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Marijuana:
Science, Public Health, & Policy
H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM
Director
Center for Substance Abuse Treatment
Substance Abuse Mental Health Services Administration
U.S. Department of Health & Human Services
ASTHO Winter Member Meeting
Marijuana & Public Health
Chapel Hill, NC December 4, 2013
President Barack Obama
“I do believe that a
comprehensive approach -not just law enforcement,
but education and
prevention and treatment - that's what we have to
do. And we’re going to
stay at it because the lives
of our children and the
future of our nations
depend on it.”
May 3, 2013
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Marijuana: Medical Uses? Health Risks?
4
Topics
Snapshots
Clinical Aspects &
Neurobiology
Epidemiology
PH & Public Policy
5
Topics
Snapshots
Clinical Aspects &
Neurobiology
Epidemiology
PH & Public Policy
6
Snapshot: Historical Perspective
Cannabis has been used medicinally & recreationally for
centuries. Early medicinal uses included amelioration of
pain.
Therapeutic use in Western medicine was increasingly
common in the 19th century; and by the early 20th century
pharmaceutical companies were routinely marketing
cannabis products.
However, shifting societal and legal sanctions emerged
associated with its psychotropic and addictive effects, such
that marijuana was:
• Removed from U.S. Pharmacopoeia in 1942; and
• Designated as a Schedule 1 drug by Congress in 1970.
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Snapshot: Historical Perspective (cont.)
In 1985, FDA approved dronabinol and
nabilone.
Increasing usage of marijuana in medical
practice has been supported by popular
votes/legislative acts at the State
level; and marijuana was legalized for
recreational use in 2 states.
8
Snapshot: Current Public Policies in the U.S.
21* states and Washington, D.C. have legal statutes
regulating medical marijuana use (some w/various
constraints): Alaska, Arizona, California, Colorado,
Connecticut, Delaware, Hawaii, Illinois, Maine,
Maryland, Massachusetts, Michigan, Montana,
Nevada, New Hampshire, New Jersey, New Mexico,
Oregon, Rhode Island, Vermont, Washington.
WA & CO have legalized recreational use of
marijuana.
*As of September 2013
http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx
http://www.whitehouse.gov/ondcp/state-laws-related-to-marijuana
http://www.justice.gov/opa/pr/2013/August/13-opa-974.html
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Snapshot: Current Public Policies in the U.S.
(cont.)
Marijuana remains a Schedule 1 controlled
substance and is illegal under federal law:
 In October 2009, the Department of Justice
sent a memo to federal prosecutors
encouraging them not to prosecute people
who distribute marijuana for medical purposes
in accordance with state law.
 In August 2013, DOJ issued a memorandum
providing guidance regarding marijuana
enforcement to U.S. Attorneys.
10
Snapshot: Private Opinions in the U.S.
 Recent Gallup
poll reports that 58% of Americans now
support legalization.
 Americans 65 and older are the only age group that still
opposes legalizing marijuana, although support among this
group has jumped 14 percentage points since 2011.
October 2013
11
Snapshot: Medical Marijuana Uses in the U.S.
ALS
Chrohn’s Disease
Alzheimer’s Disease
Chronic Pain
Anorexia
Cirrhosis,
Anxiety
decompensated
Fibromyalgia
Glaucoma
Arthritis
Cachexia
Chemotherapy Side
Effects
12
Snapshot: Medical Marijuana Uses in the U.S.
(cont.)
Hepatitis C &
HIV/AIDS
Migraine
Headaches
Multiple Sclerosis
Muscle Spasms,
severe
Muscular Dystrophy
Nausea & vomiting
Pancreatitis, severe
Parkinson’s Disease
TBI & PTSD
Seizure Disorders
(e.g., epilepsy)
Spinal Cord Injury
And more…
13
Snapshot: Health Risks
Distorted perceptions & impaired coordination
• Drugged driving
Difficulty with thinking and problem solving
 Disrupted learning and memory (long term)
Alterations in neurobiological development : Use
during pregnancy is associated with increased risk
of neurobehavioral problems in babies.
Respiratory issues
Potential immune dysfunction
Psychotic episodes
Dependency and addiction
14
Snapshot: Health Risks (cont.)
Heavy marijuana users often report lower life
satisfaction, poorer mental and physical health,
relationship problems, and less academic and career
success compared to their peers who came from
similar backgrounds.
Several studies also associate workers' marijuana
smoking with increased absences, tardiness,
accidents, workers' compensation claims, and job
turnover.
And more…
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Topics
Snapshots
Clinical Aspects &
Neurobiology
Epidemiology
PH & Public Policy
16
Addiction is like other chronic diseases…
It changes biology
It is preventable
It is treatable
Diabetes Treatment Strategies: Lifestyle + Medication
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Endogenous Endocannabinoid
Receptors & Signaling
http://www.upf.edu/cexs/actualitat/CB2receptors.html
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THC is Similar to Endogenous
Endocannabinoids
Adapted from NIDA Drug Abuse & Addiciton
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Slide courtesy of NIDA
20
Slide courtesy of NIDA
21
Slide courtesy of NIDA
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Neurobiological Sites of Interest
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Natural Cannabinoid Components Include:
 THC: Abundant;
main active ingredient in native plants &
cultivars; psychotropic effects.
 Cannabidiol : Also abundant; no detectable psychotropic
effects. Has potential in epilepsy.
 Cannabigerol: Non-Psychoactive, may relieve intraocular
pressure associated with glaucoma.
 Cannabinol: Weakly psychoactive, used as an
immunosuppressant, experimentally.
 Tetrahydrocannabivarin: a homologue of THC that is a
CB receptor antagonist, blocking THC effects.
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Marijuana: Routes of Administration


Most often smoked, but can be vaporized
– onset of effects within several minutes
– effects may last approximately 2 hours
May be taken orally
– onset of effects in 30+ minutes
– effects may last 3-5 hours
– variable absorption of THC in digestive
system
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Time Course of Effects of Marijuana
 Onset
 Coming Up
 Plateau
 Coming Down
 After Effects
0-10 minutes
5-10 minutes
15-30 minutes
45-60 minutes
30-60 minutes
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Physiological Effects of Marijuana include:
Positive Mood
Increased appetite
Relaxation
Psychomotor
slowness
awareness of senses Mouth dryness
Nausea
Psychological
Dependence
Coughing, asthma,
upper respiratory
problems
Increased
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Marijuana Overdose
Racing heart, agitation, tenseness
Mild to severe anxiety
Panic attacks at very high doses (usually
oral) or in sensitive users
Headaches
Dizziness, confusion
Paranoia (generally only in inexperienced
users)
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Synthetic Marijuana: K2 or Spice
JWH-018
JWH-073
HU-210
Cannabicyclohexanol
Other analogues
Psychoactive effects
similar to marijuana
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Synthetic Marijuana: K2 or Spice (cont.)
Adverse Effects
•
•
•
•
•
Psychosis
Rapid heart rate
Vomiting
Agitation
Confusion
30
Topics
Snapshots
Clinical Aspects &
Neurobiology
Epidemiology
PH & Public Policy
31
U.S. Marijuana Use in 2012
Most commonly used illicit drug: 18.9 million past
month users. Between 2007 and 2012, the rate of
current use increased from 5.8 to 7.3%.
• Daily or almost daily use of marijuana increased
from 5.1 million persons in 2007 to 7.6 million
persons in 2012.
In comparison, in 2012, 136 million individuals
reported past month alcohol use: 60 million
reported binge drinking & 17 million reported
heavy use.
SAMHSA NSDUH 2013
32
Past Month Binge Drinking and Marijuana Use
among Youths Aged 12-17, by Perceptions of Risk:
2012
Percent Using in Past Month
Perceive “Great Risk”
20
Perceive “Moderate,”
“Slight,” or “No Risk”
15
Past Month Binge Drinking
9.6
9.5
10
5
Past Month Marijuana Use
4.0
1.0
0
Risk of Having Five or More Drinks
Once or Twice a Week
SAMHSA NSDUH 2013
Risk of Smoking Marijuana
Once a Month
33
33
Specific Illicit Drug Dependence or Abuse in the
Past Year among Persons >12 years old
2012
Marijuana
4,304
Pain Relievers
2,056
Cocaine
1,119
Tranquilizers
629
Stimulants
535
Heroin
467
Hallucinogens
331
Inhalants
164
Sedatives
135
0
SAMHSA NSDUH 2013
1,000
2,000
3,000
Numbers in Thousands
4,000
5,000
34
Past Month Use of Selected Illicit Drugs among
Youths Aged 12-17: 2002-2012
Percent Using in Past Month
14
12
11.6+
11.2+
10.6+
10
8.2+
7.9+
8
9.9
9.8
9.6
10.1
6.7
6.7
3.3+
3.3+
3.3+
10.1
9.3
7.6
6.8
10.1
6.7
7.4
7.4
7.9+
9.5
Illicit Drugs
7.2
Marijuana
6
4.0+
4.0+
4
2
0
1.2+
1.3+
1.0+
1.0+
3.6+
1.2+
0.8
1.2+
0.8
1.3+
0.7
2.9
3.1
3.0
2.8
2.8
1.2+
1.1+
1.0
1.1+
0.9
0.8
0.7
1.0+
0.9+
0.9
0.6
0.9+
Psychotherapeutics
Inhalants
Hallucinogens
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
+ Difference between this estimate and the 2012 estimate is statistically significant at the .05 level.
SAMHSA NSDUH 2013
35
Past Month Marijuana Use among Youths Aged
12-17, by Gender: 2002-2012
Percent Using in Past Month
10
9.1+
9.0+
8.6+
8.4+
8.1
7.5
8
7.5
6.9
7.2
7.2
6
8.4
7.5
7.3
7.1
6.2
6.5
5.8+
6.1+
6.3
6.4
2008
2009
2010
6.7
7.0
Male
Female
4
2
0
2002
2003
2004
2005
2006
2007
2011
2012
+ Difference between this estimate and the 2012 estimate is statistically significant at the .05 level.
SAMHSA NSDUH 2013
36
Past Month Illicit Drug, Marijuana, and Pain Reliever
Use among Adults Aged 50-64: 2002-2012
Percent Using in Past Month
7
6.0
6
5.4
4.9
5
4.2+
3.7+
4
2.7+
2.6+
2.5+
2.5+
1
1.7+
4.3
Marijuana
3.4
2.4+
1.7+
1.3
0.7
4.0
3.8
3.1
2.1+
2
4.2+
3.8+
3.1+
3
Illicit
Drugs
5.3
0.9
0.5+
0.5+
0.9
1.2
0.7
0.9
0.9
1.1
Pain
Relievers
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
+ Difference between this estimate and the 2012 estimate is statistically significant at the .05 level.
SAMHSA NSDUH 2013
37
Past Year Marijuana among Persons >40 by Birth
Cohort among Persons Born between 1943-1962
Percent Using in Past Year
10
9.4
9.6
8
Percent Using in Past Year
8.3
8.0
7.9
45-49
40-44
9.1
8.0
50-54
55-59
2
7.9
8.0
8.3
1958-62
1953-57
7.4
6.7
6
60-64
4.5+
2.4+
8
4.4
4.3+
4
9.6
7.4
6.7
6
10
4.3
4.5
4.4
1948-52
4
1943-47
1.9+
2.8
2
1.6+
1.6
0
1.9
0
2002
2007
2012
Age Group
2002
2007
2012
Birth Cohort
Difference between this estimate and the 2012 estimate is statistically significant at the .05 level.
Note: The 2012 estimate of the 1943-1947 birth cohort estimate is based on data from respondents
aged 65 to 69.
+
SAMHSA NSDUH 2013
38
Daily or Almost Daily Marijuana Use in the Past Year
and Past Month among Persons Aged >12
Numbers in Millions
8
6.9
7
4
Used Marijuana on
20 or More Days in
the Past Month
5.4
Used Marijuana on
300 or More Days
in the Past Year
7.1
6.2+
6
5
7.6
4.8+
3.1+
4.9+
3.1+
4.9+
3.2+
5.1+
5.1+
5.1+
5.5+
4.6+
3.4+
3.6+
3.9+
5.0
4.1+
3.1+
3
2
1
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
+ Difference between this estimate and the 2012 estimate is statistically significant at the .05 level.
SAMHSA NSDUH 2013
39
Past Year Specific Illicit Drug Initiates among
Persons Aged >12: 2002-2012
Numbers in Thousands
3,000
2,617
2,456+
2,500
2,320+
2,000
2,196
1,184
1,000
500
1,032+
2,398
Marijuana
2,193+ 2,155+ 2,159 2,224
2,114
1,973+ 2,142+
1,500
1,206+
2,379 2,439
2,422+
2,061+
642+
607+
2,013
1,888 1,880
1,427
1,286
1,180
1,071+
986+ 998+
+
+
2,089+ 2,189 2,193
1,118+
1,231
1,134+
977+ 906+ 892
863
777
872+
724
615+
1,234 1,244 1,204
1,118+
949 922
642
623
670
869
639
Pain Relievers
Tranquilizers
Ecstasy
Cocaine
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
SAMHSA NSDUH 2013
Difference between this estimate and the 2012 estimate is statistically significant at the .05 level. 40
+
Past Month Marijuana Use among Youths in
MTF, by Gender: 2002-2012
Percent Using in Past Month
16
14.4
14
14.7
13.8
13.4
13.1
11.9+
12.2
11.2+
12
10
14.7
11.0+
Male
10.9+
11.8+
Female
10.7
8
10.3
9.6
10.1
9.3
8.7+
8.6+
10.1
10.2
9.3
6
4
2
0
2002 2003 2004 2005MTF2006
2007 2008 2009 2010 2011 2012
= Monitoring the Future.
SAMHSA NSDUH 2013
+ Difference between this estimate and the 2012 estimate is statistically significant at the .05
level.
Note: Estimates shown are combined 8th and 10th grades.
41
First Specific Drug Associated with Initiation of Illicit Drug
Use among Past Year Illicit Drug Initiates >12
2012
Pain Relievers (17.0%)
Inhalants (6.3%)
Tranquilizers (4.1%)
Marijuana (65.6%)
Stimulants (3.6%)
Hallucinogens
(2.0%)
Sedatives (1.3%)
Cocaine (0.1%)
Heroin (0.1%)
2.9 Million Initiates of Illicit Drugs
Note: The percentages do not add to 100 percent due to rounding or because a small number of
respondents initiated multiple drugs on the same day. The first specific drug refers to the one that
was used on the occasion of first-time use of any illicit drug.
SAMHSA NSDUH 2013 42
Past Year Initiates of Specific Illicit Drugs
among Persons > 12 years old
Numbers in Thousands
2012
3,000
2,500
2,000
2,398
1,880
1,427
1,500
869
1,000
676
639
584
500
421
166
156
90
0
Pain Relievers
Marijuana
Ecstasy
Tranquilizers
Cocaine
Stimulants
LSD
Inhalants
Heroin
Sedatives
PCP
Note: Numbers refer to persons who used a specific drug for the first time in the past year, regardless of
whether initiation of other drug use occurred prior to the past year.
SAMHSA NSDUH 2013
43
Mean Age at First Use for Specific Illicit Drugs
among Past Year Initiates Aged 12 to 49
Age in Years
2012
30
26.2
25
22.1
20
16.6
16.9
17.9
19.0
20.0
22.3
23.0
23.6
20.3
15
10
5
0
Inhalants
LSD
Ecstasy
Pain Relievers Tranquilizers
PCP
Marijuana
Cocaine
Stimulants
Heroin
Sedatives
SAMHSA NSDUH 2013
44
Substances for Which Most Recent Treatment Was Received
in the Past Year among Persons > 12 years old
2012
Alcohol
2,395
Pain Relievers
973
Marijuana
957
Cocaine
658
Tranquilizers
458
Heroin
450
Hallucinogens
366
Stimulants
357
0
500
1,000
1,500
2,000
2,500
3,000
Numbers in Thousands
SAMHSA NSDUH 2013
45
Past Month Marijuana Use among Youths in
NSDUH and MTF: 2002-2012
Percent Using in Past Month
14 13.1+
12.3
11.2 10.9
12
12.4
11.2
10.4+
10.0+
10
8.2+
7.9+
8
6.7
6.7
11.8
9.8+
7.6
6.8
12.4
6.7
7.4
7.4
7.9+
7.2
6
MTF 8th and
10th Grades
Combined
NSDUH
12 to 17
4
2
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
SAMHSA NSDUH 2013
MTF = Monitoring the Future; NSDUH = National Survey on Drug Use and Health.
+ Difference between this estimate and the 2012 estimate is statistically significant at the .05
level.
46
Topics
Snapshots
Clinical Aspects &
Neurobiology
Epidemiology
PH & Public Policy
47
Public Health & Public Policy
Scientifically-proven
medical uses
PH & Safety
Concerns
48
Scientifically-Proven Medical Uses
Despite the IOM’s recommendation for expanded
scientific investigation of cannabiniods in 1999 –
based on accumulated data suggesting a variety of
indications for its use – a robust and systematic
science has not emerged.
• Study constraints include lack of methodological
standardization; heterogeneity of cannabiniods
evaluated; and small study sizes.
Investigators have cited the Schedule 1
classification as one research constraint.
49
Scientifically-Proven Medical Uses
It is critical that we develop research policies and
guidelines that will enable the science to mature so
that we can definitively identify effective, evidencebased medical uses for cannabinoids as well as
identify and mitigate their adverse side effects.
It is equally important that we adopt evidence-
based treatments that reflect the most current
scientific data.
50
Public Health & Safety Concerns include:
Adverse health effects
Medical marijuana quality control
Drugged driving
Accidental ingestion
Vulnerable populations
51
Adverse Health Effects
Concerns include:
• Detrimental effects on: metabolism; mental
health; immunology; pulmonary and
cardiovascular function; neurodevelopment;
etc.
• Smoking (e.g., carcinogens, second-hand
smoke)
• Gateway drug
• Synthetics
• Dependence, misuse, abuse, and addiction
52
Medical Marijuana Quality Control
Medical marijuana is a highly heterogeneous
product:
• Cannabis contains many compounds including
over 60 known cannabinoids.
• Heterogeneity is complex and multidimensional:
intrinsic composition of active and inactive
components varies geographically; harvesting &
packaging practices vary.
• Some State legislation directly addresses quality
control & regulatory compliance issues (e.g., AZ).
53
Drugged Driving
Known public health issue, but currently difficult to
assess, track, and address accurately & effectively.
• Testing technology sensitivity & accuracy
• Probable cause and other reasons for delayed
testing
• Cannabinoid metabolism and delayed testing
54
Accidental Ingestion
Increasingly attractive packaging of
marijuana in edible foodstuffs, often
highly attractive to youth.
Especially a concern with toddlers,
children, and adolescents, e.g.,
• A 2013 JAMA report revealed a
significant increase in accidental
pediatric ingestions in CO following the
2009 DOJ change re: federal
prosecution for medical marijuana.
JAMA Pediatr. 2013;167(7):630-633
55
Accidental Ingestion (cont.)
Importance of public health education regarding
safe storage and use to prevent accidental
ingestion; and rapid response to possible ingestion.
Safe Storage & Use
Safe Storage & Use
Safe Storage & Use
56
Vulnerable Populations
Toddlers and children (e.g., accidental ingestion).
Teens and young adults (e.g., neurodevelopment;
gateway drug).
Individuals with diagnosed mental health issues or
at high risk for MH disorders (e.g., schizophrenia).
Elderly: potential amplification of physiological
effects (e.g., increased cardiovascular stress).
57
Testing Grounds: State Policies and
Procedures for Medical & Recreational Use
 Regulatory & quality control measures.
Provisions related to public health and safety.
 Assessments of short & long-term
consequences of legalization.
58
Closing Thoughts…
59
Behavioral Health Coordinating Council:
Subcommittee on Marijuana
Newly established trans-federal subcommittee.
Charge:
• Create comprehensive inventory of current
federal activities related to medicinal &
recreational use.
• Identify emerging issues especially those related
to state:federal statutes.
• Identify gaps & opportunities.
• Develop roadmap to address needs.
60
State Input & Recommendations
 SAMHSA, & all federal agencies, depend on State
input & recommendations to inform policies,
programs, and services: We’re listening...
61
THANK YOU,
[email protected]
62
August 29, 2013 DOJ Memo Regarding
Marijuana Enforcement: Preventing
 The Distribution
of Marijuana to minors
 Revenue from the sale of Marijuana from going to
criminal enterprises, gangs, and cartels
 Diversion of marijuana from states where it is legal
under state law in some form to other states
 State-Authorized activity from being used as a cover
or pretext for the trafficking of other illegal drugs or
other illegal activity
http://www.justice.gov/iso/opa/resources/3052013829132756857467.pdf
63
August 29, 2013 DOJ Memo Regarding
Marijuana Enforcement: Preventing
 Violence and the use of firearms in the cultivation
and distribution of marijuana
 Drugged Driving and the exacerbation of other
adverse public health consequences associated with
marijuana use
 Growing of marijuana on public lands and the
attendant public safety and environmental dangers
posed by marijuana production on public lands
 Marijuana possession or use on federal property
http://www.justice.gov/iso/opa/resources/3052013829132756857467.pdf
64
Can “legalized” Marijuana Stay Within
Colorado’s Borders
 Colorado is Bordered by 7 States
• Arizona
• Kansas
WY
• Nebraska
UT CO*
• New Mexico
AZ*
• Oklahoma
NM*
• Utah
• Wyoming
 And Texas “ain’t too far away”
NE
KS
OK
TX
* Medical Marijuana States
65