.15 1.1 p < 0.01 1.05 1 0.95 0.9 0.85 0.8 Control Abuser Source: Volkow et al., Psychiatry Research: Neuroimaging, 67, pp. 29-38 (1996). Marijuana and Driving Sewell et al. Am J Addictions 2009;18:185-193. • Laboratory tests and driving studies show that cannabis may acutely impair several driving-related skills in a dose related fashion • Effects between individuals vary more than for alcohol because of tolerance, differences in smoking technique, and different absorptions of THC • More pronounced with highly automatic driving functions; less with complex tasks that require conscious control – opposite from that seen with alcohol © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP MJ level vs. BAL • Studies of sobriety tests suggest 5ng/mL = 0.8BAL © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Effects of Marijuana Intoxication and Pilot Performance Am J Psychiatry 1985;142:1325-1329 • Ten experienced licensed private pilots trained for 8 hours on a flight stimulator landing task • Each smoked a THC cigarette (19 mg) • 24 hours later their mean performance on the flight task showed trends toward impairment in all variables, some tasks showed significant impairment • Despite the deficits, the pilots reported no awareness of impaired performance © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP MEDICAL CONSEQUENCES OF MJ USE Marijuana use and Cancer risk • Marijuana smoke contains several of the same carcinogens and co-carcinogens as tobacco smoke • Benzo[α]pyrene, a procarcinogenic polycyclic aromatic hydrocarbon, is present in marijuana tar at higher concentrations than in tobacco tar • Marijuana smoking involves inhalation of 3 times the amount of tar as tobacco smoke • Exposure is magnified due to differences in smoking a “joint” versus cigarette © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Cancer Studies involving Marijuana • Studies are small in number and are retrospective in nature • Confounded by concomitant use of tobacco • Confounded by underreporting of marijuana use because such use is often illegal © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Cannabis use and risk of Lung Cancer Aldington et al. Eur Respir J. 2008;31:280-286 • Case-controlled study of lung cancer in adults < 55yrs of age in New Zealand • 79 cases of lung cancer and 324 controls • Risk of lung cancer increased 8% for each joint-yr (1 joint/day for one year) of cannabis smoking after adjustment for confounding variables including tobacco • Risk increased 7% for each pack-yr tobacco • “Long-term cannabis use increases risk of lung cancer in young adults” © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Head and Neck Cancers Zhang et al. Cancer Epidemiol Biomark Prev 1999;8:1071-1078. • Retrospective, case-controlled study, 173 proven cases of head and neck cancer and 176 controls matched with respect to age, sex, race, education, tobacco, alcohol use • Risk of cancer 2.6 fold greater in cannabis users than non-users • 3-fold greater increase in those < 55 yrs © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Other Cancers • Sidney et al. Cancer Causes Control 1997;8:722-728. – In a cohort study – among non-tobacco smokers, ever-marijuana smokers had increased risk for prostate cancer - RR=3.1, and cervical cancer RR=1.4 • Efird et al. J Neurooncol 2004;68:57-69 – Another cohort study found an increased risk of malignant primary adult-onset glioma for evermarijuana smokers – RR=1.9 © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Marijuana’s Impact on the Cardiovascular System • Tachycardia is a common side effect of using smoked marijuana • The risk of a heart attack is 5X higher than usual in the hour after smoking MJ • According to Harvard Researchers Psychiatric Times 27(1) - 2010 © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP MARIJUANA ABUSE AND DEPENDENCE © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Marijuana and Addiction • Approximately 10% of regular marijuana users become addicted to it • Compared with 15% for alcohol, 32% for nicotine and 26% for opiates • Newer studies to revisit this are warranted due to the much higher concentrations of THC (up to 28%) available now compared to the 1970s © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP The number of adults with substance use disorders is trending upward and expected to double by the year 2020 © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Colorado ranks 5th in the nation for adolescent marijuana use. © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP MEDICAL MARIJUANA © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP MMJ IS NOT GOING ANYWHERE BECAUSE IT IS TAXED LESS THAN RECREATIONAL MJ © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP MMJ vs FDA Approved Medications • Marijuana purchased from dispensaries has not been formally investigated for safety and efficacy • No standardizations for therapeutic dosing have been established • THC content can range in strength • Marijuana is not monitored/regulated for purity (contaminants include pesticides, molds, herbicides) • Unlike FDA approved drugs – no post marketing surveillance • MJ is not subject to liability regulations • MJ has bypassed the Colorado Prescription Drug Monitoring Program (despite being a Schedule I drug) © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP ASAM’s Observation “Pharmaceutical companies are responsible for the harms caused by contaminated or otherwise dangerous products and tobacco companies can be held accountable for harm caused by cigarettes, yet MMJ dispensaries distribute cannabis products about which very little is known including their source………Efforts are being made to stem the epidemic of prescription drug abuse, including FDA-mandated risk management plans required for prescription medications, yet cannabis distribution sites proliferate in many states, virtually without regulation.” © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP The Hippocratic Oath • First……….do no harm • The practice of medicine is a privilege……. not a right! © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP 1975 Compassionate Use – not based on any research • Glaucoma - #1 cause of blindness • 1992 – American Academy of Ophthalmology’s Committee on Drugs – no scientific verifiable evidence that the use of marijuana is safe and effective in the treatment of glaucoma • 1997 – NEI – no studies have demonstrated that marijuana can safely and effectively lower IOP any more than a variety of drugs on the market © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Glaucoma • 1999 – Institute of Medicine – although IOP can be reduced by using cannabinoids and marijuana, the effect is too short lived and requires too high doses. • There are too many side effects to recommend lifelong use in the treatment of glaucoma • Would have to smoke 10-12 “joints” per 24 hours to maintain low IOP through out the day © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Research Issues • MJ is a Schedule I drug – a barrier to conducting prospective RCTs, DB w/ placebo • Studies are short - two weeks average, ranging from a few hours to one year • Most studies conducted with oral TCH preps rather than smoked cannabis • Most studies exclude anyone with a history of major psychiatric disorder other than depression and/or history of substance abuse • Most studies done to date: – Short in length (average two weeks) – Small N (lacking power) – Retrospective in nature – Confounded by uncontrolled variables • Concomitant tobacco use • Co morbid illnesses © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP The fact that it is a botanical does not preclude scientific investigation • • • • • • Digitalis purpurea – fox glove - CHF Papaver somniferum – opium poppy Atropa belladonna – nightshade -IBS Ephedra sinica – ephedrine - hypotension Salix alba – willow tree - ASA Taxis brevifolia – Pacific Yew tree – breast cancer © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP “Rocky Mountain High” Colorado November 2000 Coloradoans passed Amendment 20 A small enterprise was envisioned Colorado Department of Public Health and Environment was tasked with implementing and administrating the Medical Marijuana Registry program March 2001 Colorado Board of Health approved rules and regulations June 2001 MMJ Registry began accepting applications for Registry Identification Cards. © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP The Flood Gates Opened • February 2009 – Obama administration indicated that Medical Marijuana prosecution would have low priority • October 2009 – Obama administration will not seek to arrest medical marijuana users and suppliers as long as they conform to state laws • Applications increased dramatically – September 2009 – 3,523 applications received/month – December 2009 – 10,585 applications received/month © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP The Expansion of Amendment 20 Storefront “Medical” Marijuana dispensaries sprouted like weeds! (Pun intended) © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP “There are more medical marijuana dispensaries in Denver than Starbucks and liquor stores combined” The Denver Post © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP September 30, 2009 • 19,691 new patient applications received • 17,356 patients with valid ID cards • 73% male, average age 40, 8 minors <18 • 57% in the Denver/metro area • 67% have designated primary care-giver • Over 800 different physicians have signed for patients in Colorado June 2010 • 99,559 new patient applications received • 88,900 patients with valid ID cards • 71% male, average age 39, 24 minors <18 • 58% in Denver/metro area • 66% have designated primary care-giver • Over 1,100 different physicians have signed for patients in Colorado © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Rules and Regulations • “Patient will be deemed to have established an affirmative defense to such allegation” (possession of marijuana) where: • Patient was previously diagnosed by a physician as having a debilitating medical condition • Patient was advised by his or her physician, in the context of a bona fide physicianpatient relationship, that the patient might benefit from the medical use of marijuana in connection with a debilitating medical condition © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP The Medical Practice Act • Physicians should maintain adequate malpractice coverage – let the buyer beware! • Physicians should be able to evaluate for SUDs • Physicians should engage in continuing education – No certification available for MMJ practice! • Physicians should only practice within their scope of expertise • A retired radiologist evaluating pain conditions? • A psychiatrist recommending MMJ for a pregnant female with Braxton Hicks contractions? • An occupational medicine physician making MMJ recommendations for HIV/AIDs patients? © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP SB 109 - 2010 • Defines a bona fide relationship (MD-Patient) • Physician must have unrestricted medical and DEA licensure • Addresses physician conflict of interest – physician can not be employed by the dispensary • Allows CMB to examine care of providers • Two physicians need to independently examine those < 21 years old. © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Physicians Recommending Medical Marijuana • Should get a thorough history - medically, psychiatrically and substance abuse – keep a chart and have a patient/physician relationship • Should receive no pecuniary remuneration from caregivers or dispensaries • Will need to attempt to decide what level of marijuana use is most appropriate • Will need to recommend patients not drive etc. when under the influence • Should warn patients to avoid exposing children and adolescents to marijuana smoke • Will need to follow patients closely for side effects and unintended consequences • Obtain informed consent © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Legalization of Recreational MJ • January 1, 2014 – Recreation sales started • Definitely popular but hard to assess difference in use from illicit to legal recreational • Still federally illegal • VA, University, Denver Health have zero tolerance policies • Any institution accepting federal money may be at risk of losing that federal support © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP How will CPHP Evaluate and Monitor? © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Assess for Abuse and Dependence • • • • C – CUT Down? A – Do people ANNOY you? G – Do you feel GUILTY? E – Have you needed an EYE opener? © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP DSM V Criteria • Taking the substance in larger amounts or for longer than the you meant to • Wanting to cut down or stop using the substance but not managing to • Spending a lot of time getting, using, or recovering from use of the substance • Cravings and urges to use the substance • Not managing to do what you should at work, home or school, because of substance use © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP DSM V Criteria (cont) • Continuing to use, even when it causes problems in relationships • Giving up important social, occupational or recreational activities because of substance use • Using substances again and again, even when it puts the you in danger • Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP DSM V (cont) • Needing more of the substance to get the effect you want (tolerance) • Development of withdrawal symptoms, which can be relieved by taking more of the substance © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Urine Monitoring © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP U/A’s are for SCREENING • Show whether the client has used cannabinoids within the past 1-90 days • Does provide a quantitative level but clinical significance is not direct • Can monitor to show use has stopped – values drift to zero • Complicated by the fact that cannabinoids are stored in the fat © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP U/A’s (cont) • Intitally immunoassay • Confirmed by gas chromatography-mass spectrometry • Tests for THC-COOH © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Blood Monitoring • Assesses for THC in the blood stream • Directly related to the amount of active rather than stored psychoactive substance (THC) • Detectable blood levels up to 2 weeks after use in heavy users – leeching • DUI in Colorado – 5 nanograms/ml © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Other Monitoring THC • Saliva • Hair © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Complete Eval • • • • • Workplace and personal collaterals Personal interview Tissue testing Cognitive screening/testing Assessment for comorbid conditions © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Physicians Using MMJ • The Colorado Physician Health Program Policy – Physicians suffering from a debilitating condition requiring “treatment” with marijuana will be considered unsafe to practice medicine with reasonable skill and safety. – This is due to significant cognitive impairment associated with the use of MJ – This is also due to the fact that it is virtually impossible to establish a stable dose/serum level due to variable concentrations of THC – The CMB/DORA are also examining this issue – No case law exists regarding this issue © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Physicians Using MJ • Assess for substance disorder • Counsel regarding risks – legal, occupational, personal and health • Advise client to stop using • Tissue testing – often ongoing © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP Contacting CPHP Phone • 303-860-0122 or 800-927-0122 Office Hours: • 8:30 a.m.- 4:30 p.m. • Monday – Friday After Hours Clinical Emergencies: • Pager: 303-916-8837 For additional information visit the CPHP website: • www.CPHP.org © Colorado Physician Health Program 2015 All Rights Reserved Please do not reproduce or use without written permission of CPHP