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Cannabis and Gambling: Financial Disclosures What’s Lying in the Weeds Research Support Connections in Recovery Timothy Fong MD Milestones Ranch UCLA Cannabis Research Initiative Creative Care UCLA Gambling Studies Program Consultant WeRecover 17th Annual Ohio Problem Gambling Conference February 2020

Goals Recent Case at UCLA

• Gain knowledge of the relationship • 52 year old male presents for gambling between cannabis and gambling. disorder and depression treatment • Recognize how the legalization of • Classic presentation cannabis is likely to impact gambling – Debt and gambling disorder. – Stress / emotional pain • Use best treatment practices to – Impaired work / home / social functioning address cannabis use disorders and – Poor Self-Care gambling disorder.

Recent Case at UCLA Recent Case at UCLA

• Preferred form of gambling is poker, • After 6 sessions, reveals that he uses table games, online and live cannabis ”regularly” but doesn’t see it • Tobacco, no other substances reported as a problem because ”it’s just weed” at intake • Additional elements • Standard treatment doesn’t appear to – Meets criteria for cannabis use disorder work – Amotivated, emotionally absent – GA, Therapy, Medications – Thinks it helps calm him prior to gambling but no evidence that it is “performance enhancing”

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Issues Raised

• How did gambling disorder impact cannabis use? The Current Cannabis • How did cannabis use impact gambling Landscape disorder? • How should cannabis be addressed in the office and how much time should be spent on this? • How many others are out there?

Terminology Cannabis

• Cannabis is the botanical term for the >500 distinct compounds plant and its products Cannabinoids: Class of compounds that act on • Marijuana is a cultural term for the cannabinoid receptors cannabis plant THC (Psychoactive) – Not scientifically recognized – Roots in Mexican immigrant culture CBD (Non-psychoactive)

National Trends

• Topic of National (global) interest th • Perception of harm among 12 graders The California Cannabis Story decreased leading to increased use

• Emergence of “Big Weed” – Environmental, economic, political power • Cannabis Medicine as a specialty ? or ! – Skewed direction?

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Current policy: Federal 1996

• Schedule I Controlled Substance by the • In 1996, voters approved Proposition United States Drug Enforcement Agency 215, which legalized the use of • Substances in this schedule have no currently accepted medical use in the medicinal cannabis in California. United States, – a lack of accepted safety for use under medical supervision, and a high potential for • Since the proposition was passed most abuse regulation was done by local • Heroin, lysergic acid diethylamide (LSD), governments. peyote, Ecstasy”)

2016 2018-2019

• In November of 2016, voters approved • January 1, 2018: Proposition 64, the Adult Use of – AUMA makes it legal to sell and distribute Marijuana Act (AUMA). Under cannabis through a regulated business. Proposition 64, adults 21 years of age • May 2019 or older can legally grow, possess, and – 10:1 ratio of unregulated to regulated use cannabis for non-medicinal dispensaries purposes, with certain restrictions. – Lower than expected revenues – Expected level of red tape

California Offices

• Bureau of Cannabis Control – Regulates commercial cannabis licenses • California Dept. of Public Health – Medical Marijuana Program – Manufactured Cannabis Safety Branch Center for Healthy Communities – Office of Problem Gambling – California Tobacco Control

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Why do People Use Medical Cannabis?

REASON FOR USE % REPORTING REASON Pain Relief 82.6% Cannabis as Medicine To Sleep 70.6% To Relax 55.6% Muscle Spasms 41.3% Anxiety 38.1% To Stimulate Appetite 38.0% Nausea 27.7% Depression 26.1% 20 SOURCE: Reinarman et al., 2011 (reference list).

2017 State of Evidence Accepted Therapeutic Use • Health and Medicine • Marinol (synthetic THC) division of the – Chemotherapy-induced nausea and National Academy of vomiting Sciences (Formerly the Institute of • Epidiolex (CBD) Medicine) – Pediatric seizures • Emphasis on review • Sativex (THC and CBD) of research since – Muscle Spasticity (MS); non-USA 2011

Main Takeaways with Cannabis Use Disorder (CUD) Cannabis LIFETIME RISK OF • Positive • Negative DRUG DEPENDENCE – Chronic Pain – Addiction risk Nicotine 32% – Nausea from – Adversely chemotherapy impacts mental Heroin 23% Cocaine 17% – Multiple health Alcohol 15% Sclerosis • Suicide,mood, impulsivity Cannabis 9% – Harmful for 24 persons under 21 SOURCE: Bostwick, 2012 (reference list).

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Could Expanding Access and Cannabis Withdrawal Acceptability of Cannabis Be a Big • Three (or more) of the following signs and symptoms Mistake? develop within approximately 1 week: (and how to avoid it) – Irritability, anger, or aggression. – Nervousness or anxiety. • What might happen in 10, 20, 30 years? – Sleep difficulty (e.g., insomnia, disturbing – Public Health Impact dreams). • Car accidents, environmental impact, – Decreased appetite or weight loss. – Addiction and Mental Health – Restlessness. • Cannabis epidemic? – Depressed mood. • At least one of the following physical symptoms – Medical Impact causing significant discomfort: abdominal pain, • Research must guide treatment shakiness/tremors, sweating, fever, chills, or • Without proper education, mythology persist headache.

How do cannabis and gambling relate to one another?

Las Vegas Tasting Room (Cannabis Consumption Lounge)

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Cannabis and Gambling The present and the future? Venues

• Located on sovereign land owned by the Las • From the gambling industry view Vegas Paiute Tribe, the nearly 16,000- – Managing gambling intoxication square-foot marketplace, located just north • Policies, procedures, training required of the Fremont Street casino corridor, is not – Navigating local, state and federal laws beholden to restrictions – Promote or prohibit cannabis usage? • It’s self-regulated through the Las Vegas – Managing employees (urine testing) Paiute Cannabis Authority. – How to relate to cannabis industry • As such, there are no Nevada marijuana • Convention business taxes, no waiting rooms and no reason not to open a consumption lounge.

Cannabis by the Numbers Nevada 2018 Cannabis Money

• Nevada Total Sales: $529.9M • As state laws and federal laws don’t • Nevada Population: 3M match up on marijuana, gambling • Visitors to Las Vegas: 42.12M • MJBizCon trade show industry are unable to accept money – 158 Speakers from anyone involved in the medical or – 27,600 Attendees recreational marijuana industry, – 1,027 Exhibitors whether it’s legal in the state or not. • Square footage of Planet 13: 112,000 – Visitors per day: +3,000

From the field: Future of Gambling

“Edibles and vapes are the way to go till • Integration of technology and the video we get smoking lounges but reality is, the game industry Las Vegas police have handed out very • Marketing to the digital consumer few of the $600 fines for smoking in – Twitch, YouTube, Social Media Channels public. I would find a parking lot or an • Focus on the phone alley near your casino and smoke the joint – Social casinos and mobile gaming there, head on a swivel.” – A pathway to the land-based casino • Social use venues

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What We Think We Know Now Impact of cannabis on • Cannabis consistently should: – Increase impulsivity gambling behaviors – Increase risk-taking – Increase ingestion of other available substances – Change perception of time – Alter moods – Impair decision-making

Does gambling lead to How does cannabis use cannabis use? impact gambling?

– Most certainly if they are sold together or – Attention / Concentration available together – Risk-taking behaviors – Most certainly if they are marketed together to enhance each other’s – Diminish emotional experience responses? – Impact of professional gamblers, gambling role models – Impulsivity

– Urges and cravings?

Other questions to consider problemgambling.ca.gov

• Impact of cannabis on gambling disorder? – Essentially unknown • Could cannabis treat gambling disorder? – What is the basis of this? – Target urges / cravings / reward circuitry?

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Since the beginning of CalGETS in 2009, over 12,500 individuals have received no-cost treatment to address the harmful impact of problem gambling.

Clinical Relevance Roadmap for Clinicians

• Most providers have not received • No cannabis for under anyone under 21 formal training about cannabis • Focus on changing perception of risk • Recognizing cannabis use vs – “Respect the power of cannabis” risky/harmful use is not as evident as • Screen for cannabis use with other substances – Cannabis Use Disorders Identification Test • Is cannabis being used as a drug or a • Follow the lead of professional societies medication? • Track impact of cannabis on gambling • Cannabis and gambling • Familiarize with local cannabis laws – Improve, exacerbate or no effect? • Visit a dispensary

The UCLA Cannabis uclahealth.org/cannabis Research Initiative • To investigate the therapeutic potential and health risk of cannabis through the interdisciplinary study of all facets of cannabis’ effect on society, including legal, economic, and social impact. • UCLA-CRI will provide timely education, research, and service to lead public policy and public health decisions regarding cannabis.

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Q and A Contact Information Timothy Fong MD UCLA Gambling Studies Program 310-825-1479 (office) [email protected] uclahealth.org/cannabis/

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