Manual Should Marijuana Be Legalized as a Medicine?: No, Its Dangerous and Addictive

Pot is dangerous, not funny -- a doctor tells us why

Contents:

Blurred Boundaries: The Therapeutics and Politics of Medical Marijuana

Marijuana continues to have the reputation among the general public as being benign, non—habit-forming, and incapable of inducing true addiction. Experimentation with marijuana has become an adolescent rite of passage, with the prevalence of use peaking in the late teens and early 20s, then decreasing significantly as youths settle into the adult business of establishing careers and families. Unlike cocaine dependence, which develops explosively after first use, marijuana dependence comes on insidiously.

The risk for new-onset dependence is essentially zero after the age of 25 years, whereas cocaine dependence continues to accrue until the age of 45 years. Likewise, the average age at first alcohol use is the same as for marijuana, but alcohol users will keep on making the transition from social use to dependence for decades after first use. One in 11 users—1 in 6 for those starting in their early teens—is hardly an inconsequential percentage, however.

The disputed amotivational syndrome of heavy use resembles the negative symptom complex of schizophrenia. Using hospitalization as a proxy for serious psychiatric illness, Schubart et al 55 identified a dose-response relationship, with incidental users having 1.

More specifically and more ominously, those with a psychotic predisposition may respond to marijuana with more marked perceptual changes into which they have little insight, accompanied by elevations in hostility and paranoia. During a year follow-up period, the more cannabis individuals had used in adolescence, the more likely they were to develop schizophrenia, with those who had used cannabis on more than 50 occasions nearly 7 times more likely to manifest the disease than those who had never used cannabis.

Will legalization increase addiction?

This association between cannabis and psychosis notwithstanding, the question of whether cannabis causes psychosis remains unresolved, even as evidence mounts that its use worsens the course of psychotic illness. In an Australian cohort, Degenhardt et al 61 tested 4 hypotheses regarding the association between cannabis use and schizophrenia, including that cannabis use 1 may cause schizophrenia in some patients, 2 may precipitate psychosis in vulnerable individuals, 3 may exacerbate symptoms of schizophrenia, or 4 may be more likely in individuals with schizophrenia.

They noted that during the last 3 decades of the 20th century, cannabis use had significantly increased in Australia without a corresponding increase in schizophrenia prevalence, an observation that gravitated against a simple cause-and-effect relationship between the two. However, they also found that cannabis use precipitated the onset of the disease in the vulnerable and exacerbated the course of the illness in those who already had it. In a meta-analysis pooling 35 longitudinal, population-based studies, Moore et al 59 found an elevated odds ratio OR of 1. They also demonstrated a dose-response effect, with the OR increasing to 2.

A Dutch study 62 shows how this association plays out in actual numbers. For 3 years, van Os et al followed up psychosis-free individuals, of whom used cannabis. During the observation period, 8 of the 2.

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Of the nonusers, 30 0. The risk was small in both groups but impressively elevated in users vs nonusers. For individuals already diagnosed as having a schizophrenic spectrum disorder, ongoing cannabis use predicts a rockier course. The longer the period of cannabis use, the higher the risk of relapse. The association was bidirectional: Moreover, increasing evidence implicates a vulnerable developmental period—peripuberty—when cannabis use is more likely to cause trouble.

Whereas adult users appear comparatively immune to cannabis-induced behavioral and brain morphologic changes, the same cannot be said of individuals initiating use during their early teens, when effects are both more severe and more long-lasting than in adults. Furthermore, in keeping with the epigenetic hypothesis of Henquet et al, carriers of a specific polymorphism of the catechol oxidase methyltransferase gene COMT valine allele are especially likely to develop psychotic symptoms or full-blown schizophrenia, an effect attenuated or eliminated if cannabis use is delayed until after brain maturity.

Short of full-blown schizophrenia, many other persistent effects have been observed in heavy defined as weekly or more often pubertal users, including working memory deficits, reduced attention, reduced processing speed, anhedonia, abnormal social behavior, susceptibility to mood and anxiety disorders, and greater likelihood of dependence. A study from 6 European countries comparing the health and legal implications of cannabis initiation before the age of 16 years found it associated with higher levels of abuse not only of cannabis but also of other illicit drugs, higher rates of both physical injuries and psychosomatic symptoms, academic failure, and delinquency.

Moderate use after the age of 18 years was not associated with increased rates of mental illness, concluded Schubart et al. Cannabis use may simply be a marker for deviant behavior, with the tendency to advance to harder drugs the result of their simply being available. Schneider 66 reminds us that most adolescents who use cannabis do not experience harmful outcomes. Nonetheless, reducing or delaying cannabis use could postpone or even prevent 1 in 6 cases of new-onset psychosis. Adolescent cannabis use is also associated with depressive and anxiety disorders that emerge later in life.

Although the presence of current depression and anxiety did not predict cannabis use, gravitating against a self-medication hypothesis, Patton et al 50 observed a dose-related risk of eventual depression and anxiety. Weekly use was associated with nearly double the risk OR, 1.

Medical cannabis

The authors were reluctant to attribute the increased risk to cannabis alone, observing that social consequences of frequent use, including educational failure, unemployment, and crime, could account—at least in part—for the psychopathology. Even as Patton et al 50 did not find that depression or anxiety drove teens to smoke marijuana, some recreational users appear to use it in a manner suggestive of antidepressant or anxiolytic medications.

Teens using cannabis to decrease anxiety frequently meet criteria for anxiety disorders before their cannabis dependence begins. They titrated their intake, often using several times a day and beginning and ending the day with smoking, and frequently using alone. The paradox of marijuana both inducing and relieving anxiety is reconciled by understanding that effects on anxiety levels are dose dependent. Individuals with anxiety disorders who use marijuana, alcohol, or other drugs in this way are up to 5 times more likely to develop substance dependence than anxious individuals who do not self-medicate.

In sum, marijuana offers the recreational substance abuse version of caveat emptor. Although cannabis is an enjoyable diversion for most, it is linked to self-medication, addiction, or mental illness in a few, particularly those who start young. Those skeptical of botanical cannabis do not argue that it is necessarily bad. Rather they contend that the benefits of cannabis—particularly when smoked—remain scientifically unproven, not only on its own merits but also compared with other available treatments.

They contend that the usual standards for evaluating pharmacotherapies have been largely side-stepped. Critics of botanical cannabis are less sanguine than the American College of Physicians. They assert that garden-grown cannabis is neither pure nor refined, standards Americans have come to expect in their medications. So what is already known about the therapeutic potential of cannabis and where might research go were there no proscriptions against studying the plant? Although cannabis has been part of the world's herbal pharmacopoeia for millennia, next to nothing about its mechanisms of action was known until the last half century.

As with all folk medicines, practitioners established the therapeutic benefits and risks of their plant-derived remedies through careful observation. In this respect, the cannabis story mirrors that of the Oriental poppy, Papaver somniferum , the source of opium, which was appreciated both as a renowned painkiller and a tantalizing drug of abuse for thousands of years before its active agent, morphine, was identified in modern times along with opioid receptors, endogenous opioids, and an internal opioid system. Modern scientific study of cannabis commenced with the isolation and structural elucidation of THC in The most common G protein—coupled receptors in the central nervous system CB1 receptors concentrate in specific brain areas that govern pleasure, movement, learning and memory, and pain, including the frontal cortex, basal ganglia, hippocampus, and cerebellum.

Exogenous plant-derived THC is a sledgehammer compared with anandamide's delicate chisel, the former causing marked disruption of neuronal signaling and circuit dynamics in the finely tuned endogenous system 56,88 and inducing addiction in the susceptible. CB1 receptors modulate the activity of dopaminergic neurons that project to the prefrontal cortex from the brainstem reward center, thereby factoring in susceptible individuals into cannabis abuse and dependence.

Rising Potency

As a physician, my doctoring knowledge tells me that making marijuana legally available is a bad idea, except perhaps for certain medical conditions. Between 9 and 30 percent of users may develop some degree of this disorder. Be part of The Conversation. Wheeler 11 October Science Highlight Stopping marijuana use improves memory. For example, when rodents are repeatedly exposed to THC when they're young, they later show an enhanced response to other addictive substances—such as morphine or nicotine—in the areas of the brain that control reward, and they're more likely to show addiction-like behaviors.

In the rapidly growing field of endocannabinoid pharmacology, the potential for designing pharmacologic interventions is as broad as the endocannabinoid system's bodily distribution. More recently, researchers have stated that the power of new pharmacologic products will obviate the need for botanical cannabis. Examples of specific strategies include using cannabinoid receptor agonists to increase gut motility in conditions such as ileus and using antagonists to decrease motility in inflammatory bowel disease.

The relationship between cannabis use and psychotic illness remains unsettled, even as hypothesized dysregulation of the endocannabinoid system in a number of psychiatric disorders has implications for developing treatments capable of manipulating relevant brain regions. Regardless, each shows promise as a novel agent for treating psychotic disorders. To date, only 4 pharmaceutical cannabinoids have been marketed. The first and second dronabinol and nabilone have been available in the United States since and a third one nabiximols in Canada since Available in Europe since , the FDA failed to approve its release in the United States over concerns it can induce depression and suicidal behavior.

With similar indications, nabilone Cesamet is a synthetic analog of THC. Dronabinol's therapeutic effect unfolds gradually for 30 to 60 minutes and lasts up to 6 hours. At 60 to 90 minutes, nabilone takes longer to act but persists as long as 12 hours. Even though the antiemetic efficacy of both dronabinol and nabilone equals or exceeds that of phenothiazines, their use is limited by the narrow gap between effective therapeutic doses and doses that cause such adverse effects as euphoria, dysphoria, cognitive clouding, drowsiness, and dizziness that are particularly problematic in naive users, whether smoking marijuana or taking oral pharmaceuticals.

Interest in these agents has waned for arresting nausea and emesis with the advent of 5-HT 3 receptor antagonists like ondansetron that have greater potency, minimal psychotropic effects, and intravenous capabilities. Playing the devil's advocate, Ware and St Arnaud-Trempe 99 question why dronabinol or nabilone would ever be preferable to inhaled THC, given their adverse effects and delayed onset of action and botanical cannabis' lower cost and readier availability.

Although the delayed onset is problematic when treating acute nausea, these pharmaceutical cannabinoids may have a therapeutic edge over other oral agents in managing delayed nausea and vomiting or preventing it altogether. For an indication such as emesis, dronabinol or nabilone is best reserved for cases resistant to standard therapies. Cannabidiol, the other important component found in botanical cannabis, is distinguished by its multiple peripheral mechanisms, including interaction with vanilloid receptors, modulation of adenosine signaling, interference with proinflammatory cytokines, and both immunosuppressant and antioxidant activity.

In Canada, an additional agent not yet available in the United States but currently in phase 3 trials more closely approximates the beneficial delivery method of smoked cannabis absent some of the risks, including tolerance, withdrawal, and high abuse potential. Rapid uptake notwithstanding, a clinically significant difference between botanical cannabis and nabiximols is the latter's reduced bioavailability. With peak plasma THC concentrations nearly 20 times lower than with smoked cannabis, nabiximols flattens the steep-slope pharmacokinetic profile found in botanical cannabis, with corresponding reductions in adverse psychotropic effects.

For nearly a century, cannabis was a part of the American pharmacopeia, 83 but by the s, its days as a legitimate treatment were numbered. Not until , however, citing marijuana's potential for abuse and addiction, did the US Congress finally declare it to have no medical value, rendering illegal a plant that had been used medicinally throughout the world for thousands of years. It declared cannabis illegal in the absence of such evidence. In challenging the one-sided devaluation of cannabis as a dangerous substance, Cohen 35 emphasizes that medical decision making is not based on risk alone.

Opioids, including morphine, are derived from the sap of P somniferum, the opium poppy.

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Widely abused in forms ranging from intravenous heroin to oral oxycodone, opioids nonetheless remain in other forms the most potent painkillers in the legitimate pharmacologic armamentarium. Cocaine, a product of the leaves of the Erythroxylum coca plant, likewise has ongoing utility as a topical anesthetic and vasoconstrictor. All these drug classes, plus barbiturates and sedative-hypnotics such as benzodiazepines, have high abuse potential but also important legitimate medical roles.

The involvement of an alphabet soup of federal agencies with divergent missions creates a series of potential barriers because several have the power to veto proposed initiatives.

Any one of these agencies has the power to halt an initiative in its tracks. Ill-informed practitioners are thus left to make do with anecdotal testimony and case reports—the least rigorous form of evidence—to guide their prescribing. It is a judicial fluke that the National Institute on Drug Abuse has provided medical marijuana to a handful of patients never more than 32, currently 4 surviving as the outcome of the settlement in a lawsuit pressed in by a man with cannabis-responsive glaucoma.

No patient has been enrolled since , when the George H. Bush administration suspended new registration in reaction to a large influx of applications from AIDS patients. Meanwhile, in the legal arena, the federal government pits itself against increasing numbers of states—16 plus the District of Columbia—with regulations permitting botanical cannabis use for certain chronically or critically ill patients that contradict federal law. A new industry has arisen around cultivating and dispensing medical marijuana to the hundreds of thousands of individuals authorized to use it.

Organized medicine continuing to condemn the federal government for its stance toward medical marijuana drives the ongoing legislative and scientific chaos.

Blurred Boundaries: The Therapeutics and Politics of Medical Marijuana

Given cannabis' worldwide use for thousands of years for medical and spiritual purposes, the contemporary American tumult over medical marijuana seems peculiar and misguided. Despite cannabis being part of the US pharmacopeia through much of the 19th and early 20th centuries, a federal government deeply suspicious of mind-altering substances began imposing restrictions on its prescription in the late s, culminating in when the US Congress classified it as a Schedule I substance, illegal, without redeeming qualities.

Despite its illegality, cannabis has in the latter half of the 20th century become the most abused illicit substance in the United States. For most individuals, recreational cannabis use is essentially harmless, a rite of passage ending as young people settle into careers and adult intimate relationships. For an even smaller proportion—those with a predisposition toward psychotic illness—it may abet the earlier emergence of psychosis and a rockier illness course if use persists. Prohibition notwithstanding, cannabis' recognized medical uses never went out of favor in alternative medicine circles.

Its therapeutic properties have been particularly favored by former recreational users familiar with its psychoactive effects, some of whom blur boundaries by continuing to use it recreationally. In the s, it was found effective for treating severe nausea induced by cancer chemotherapy and cachexia in AIDS patients. Marijuana use disorders are often associated with dependence —in which a person feels withdrawal symptoms when not taking the drug.

Marijuana use disorder becomes addiction when the person cannot stop using the drug even though it interferes with many aspects of his or her life. Estimates of the number of people addicted to marijuana are controversial, in part because epidemiological studies of substance use often use dependence as a proxy for addiction even though it is possible to be dependent without being addicted.

Those studies suggest that 9 percent of people who use marijuana will become dependent on it, 24,25 rising to about 17 percent in those who start using in their teens. In , about 4. Marijuana potency, as detected in confiscated samples, has steadily increased over the past few decades. In , it was The average marijuana extract contains more than 50 percent THC, with some samples exceeding 80 percent. Researchers do not yet know the full extent of the consequences when the body and brain especially the developing brain are exposed to high concentrations of THC or whether the recent increases in emergency department visits by people testing positive for marijuana are related to rising potency.

The extent to which people adjust for increased potency by using less or by smoking it differently is also unknown. Recent studies suggest that experienced people may adjust the amount they smoke and how much they inhale based on the believed strength of the marijuana they are using, but they are not able to fully compensate for variations in potency. The popularity of edibles also increases the chance of harmful reactions.

Edibles take longer to digest and produce a high. Therefore, people may consume more to feel the effects faster, leading to dangerous results. Higher THC levels may also mean a greater risk for addiction if people are regularly exposing themselves to high doses. Marijuana use has also been linked to other mental health problems, such as depression, anxiety, and suicidal thoughts among teens.

However, study findings have been mixed. While it's possible to fail a drug test after inhaling secondhand marijuana smoke, it's unlikely. Studies show that very little THC is released in the air when a person exhales. Research findings suggest that, unless people are in an enclosed room, breathing in lots of smoke for hours at close range, they aren't likely to fail a drug test. Similarly, it's unlikely that secondhand marijuana smoke would give nonsmoking people in a confined space a high from passive exposure.

Studies have shown that people who don't use marijuana report only mild effects of the drug from a nearby smoker, under extreme conditions breathing in lots of marijuana smoke for hours in an enclosed room. More research is needed to know if secondhand marijuana smoke has similar health risks as secondhand tobacco smoke. A recent study on rats suggests that secondhand marijuana smoke can do as much damage to the heart and blood vessels as secondhand tobacco smoke.

What they do know is that the toxins and tar found in marijuana smoke could affect vulnerable people, such as children or people with asthma. Compared to those who don't use marijuana, those who frequently use large amounts report the following:.

People also report less academic and career success. For example, marijuana use is linked to a higher likelihood of dropping out of school. Use of alcohol, tobacco, and marijuana are likely to come before use of other drugs. For example, when rodents are repeatedly exposed to THC when they're young, they later show an enhanced response to other addictive substances—such as morphine or nicotine—in the areas of the brain that control reward, and they're more likely to show addiction-like behaviors.

Read more about marijuana as a gateway drug in our Marijuana Research Report. An overdose occurs when a person uses enough of the drug to produce life-threatening symptoms or death. There are no reports of teens or adults dying from marijuana alone. However, some people who use marijuana can feel some very uncomfortable side effects, especially when using marijuana products with high THC levels.

People have reported symptoms such as anxiety and paranoia, and in rare cases, an extreme psychotic reaction which can include delusions and hallucinations that can lead them to seek treatment in an emergency room. While a psychotic reaction can occur following any method of use, emergency room responders have seen an increasing number of cases involving marijuana edibles. So they consume more of the edible, trying to get high faster or thinking they haven't taken enough. In addition, some babies and toddlers have been seriously ill after ingesting marijuana or marijuana edibles left around the house.

Marijuana use can lead to the development of a substance use disorder, a medical illness in which the person is unable to stop using even though it's causing health and social problems in their life. Severe substance use disorders are also known as addiction. Research suggests that between 9 and 30 percent of those who use marijuana may develop some degree of marijuana use disorder. Many people who use marijuana long term and are trying to quit report mild withdrawal symptoms that make quitting difficult.

No medications are currently available to treat marijuana use disorder, but behavioral support has been shown to be effective. Examples include therapy and motivational incentives providing rewards to patients who remain drug-free. Continuing research may lead to new medications that help ease withdrawal symptoms, block the effects of marijuana, and prevent relapse. Published September 8, Accessed January 18, Key Findings on Adolescent Drug Use. Butane Hash Oil Burns: A 7-Year Perspective on a Growing Problem.

Persistent cannabis users show neuropsychological decline from childhood to midlife. Impact of adolescent marijuana use on intelligence: Results from two longitudinal twin studies. National Academies of Sciences, Engineering, and Medicine. The Health Effects of Cannabis and Cannabinoids: