Exploring the Social, Legal, and Neurodevelopmental Impacts of Cannabis Use: A Colorado Perspective
Sean LeNoue, M.D. University of Colorado School of Medicine Department of Psychiatry Divisions of Child/Adolescent Psychiatry & Substance Dependence Disclosures
• European Cities Against Drugs (ECAD) Travel & Lodging stipend Objectives
1. Review history & background of cannabis
2. Assess the effects of cannabis use on the body & mind from a neurodevelopmental perspective
3. Review the history of cannabis regulation in the United States & Colorado
4. Explore the impact on academic performance of youth using cannabis in Colorado
5. Review evidence-based treatment modalities for substance use disorders Background of Cannabis
• History • Originated from central & southeast Asia
• First noted in historical texts around 3000 B.C.
• Strains • Sativa, Indica, & Ruderalis
• Preparations • Marijuana, Kief, Hashish, Tincture, Hash Oil, & Infusions
• Consumption • Smoking, Vaporizing, Injecting, Teas, & Butters/Edibles
• Effects
Joy et al, 1999 Background of Cannabis
www.erowid.org Background of Cannabis
• Strains • Sativa • THC > CBD • Energizing • Euphoria • Mind > Body • Indica • CBD > THC • Sedating • “Body Melt” • Body > Mind • Ruderalis • Hybridization
Joy et al, 1999 Background of Cannabis
• Strains • Sativa • THC > CBD • Energizing • Euphoria • Mind > Body • Indica • CBD > THC • Sedating • “Body Melt” • Body > Mind • Ruderalis • Hybridization
Joy et al, 1999 Background of Cannabis
• Strains • Sativa • THC > CBD • Energizing • Euphoria • Mind > Body • Indica • CBD > THC • Sedating • “Body Melt” • Body > Mind • Ruderalis • Hybridization
Joy et al, 1999 Background of Cannabis
• Strains • Sativa • THC > CBD • Energizing • Euphoria • Mind > Body • Indica • CBD > THC • Sedating • “Body Melt” • Body > Mind • Ruderalis • Hybridization
Joy et al, 1999 Background of Cannabis
• Preparations • Marijuana • Kief • Hashish • Tincture • Infusions
www.thesmokingbud.com Background of Cannabis
• Preparations • Marijuana • Kief • Hashish • Tincture • Infusions
www.theweedblog.com Background of Cannabis
• Preparations • Marijuana • Kief • Hashish • Oil • Shatter • Dabs • Wax • Tincture • Infusions
www.flikr.com Background of Cannabis
• Preparations • Marijuana • Kief • Hashish • Oil • Shatter • Dabs • Wax • Tincture • Infusions
www.wired.com Background of Cannabis
• Preparations • Marijuana • Kief • Hashish • Oil • Shatter • Dabs • Wax • Tincture • Infusions
www.slate.com Background of Cannabis
• Preparations • Marijuana • Kief • Hashish • Oil • Shatter • Dabs • Wax • Tincture • Infusions
www.grasscity.com Background of Cannabis
• Preparations • Marijuana • Kief • Hashish • Oil • Shatter • Dabs • Wax • Tincture • Infusions
www.rollingstone.com Background of Cannabis
• Preparations • Marijuana • Kief • Hashish • Tincture • Infusions
www.lilly.com Background of Cannabis
• Preparations • Marijuana • Kief • Hashish • Tincture • Infusions • Butters
www.eatyourcannabis.com Background of Cannabis
• Relative THC concentration by preparation
• Marijuana: ~ 5% THC
• Resins: ~ 20% THC
• Oils: ≥ 60% THC
United Nations Office on Drugs & Crime (UNODC), 2009 Effects of Cannabis on the Body
www.sciencekids.co.nz Effects of Cannabis on the Brain
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Brain Development, Appetite, Immunological Function, Reproduction, Pain Regulation/Analgesia
Adapted from Compton 2014 & www.drugabuse.gov In utero Infancy Childhood Adolescence Adulthood
• ~ 33% THC crosses placenta (Gray et al, 2005)
• Affects fetal oxygen delivery (Marroun et al, 2010)
• Possible effects on fetal growth similar to tobacco (Marroun et al, 2009)
• Endocannabanoid, immune systems, cytoskeletal dynamics (axonal connections) (Volkow et al, 2014)
• Concern for consequences comparable to lead exposure (Canfield et al, 2003; CDC 2013)
www.cdc.gov/nceh/lead In utero Infancy Childhood Adolescence Adulthood
• ↓ IQ by 5 points at age 6 (Goldschmidt et al, 2012)
• ↑ depression at age 10 (Gray et al, 2005)
• ↑ hyperactivity, impulsivity, inattention at age 10 (Goldschmidt et al, 2000)
• ↑ odds of cannabis use by age 14 & possibly heavier cannabis use later in life (Day et al, 2006)
• ↓ achievement at age 14 (Goldschmidt et al, 2012) In utero Infancy Childhood Adolescence Adulthood
• Low birth weight (LBW), prematurity, poor sleep, poor self-regulation, hyper-arousal, SIDS risk
• Breastfeeding (~ 50% THC transfer)
• Case report of 13-month old admitted to hospital with lethargy, ↓ appetite, T= 38 C after 2nd hand exposure to cannabis (Zarfin et al, 2012)
Gray et al, 2005 Marroun et al, 2010 In utero Infancy Childhood Adolescence Adulthood
• Second-hand exposure primarily
• Edibles & packaging In utero Infancy Childhood Adolescence Adulthood
• Inadvertent ingestion of marijuana edibles in Colorado
• Infants-12 year olds
• 15 hospital observations/admissions from 2009-2011
• NONE from 2007-2009
Wang et al, 2013 In utero Infancy Childhood Adolescence Adulthood
• 1 in 6 develop addiction
• ↓ IQ by 8 points when heavy use occurs from age 13-38
• Confers a 2-fold increased risk of psychosis in adulthood
• Daily use of cannabis predicts a doubling in odds of having an anxiety disorder at age 29
Hall and Degenhardt (2009), Lancet 374:1383-1391 Degenhardt et al. (2012), Addiction 108:124-133 Meier et al., (2012), Proc Natl Acad Sci USA 109:E2657-E2664 In utero Infancy Childhood Adolescence Adulthood
• Cannabis use by age 15:
• 3.6x less likely to graduate from high school
• 2.3x less likely to enroll in university
• 3.7x less likely to obtain a university degree
• Cannabis before sex: 50% less likely to use a condom
• Association with aggression
• 2x ↑ risk of other drug use Fergusson et al. (2006), Addiction 101:556-569 Hendershot et al. (2010), Psychol Addict Behav 24:404-414 Horwood et al. (2010), Drug Alcohol Dep 110:247-253 Smith et al. (2013), Drug Alcohol Depend:63-68 In utero Infancy Childhood Adolescence Adulthood
Brain reward circuit
Prefrontal system Functional Development Functional
Age Adapted from Casey et al. (2008), Dev Rev 28: 62-77
Consider the Developing Mind of a Child or Adolescent In utero Infancy Childhood Adolescence Adulthood
• 1 in 9-11 develop addiction
• 4x ↑ risk of MI in the hour after using
• Doubles risk of bronchitis, wheezing, & chronic cough
• May increase risk of head/neck, lung, & testicular cancers
Lacson et al. (2012), Cancer 118:5734-5783 Hall and Degenhardt (2009), Lancet 374:1383-1391 Hall and Degenhardt (2013), Drug Testing and Analysis Pope et al., (2002), J Clin Pharmacol 42:41S-47S Mittleman et al. (2001), Circulation 103:2805-2809 Bosker et al. (2013), PLoS One 8:e53127 In utero Infancy Childhood Adolescence Adulthood
• Chronic use:
• Cognitive impairment for up to 1 month
• Psychomotor impairment for up to 3 weeks
• Decreased fertility
• Disrupts menstrual cycle in women
• Decreased testosterone, sperm quality/quantity in men
Hall and Degenhardt (2009), Lancet 374:1383-1391 Bosker et al. (2013), PLoS One 8:e53127 In utero Infancy Childhood Adolescence Adulthood
• If THC > 1ng/ml:
• 2.5x more likely to be involved in a car crash
• 3.3x more likely to be involved in a fatal car crash
• If THC ≥ 5ng/ml:
• 4.7-6.6x more likely of being involved in a fatal car crash
Drummer et al. (2003), Forensic Sci Int 134:154-162 Laumon et al. (2005), BMJ 331:1371 Mura et al. (2003), Forensic Sci Int 133:79-85 The Story of Cannabis Regulation in the United States The Story of Cannabis Regulation in the United States
• Pure Food & Drug Act (1906)
• Required special drugs, including cannabis, to be accurately labeled with contents
• Restricted sales of narcotics, including cannabis, to pharmacies with physician’s prescription
www.weebly.com • Cannabis remains legal in the United States 1906
Pure Food and Drug Act (1906). United States. United States Statutes at Large (59th Cong., Sess. I, Chp. 3915, p. 768-772; cited as 34 U.S. Stats. 768) The Story of Cannabis Regulation in the United States
• International Opium Convention (1925)
• Banned exportation of Indian hemp (hashish) & derivatives to countries prohibiting its use
• Required importing countries to issues certificates approving importation
• Cannabis remains legal in the United States
1906: Pure Food 1925 & Drug Act
UNODC, www.unodc.org The Story of Cannabis Regulation in the United States
• Uniform State Narcotic Act (1925)
• Aimed to provide uniform monitoring & regulation of narcotics in all states.
• Cannabis remains legal in the United States
1906: Pure Food 1925 & Drug Act
Frontline, www.pbs.org The Story of Cannabis Regulation in the United States
• Federal Bureau of Narcotics (1930)
• Federal Bureau of Narcotics founded to provide greater oversight, regulation of cannabis & other controlled substances
• Cannabis remains legal in the United States
1906: 1925: Pure Food Int’l Opium Conv. & 1930 & Drug Act U.S. Narcotic Act
FBN, www.dea.gov The Story of Cannabis Regulation in the United States
• The 1936 Geneva Trafficking Conventions
• Aimed to criminalize the “cultivation, production, manufacture and distribution of opium, coca, & cannabis” for non-medical/non-scientific purposes.
• Cannabis remains legal in the United States
1906: 1925: 1930: Pure Food Int’l Opium Conv. & FBN 1936 & Drug Act U.S. Narcotic Act
www.druglibrary.org The Story of Cannabis Regulation in the United States
• Marihuana Tax Act (1937)
• “The Marihuana Tax Act of 1937 effectively made possession or transfer of cannabis ILLEGAL throughout the United States under federal law”
• Excluded medical & industrial uses; tax was excised
1906: 1925: 1936: Pure Food Int’l Opium Conv. & 1930: Geneva Traff. 1937 & Drug Act U.S. Narcotic Act FBN Conv
Frontline, www.pbs.org The Story of Cannabis Regulation in the United States
• Mandatory Sentencing: Boggs Act (1952)
• Mandatory sentencing & increased punishment for first- time cannabis possession
1906: 1925: 1936: 1937: Pure Food Int’l Opium Conv. & 1930: Geneva Traff. MJ Tax Act 1952 & Drug Act U.S. Narcotic Act FBN Conv
Frontline, www.pbs.org The Story of Cannabis Regulation in the United States
• Mandatory Sentencing: Narcotics Control Act (1956)
• Mandatory sentencing & further increased punishment for first-time cannabis possession
• Prison: 2-10 years
• Fine: up to $20,000
1906: 1925: 1936: 1937: 1952: Pure Food Int’l Opium Conv. & 1930: Geneva Traff. MJ Tax Act Boggs Act 1956 & Drug Act U.S. Narcotic Act FBN Conv
Frontline, www.pbs.org The Story of Cannabis Regulation in the United States • Controlled Substances Act (1970)
• Leary v. United States deemed MTA (1937) unconstitutional
• Violated 5th Amendment right against self- incrimination
• Congress passes Controlled Substances Act in response, thereby repealing MTA (1937)
1956: 1906: 1925: 1936: 1937: 1952: Narcotics Pure Food Int’l Opium Conv. & 1930: Geneva Traff. MJ Tax Act Boggs Act Control Act 1970 & Drug Act U.S. Narcotic Act FBN Conv
Controlled Substances Act, www.fda.gov The Story of Cannabis Regulation in the United States • Decriminalization - 1970s
• 1973: Oregon (OR)
• 1974: Alaska (AK)
• 1976: Maine (ME)
• 1978: California (CA), Colorado (CO), Mississippi (MS), New York (NY), Nebraska (NE), North Carolina (NC), & Ohio (OH)
1956: 1970: 1906: 1925: 1936: 1937: 1952: Narcotics Controlled Pure Food Int’l Opium Conv. & 1930: Geneva Traff. MJ Tax Act Boggs Act Control Act Sub. Act 1970s & Drug Act U.S. Narcotic Act FBN Conv
Pacula et al, 2003 The Story of Cannabis Regulation in the United States Medical Marijuana Legalization Year State 1996 Califronia (CA) 1998 Alaska (AK), Oregon (OR), Washington (WA) 1999 Maine (ME) 2000 Colorado (CO), Hawaii (HI), Nevada (NV) 2004 Montana (MT) 2006 Rhode Island (RI) 2007 New Mexico (NM), Vermont (VT) 2008 Michigan (MI) 2010 Arizona (AZ), New Jersey (NJ) 2011 Delaware (DE), Washington, D.C. 2012 Connecticut (CT), Massachusetts (MA) 2013 New Hampshire (NH), Illinois (IL) 2014 Maryland (MD), Minnesota (MN)
National Conference of State Legislators, www.ncsl.org, 2015 The Story of Cannabis Regulation in the United States
Motel et al, 2015 The Story of Cannabis Regulation in the United States
• “Increasingly positive & permissive public opinion despite scientific data about harm/consequences.” • Potency • Sources • Availability • Public perception • Legal status • Patterns of use
Compton, 2014 The Story of Cannabis Regulation in Colorado The Story of Cannabis Regulation in Colorado • Amendment 20 (November 2000)
• Medicinal cannabis use
• “Provided defense for possession & use of cannabis for debilitating medical conditions when recommended by a physician”
• Cancer, glaucoma, HIV/AIDS (also cachexia, severe pain, severe 2000 nausea, & persistent muscle spasm)
Colorado Department of Public Health & Environment, www.colorado.gov, 2015 The Story of Cannabis Regulation in Colorado • De Facto Legalization (July 2009)
• Minimal restriction on eligibility for medical cannabis
• Increase in patients: 5,000 to 120,000 in a year
• Increase in dispensaries: just a few to ~700 in a year
• Ogden Memo: Federal government has low priority for prosecuting individuals abiding by individual state cannabis laws
• Colorado Board of Health fails to reach consensus regarding patient/ care-giver limit 2000: 2009 Amend. 20
Colorado Department of Public Health & Environment, www.colorado.gov, 2015 Ogden Memo, www.justice.gov, 2009 The Story of Cannabis Regulation in Colorado
• Senate Bill 109 (June 2010)
• Required “bona fide physician-patient relationship”
• Previously, NO exam to confirm existence of qualifying condition.
2000: 2009: de facto Amend. 20 Legalization 2010
Colorado Department of Public Health & Environment, www.colorado.gov, 2015 What has Denver done?
4 With the entire world watching, Denver effectively implemented first- of-its-kind sales and commercialization of retail marijuana. • Denver made the necessary investments in time, money and people to responsibly implement the will of the voters and create an entirely new regulatory structure for this new industry. 4 Denver’s employees committed to Mayor Michael B. Hancock’s direction that the city adopt a collaborative approach in the implementation of retail marijuana.
CITY AGENCIES 12 working collaboratively on marijuana issues
• There was no template for how to implement the law—Denver has effectively managed the issues around marijuana with no roadmap.
WhatThe hasStory happened of Cannabis so far? Regulation in Colorado 4 In 2009 Denver began allowing medical marijuana cultivation and sales. In November 2012 the voters of Colorado approved Amendment • Amendment64, allowing the legal 64 sales (November of retail marijuana. 2012) 4 The city acted quickly, responsibly and in accordance with the wishes of voters:
DENVER VOTER RESULTS AMENDMENT 64: REGULATING PERSONAL 66% 34% USE OF MARIJUANA 186,671 94,714 4 In anticipation of legal retail marijuana sales initiating on Jan. 1, 2014, Mayor Hancock and the Denver City Council worked with the marijuana industry and countless others to develop the world’s first municipal 2000: retail marijuana2009: regulatoryde facto framework.2010: Amend. 20 Legalization Sen. Bill 109 2012
Colorado Department of Public Health & Environment, www.colorado.gov, 2015 City & County of Denver: Marijuana Annual Report, 2015 What has Denver done?
4 With the entire world watching, Denver effectively implemented first- of-its-kind sales and commercialization of retail marijuana. The Story of Cannabis • Denver made theRegulation necessary investments in time, money and people to responsibly implement the will of the voters and create an entirely new regulatory structure for this new industry. in Colorado4 Denver’s employees committed to Mayor Michael B. Hancock’s direction that the city adopt a collaborative approach in the implementation of retail marijuana.
• Amendment 64 (November 2012)CITY AGENCIES 12 working collaboratively on marijuana issues
• There was no template for how to implement the law—Denver has • Legalized recreational cannabiseffectively managed (≥ the21 issues years around marijuana of withage) no roadmap.
• May grow 3 immature & What3 mature has happened plants so in far? locked space 4 In 2009 Denver began allowing medical marijuana cultivation and sales. In November 2012 the voters of Colorado approved Amendment • May possess up to 1 ounce64, allowing cannabis the legal sales of inretail marijuana.public 4 The city acted quickly, responsibly and in accordance with the wishes of voters: • DUID: ≥ 5ng/ml DENVER VOTER RESULTS AMENDMENT 64: REGULATING PERSONAL 66% 34% USE OF MARIJUANA 186,671 94,714 4 In anticipation of legal retail marijuana sales initiating on Jan. 1, 2014, 2000: 2009: de facto 2010: Mayor Hancock and the Denver City Council worked with the marijuana industry and countless2012 others to develop the world’s first municipal Amend. 20 Legalization Sen. Bill 109retail marijuana regulatory framework.
Colorado Department of Public Health & Environment, www.colorado.gov, 2015 City & County of Denver: Marijuana Annual Report, 2015 The Story of Cannabis Regulation in Colorado
• Amendment 64 “Go Live” (January 1, 2014)
2000: 2009: de facto 2010: 2012: Amend. 20 Legalization Sen. Bill 109 Amend. 64 2014
www. denverpost.com www.westword.com The Story of Cannabis Regulation in Colorado
Let’s Talk…
2014: 2000: 2009: de facto 2010: 2012: Amend. 64 Amend. 20 Legalization Sen. Bill 109 Amend. 64 “Go Live” Today
www.slate.com www.cnn.com www.huffingtonpost.com The Story of Cannabis Regulation in Colorado: Post-Legalization
RETAIL MARIJUANA: THE DENVER Retail Marijuana Businesses COLLABORATIVE • 4 types of licenses: • Cultivation facilities APPROACH • Manufacturers of Infused Products (MIPS) • Marijuana testing facilities • Retail stores
CULTIVATION MIPS TESTING RETAIL FACILITIES FACILITIES STORES
1/1/14 20 4 0 19
1/1/15 154 41 7 106 City & County of Denver: Marijuana Annual Report, 2015 Youth Cannabis Use
• Past Month Marijuana Use (2013), age 12-17
• National average: 7.15%
• Colorado average: 11.16%
• ↑ 6.6% in just one year after legalization
• Colorado ranked 3rd in the nation for current marijuana use
• 56.08% higher than U.S. national average
• 2006: Colorado ranked 14th in the U.S. for current marijuana use
The Legalization of Marijuana in Colorado: The Impact Vol. 3, Preview 2015 Rocky Mountain High Intensity Drug Trafficking Area (www.rmhidta.org) TheYouth Legalization of MarijuanaCannabis in Colorado: The Impact Use in ColoradoVol. 3 Preview 2015 Data
SOURCE: SAMHSA.gov, National Survey on Drug Use and Health 2012 and 2013 SAMHSA.gov, National Survey on Drug Use and Health 2012 and 2013
SECTION 2: Youth Marijuana Use Page | 10 The Legalization of Marijuana in Colorado: The Impact Vol. 3 Preview 2015
Past Month Usage by 12 to 17-Year-Olds, 2013
RhodeThe Legalization Island of Marijuana in Colorado: The Impact Vol. 3 Preview 2015 The LegalizationVermont of Marijuana in Colorado: The Impact Vol. 3 Preview 2015 Colorado Washington New Hampshire Past Month Usage by 12 to 17-Year-Olds, 2013 Oregon Past Month Usage by 12 to 17-Year-Olds, 2013 HawaiiRhode Island Maine Vermont Rhode Island New Mexico Colorado VermontWashington Delaware NewColorado Hampshire Michigan WashingtonOregon Massachusetts New HampshireHawaii Alaska OregonMaine Montana NewHawaii Mexico Connecticut Delaware Maine Nevada Michigan New Mexico ArizonaMassachusetts DelawareAlaska New York MichiganMontana California MassachusettsConnecticut Florida AlaskaNevada Maryland MontanaArizona OhioNew York Connecticut WisconsinCalifornia Nevada Georgia Florida Arizona South CarolinaMaryland New York Missouri Ohio CaliforniaWisconsin Pennsylvania FloridaGeorgia Minnesota SouthMaryland Carolina North Carolina MissouriOhio IllinoisPennsylvania Wisconsin IowaMinnesota Georgia NebraskaNorth Carolina South Carolina Virginia Illinois Missouri Tennessee Iowa PennsylvaniaNebraska Indiana MinnesotaVirginia Wyoming North CarolinaTennessee Texas Indiana Illinois ArkansasWyoming Iowa Idaho Texas New JerseyNebraskaArkansas UtahVirginiaIdaho West VirginaTennesseeNew Jersey Utah North DakotaIndiana As of 2013: West Virgina OklahomaWyoming Legalized Recreational/Medical State North Dakota As of 2013: Mississippi Texas Oklahoma LegalizedLegalized Medical Recreational/Medical Marijuana State State Arkansas South DakotaMississippi NonLegalized-Legalized Medical Medical Marijuana Marijuana State State Louisiana Idaho South Dakota Non-Legalized Medical Marijuana State KansasNew LouisianaJersey Kentucky UtahKansas AlabamaWest VirginaKentucky North DakotaAlabama As of 2013: Oklahoma0.00% 2.00% 4.00% 6.00% Legalized8.00% Recreational/Medical10.00% 12.00% State 14.00% 0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% 14.00% Mississippi Legalized Medical Marijuana State AverageAverage Percentage Percentage South Dakota Non-Legalized Medical Marijuana State Louisiana SOURCE: SAMHSA.gov, National Survey on Drug Use andSAMHSA.gov, Health 2012 and 2013 National Survey on Drug Use and Health 2012 and 2013 SOURCE: KansasSAMHSA.gov, National Survey on Drug Use and Health 2012 and 2013 Kentucky Alabama SECTIONSECTION 2: Youth 2: Youth Marijuana Marijuana Use Use PagePage | 11 | 11 0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% 14.00% Average Percentage
SOURCE: SAMHSA.gov, National Survey on Drug Use and Health 2012 and 2013
SECTION 2: Youth Marijuana Use Page | 11 The Legalization of Marijuana in Colorado: The Impact Vol. 3 Preview 2015
Past Month Usage by 12 to 17-Year-Olds, 2013
RhodeThe Island Legalization of Marijuana in Colorado: The Impact Vol. 3 Preview 2015 Vermont Colorado Washington New Hampshire Past Month Usage by 12 to 17-Year-Olds, 2013 Oregon Hawaii Rhode Island Maine Vermont Colorado New Mexico Washington Delaware New Hampshire Michigan Oregon Massachusetts Hawaii Alaska Maine Montana New Mexico Connecticut Delaware Nevada Michigan Massachusetts Arizona Alaska New York Montana California Connecticut Florida Nevada Maryland Arizona Ohio New York Wisconsin California Georgia Florida South Carolina Maryland Ohio Missouri Wisconsin Pennsylvania The LegalizationGeorgia of Marijuana in Colorado: The Impact Vol. 3 Preview 2015 The Legalization of Marijuana in Colorado: The Impact Vol. 3 Preview 2015 MinnesotaSouth Carolina North Carolina Missouri Rhode Island Illinois Pennsylvania Vermont Iowa Minnesota Colorado PastWashington Month Usage by 12 to 17-Year-Olds, 2013 NebraskaNorth Carolina PastNew Hampshire Month Usage by 12 to 17-Year-Olds, 2013 Illinois Oregon Virginia Rhode Island Hawaii Iowa Maine Tennessee Vermont Rhode IslandNebraska New Mexico Indiana Colorado Delaware VermontVirginia Michigan Wyoming Washington ColoradoTennessee Massachusetts TexasNew Hampshire Alaska WashingtonIndiana Montana Oregon Arkansas Wyoming Connecticut New HampshireHawaii Nevada Idaho Texas Arizona Oregon Maine New Jersey Arkansas New York HawaiiNew Mexico California Idaho Utah Florida MaineDelaware New Jersey Maryland West Virgina New MexicoMichigan Ohio Utah Wisconsin North Dakota Massachusetts As of 2013: DelawareWest Virgina Georgia Oklahoma Alaska South Carolina MichiganNorth Dakota LegalizedAs of 2013:Recreational/Medical State Montana Missouri MississippiMassachusettsOklahoma Pennsylvania LegalizedLegalized Medical Recreational/Medical Marijuana State State South Dakota Connecticut Minnesota AlaskaMississippi North Carolina Nevada Non-LegalizedLegalized Medical Medical Marijuana Marijuana State State Louisiana South Dakota Illinois MontanaArizona Iowa Non-Legalized Medical Marijuana State Kansas Louisiana ConnecticutNew York Nebraska Kentucky Kansas Virginia NevadaCalifornia Tennessee Kentucky AlabamaArizonaFlorida Indiana Alabama Wyoming New YorkMaryland Texas 0.00% Ohio 2.00% Arkansas 4.00% 6.00% 8.00% 10.00% 12.00% 14.00% California 0.00% Idaho2.00% 4.00% 6.00% 8.00% 10.00% 12.00% 14.00% Wisconsin New Jersey Florida AverageAverage Percentage Percentage Georgia Utah Maryland West Virgina South Carolina North Dakota As of 2013: Ohio SOURCE: SOURCE:SAMHSA.gov MissouriSAMHSA.gov, NationalOklahoma, NationalSurvey onSurvey Drug on Use Drug and Use Health andLegalized Health 2012 Recreational/Medical 2012and and2013 2013 State Mississippi Legalized Medical Marijuana State WisconsinPennsylvania South Dakota Non-Legalized Medical Marijuana State GeorgiaMinnesota Louisiana Kansas SECTIONSouth CarolinaNorth Carolina 2: Youth MarijuanaKentucky Use Page | 11 SECTION 2: YouthMissouri Illinois MarijuanaAlabama Use Page | 11 Pennsylvania Iowa 0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% 14.00% MinnesotaNebraska Virginia SAMHSA.gov, National Survey on Drug Use and Health 2012 and 2013 North Carolina Tennessee Illinois Indiana Iowa Wyoming Nebraska Texas VirginiaArkansas Tennessee Idaho IndianaNew Jersey Wyoming Utah TexasWest Virgina North Dakota As of 2013: Arkansas Oklahoma Legalized Recreational/Medical State Idaho Mississippi Legalized Medical Marijuana State New Jersey South Dakota Non-Legalized Medical Marijuana State UtahLouisiana West VirginaKansas North DakotaKentucky As of 2013: OklahomaAlabama Legalized Recreational/Medical State Mississippi 0.00% 2.00% 4.00% 6.00%Legalized8.00% Medical 10.00%Marijuana12.00% State 14.00% South Dakota Non-Legalized Medical Marijuana State Louisiana Average Percentage Kansas SOURCE:Kentucky SAMHSA.gov, National Survey on Drug Use and Health 2012 and 2013 Alabama
SECTION0.00% 2: Youth Marijuana2.00% Use4.00% 6.00% 8.00% 10.00% 12.00%Page | 11 14.00% Average Percentage
SOURCE: SAMHSA.gov, National Survey on Drug Use and Health 2012 and 2013
SECTION 2: Youth Marijuana Use Page | 11 The LegalizationYouth of Marijuana inCannabis Colorado: The Impact UseVol. 3 Preview 2015
Average Past Month Use by 12 to 17-Year-Olds, 2013
10.5% 12.0% 8.9%
10.0%
8.0% 6.1%
6.0%
4.0% Average Percentage 2.0%
0.0% Non-Medical Medical Marijuana Recreational/Medical Marijuana States States Marijuana States
SOURCE: SAMHSA.gov, National Survey on Drug Use and Health 2012 and 2013 SAMHSA.gov, National Survey on Drug Use and Health 2012 and 2013
SOURCE: SAMHSA.gov, National Survey on Drug Use and Health, 2006-2013
SECTION 2: Youth Marijuana Use Page | 12 The Legalization of Marijuana in Colorado: The Impact Vol. 3 Preview 2015
Average Past Month Use by 12 to 17-Year-Olds, 2013
10.5% 12.0% 8.9%
10.0%
8.0% 6.1%
6.0%
4.0% Average Percentage 2.0%
0.0% Non-Medical Medical Marijuana Recreational/Medical Marijuana States States Marijuana States
SOURCE:Youth SAMHSA.gov, National SurveyCannabis on Drug Use and Health 2012 and 2013 Use
SOURCE: SAMHSA.gov, National Survey on Drug Use and Health, 2006-2013
SAMHSA.gov, National Survey on Drug Use and Health 2012 and 2013
SECTION 2: Youth Marijuana Use Page | 12 Youth Cannabis Use in Colorado The Legalization of Marijuana in Colorado: The Impact Vol. 3 Preview 2015
SOURCE: Colorado Department of Education, 10-Year Trend Data: State Suspension and Expulsion Incident Rates and Reasons Colorado Department of Education 10-Year Trend Data: State Suspension and Expulsion Incident Rates and Reasons
Average Drug-Related Suspensions/Expulsions
5,167
3,864 6,000 5,000 4,000 3,000 2,000 1,000 (34% Increase)
Average Number of 0
Suspensions/Expulsions 2004-2005 2009-2010 to to 2008-2009 2013-2014 Academic Years
SOURCE: Colorado Department of Education, 10-Year Trend Data: State Suspension and Expulsion Incident Rates and Reasons
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SOURCE: Colorado Department of Education, 10-Year Trend Data: State Suspension and Expulsion Incident Rates and Reasons Youth Cannabis Use in Colorado
Average Drug-Related Suspensions/Expulsions
5,167
3,864 6,000 5,000 4,000 3,000 2,000 1,000 (34% Increase)
Average Number of 0
Suspensions/Expulsions 2004-2005 2009-2010 to to 2008-2009 2013-2014 Academic Years
SOURCE: Colorado Department of Education, 10-Year TrendColorado Data: State Department Suspension of Education and Expulsion Incident 10-Year Trend Data: State Suspension and Expulsion Incident Rates and Reasons Rates and Reasons
SECTION 2: Youth Marijuana Use Page | 13 The LegalizationYouth of Marijuana in Colorado:Cannabis The Impact UseVol. 3 Preview 2015
SOURCE: Colorado Department of Education, 10-Year Trend Data:Colorado State DepartmentSuspension of and Education Expulsion Incident Rates and Reasons 10-Year Trend Data: State Suspension and Expulsion Incident Rates and Reasons
SOURCE: Colorado Department of Education, 10-Year Trend Data: State Suspension and Expulsion Incident Rates and Reasons
SECTION 2: Youth Marijuana Use Page | 14 The Legalization of Marijuana in Colorado: The Impact Vol. 3 Preview 2015
SOURCE: Colorado Department of Education, 10-Year Trend Data: State Suspension and Expulsion Incident YouthRates and Reasons Cannabis Use
SOURCE: Colorado Department of Education, 10-Year Trend Data: State Suspension and Expulsion Incident Colorado Department of Education Rates and Reasons 10-Year Trend Data: State Suspension and Expulsion Incident Rates and Reasons
SECTION 2: Youth Marijuana Use Page | 14 The LegalizationYouth of Marijuana in Colorado: Cannabis The Impact UseVol. 3 Preview 2015
SOURCE: Colorado Department of Education, 10-Year Trend Data: State Suspension and Expulsion Incident Colorado Department of Education Rates and Reasons 10-Year Trend Data: State Suspension and Expulsion Incident Rates and Reasons
SOURCE: State of Colorado Judicial Branch, Division of Probation Services
SECTION 2: Youth Marijuana Use Page | 15 The Legalization of Marijuana in Colorado: The Impact Vol. 3 Preview 2015
SOURCE: Colorado Department of Education, 10-Year Trend Data: State Suspension and Expulsion Incident Rates and Reasons Youth Cannabis Use
SOURCE: State of Colorado Judicial Branch, Division of ProbationColorado Services Department of Education 10-Year Trend Data: State Suspension and Expulsion Incident Rates and Reasons
SECTION 2: Youth Marijuana Use Page | 15 Young Adult Cannabis Use
• Current Marijuana Use (2013), College Age Adults (age 18-25)
• National average: 18.91%
• Colorado average – 29.05%
• Colorado was ranked 2nd in the nation for current marijuana use
• 53.62% higher than U.S. national average
• 2006: Colorado was ranked 8th in the nation for current marijuana use
• In just one year since Colorado legalized recreational marijuana, past month marijuana use increased 8.4%
The Legalization of Marijuana in Colorado: The Impact Vol. 3, Preview 2015 Rocky Mountain High Intensity Drug Trafficking Area (www.rmhidta.org)
SECTION 3: Adult Marijuana Use
Findings (College Age)
College Age Adults (ages 18 to 25 years) Current Marijuana Use 2013 o National average – 18.91 percent o Colorado average – 29.05 percent Colorado was ranked 2nd in the nation for current marijuana use among college-age adults (53.62 percent higher than the national average) In 2006, Colorado was ranked 8th in the nation for current marijuana use among college-age adults In just one year when Colorado legalized marijuana (2013), past month marijuana use among college-age (18 to 25 years) use increased 8.4 percent Young Adult Cannabis Use Data in Colorado
SOURCE: SAMHSA.gov, National Survey on Drug Use and Health, 2006–2013
SAMHSA.gov, National Survey on Drug Use and Health, 2006–2013
SECTION 3: Adult Marijuana Use Page | 17 Young Adult Cannabis Use
SOURCE: SAMHSA.gov, National Survey on Drug Use and Health, 2006 - 2013 SAMHSA.gov, National Survey on Drug Use and Health, 2006–2013
SOURCE: State of Colorado Judicial Branch, Division of Probation Services
SECTION 3: Adult Marijuana Use Page | 18
YoungSOURCE: SAMHSA.gov, Adult National Survey on Drug UseCannabis and Health, 2006 - 2013 Use
SOURCE: State of Colorado Judicial Branch, Division of Probation Services State of Colorado Judicial Branch, Division of Probation Services
SECTION 3: Adult Marijuana Use Page | 18 Cannabis in the Media What Can We Do?
Hopeless?
Don’t be! ENCOMPASS/STEP
• 17 week, outpatient manualized treatment (dual-diagnosis)
• Cognitive Behavioral Therapy (CBT)
• Motivational Enhancement (MET)
• Contingency Management (CM)
www.ucdenver.edu/academics/colleges/medicalschool/departments/psychiatry/Research/Subdep/ENCOMPASS/Pages/default.aspx Treatment
STEP PROGRAM
www.denverhealth.org/medical-services/mental-health/our-services/step-program Strategies for Treatment Summary & Take-Home Points
• Cannabis is a harmful substance that can have serious consequences on the mind and body
• Legalization/commercialization of a substance impacts perception and use by youth
• Prevention & education are key
• Treatment is available: ENCOMPASS/STEP References 1. Bonnie et al. (1972). "The Marihuana Consensus: A History of American Marihuana Prohibition". University of Virginia Law School. 2. Bosker et al. (2013), “Psychomotor Function in Chronic Daily Cannabis Smokers during Sustained Abstinence.” PLoS One 8(1):e53127. 3. Canfield et al. (2003), “Intellectual Impairment in Children with Blood Lead Concentrations below 10 μg per Deciliter.” NEJM 348: 1517-26. 4. Casey et al. (2008), “The Adolescent Brain.” Dev Rev 28: 62-77. 5. Centers for Disease Control (CDC). www.cdc.gov/nceh/lead/ Accessed 3/1/2015. 6. City & County of Denver: Marijuana Annual Report, “Retail Marijuana: The Denver Collaborative Approach.” http:// www.denvergov.org/Portals/782/documents/CCD15002-MrjnAnnlRprt_5.5x8.5noCrops.pdf, Accessed 3/23/2015. 7. Colorado Department of Education. “10-Year Trend Data: State Suspension and Expulsion Incident Rates and Reasons.” http:// www.cde.state.co.us/cdereval/suspend-expelcurrent. Accessed 4/1/2014. 8. Colorado Department of Public Health & Environment - Legislation & Retail Marijuana, https://www.colorado.gov/cdphe/retail- marijuana, Accessed 2/19/2015. 9. Controlled Substances Act (2009), http://www.fda.gov/regulatoryinformation/legislation/ucm148726.htm. Accessed 3/27/2015. 10. Day et al. (2006), “Prenatal marijuana exposure contributes to the prediction of marijuana use at age 14.” Addiction 101: 1313-1322. 11. Drummer et al. (2003), “The incidence of drugs in drivers killed in Australian road traffic crashes.” Forensic Sci Int 134:154-162. 12. ENCOMPASS, www.ucdenver.edu/academics/colleges/medicalschool/departments/psychiatry/Research/Subdep/ ENCOMPASS/Pages/default.aspx, Accessed: 2/28/2015. 13. Fergusson et al. (2006), “Cannabis use and other illicit drug use: testing the cannabis gateway hypothesis.” Addiction 101: 556-69. 14. Frontline (2014). http://www.pbs.org/wgbh/pages/frontline/shows/dope/etc/cron.html. Accessed 3/29/2015. 15. Goldschmidt et al. (2000), “Effects of prenatal marijuana exposure on child behavior problems at age 10.” Neurotoxicol Teratol 22: 325-336. 16. Goldschmidt et al. (2008), “Prenatal Marijuana Exposure and Intelligence Test Performance at Age 6.” J Am Acad Child Adolesc Psychiatry 47: 254-263. References (cont.)
1. Goldschmidt et al. (2012), “School achievement in 14-year-old youths prenatally exposed to marijuana.” Neurotoxicol Teratol 34:161-167. 2. Gray et al. (2005), “Prenatal marijuana exposure: Effect on child depressive symptoms at ten years of age.” Neurotoxicol Teratol 27: 439-448. 3. Gray et al. (2010), “Identifying Prenatal Cannabis Exposure and Effects of Concurrent Tobacco Exposure on Neonatal Growth.” Clinical Chemistry 56(9): 1442–1450. 4. Hall and Degenhardt (2009), “Adverse health effects of non-medical cannabis use.” Lancet 374: 1383-1391. 5. Degenhardt et al. (2012), “The persistence of the association between adolescent cannabis use and common mental disorders into young adulthood.” Addiction 108: 124-133. 6. Hendershot et al. (2010), “Associations of Marijuana Use and Sex-Related Marijuana Expectancies With HIV/STD Risk Behavior in High-Risk Adolescents.” Psychol Addict Behav 24: 404-14. 7. Horwood et al. (2010), “Cannabis use and educational achievement: Findings from three Australasian cohort studies.” Drug Alcohol Dep 110: 247-53. 8. Joy et al. (1999), Marijuana and Medicine: Assessing The Science Base. Washington, D.C.: National Academy of Sciences Press. 9. Laumon et al. (2005), “Cannabis intoxication and fatal road crashes in France: population based case-control study.” BMJ 331:1371 10. Lacson et al. (2012), “Population-Based Case-Control Study of Recreational Drug Use and Testis Cancer Risk Confirms an Association Between Marijuana Use and Nonseminoma Risk.” Cancer 118: 5734-5783. 11. Marroun et al. (2010), “A prospective study on intrauterine cannabis exposure and fetal blood flow.” Early Human Development 86: 231-236. 12. Meier et al. (2012), “Persistent cannabis users show neuropsychological decline from childhood to midlife.” Proc Natl Acad Sci USA 109: E2657-64. 13. Mittleman et al. (2001), “Triggering Myocardial Infarction by Marijuana.” Circulation 103: 2805-2809. 14. Motel, S., (2015). “Six Facts about Marijuana.” Pew Research. (www.pewresearch.org/fact-tank/2015/04/14/6-facts-about- marijuana). Accessed 4/19/2015. References (cont.)
1. Mura et al. (2003), “Comparison of the prevalence of alcohol, cannabis and other drugs between 900 injured drivers and 900 control subjects: results of a French collaborative study.” Forensic Sci Int 133:79-85. 2. National Conference of State Legislators,”The Legalization of Medical Marijuana by State.” www.ncsl.org, Accessed 4/30/2015. 3. Ogden Memo, http://www.justice.gov/opa/blog/memorandum-selected-united-state-attorneys-investigations-and-prosecutions-states, Accessed 4/30/2015. 4. Pacula et al. (2003), “Marijuana Decrominaliztion: What Does it Mean in the United Stated?” National Bureau of Economic Research; http://www.nber.org/papers/w9690.pdf. 5. MARIJUANA DECRIMINALIZATION: WHAT DOES IT MEAN IN THE UNITED STATES? 6. Pope et al. (2002), “Cognitive Measures in Long-Term Cannabis Users.” J Clin Pharmacol 42: 41S-47S. 7. Rocky Mountain High Intensity Drug Trafficking Area (RMHIDTA). “The Legalization of Marijuana in Colorado: The Impact Vol. 3, Preview 2015.” http://www.rmhidta.org/html/August%202014%20Legalization%20of%20MJ%20in%20Colorado%20the%20Impact.pdf. Accessed 4/18/2015. 8. Substance Abuse and Mental Health Services Administration (SAMHSA), “National Survey on Drug Use and Health 2012 and 2013.” http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf” Accessed 3/14/2015. 9. Science Kids: Fun Science and Technology for Kids. www.sciencekids.co.nz, Accessed 3/15/2015. 10.Smith et al. (2013), “Marijuana withdrawal and aggression among a representative sample of U.S. marijuana users.” Drug Alcohol Depend 132: 63-68. 11.State of Colorado Judicial Branch, Division of Probation Services. https://www.courts.state.co.us/Administration/Division.cfm? Division=prob. Accessed 4/17/2015. 12. Substance abuse Treatment, Education, & Prevention (STEP). www.denverhealth.org/medical-services/mental-health/our-services/ step-program, Accessed: 1/30/2015. 13. United Nations Office on Drugs and Crime. “Why Does Cannabis Potency Matter?” (2009). http://www.unodc.org/unodc/en/frontpage/ 2009/June/why-does-cannabis-potency-matter.html. 14. United States. Pure Food and Drug Act (1906). United States Statutes at Large (59th Cong., Sess. I, Chp. 3915, p. 768-772; cited as 34 U.S. Stats. 768). 15. Volkow et al. (2014), “Adverse Health Effects of Marijuana Use.” NEJM 370: 23, 2219-27. 16. Wang et al. (2013), “Pediatric Marijuana Exposures in a Medical Marijuana State.” JAMA Pediatrics 167(7): 630-633. 17. Zarfin et al. (2012), “Infant with altered consciousness after cannabis passive inhalation.” Child Abuse Negl 36: 81-83. Acknowledgments
• Christian Thurstone, M.D.
• Paula Riggs, M.D.
• Douglas Novins, M.D.
• Kim Kelsay, M.D.
• Robert House, M.D.
• Austin Butterfield, M.D. Questions?