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It's Just Pot…Right?

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It's Just Pot…Right? 2/11/2016 SAATDE WORKSHOP HOW MARIJUANA EDUCATIONAL OBJECTIVES: LEGISLATION • Appraise the effects of the main forms, modes of delivery IS SHAPING TOMORROW and active ingredients of cannabis. • Recognize the signs of marijuana use and distinguish 2016 American Dental Education Association Annual Session different levels of marijuana habituation and addiction. March 12 – 15 Denver, CO • Review varying legal controls on marijuana for medical Sponsored by: The Substance Abuse, Addiction, and Tobacco Dependence Education Section Co-Sponsored by the following Sections: Behavioral Sciences, Dental Hygiene Education, and recreational use. Gay-Straight Alliance, Oral and Maxillofacial Pathology • Assess tools and opportunities for incorporating marijuana counseling into dental and allied dental curricula. PRESENTERS • Sean LeNoue, MD IT’S JUST POT…RIGHT? • Child & Adolescent Psychiatry Fellow (CR-2) EXPLORING THE SOCIAL, LEGAL, & • Chief Resident, Denver Health Medical Center, University of Colorado, NEURODEVELOPMENTAL IMPACTS Department of Psychiatry • Victoria Patrounova RDH, MHA OF CANNABIS USE • Assistant Professor, University of Texas School of Dentistry at Houston • Joan M. Davis RDH, PhD Sean LeNoue, M.D. • Professor, School of Allied Health, Southern Illinois University Carbondale University of Colorado School of Medicine Department of Psychiatry Divisions of Child/Adolescent Psychiatry & Substance Dependence DISCLOSURES PROGRAM OBJECTIVES 1. Review history & background of cannabis • Nothing to disclose 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 1 2/11/2016 BACKGROUND OF CANNABIS 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 www.erowid.org BACKGROUND OF CANNABIS BACKGROUND OF CANNABIS • Strains • Strains • Sativa • Sativa • THC > CBD • THC > CBD • Energizing • Energizing • Euphoria • Euphoria • Mind > Body • Mind > Body • Indica • Indica • CBD > THC • CBD > THC • Sedating • Sedating • “Body Melt” • “Body Melt” • Body > Mind • Body > Mind • Ruderalis • Ruderalis • Hybridization • Hybridization Joy et al, 1999 Joy et al, 1999 BACKGROUND OF CANNABIS BACKGROUND OF CANNABIS • Strains • Strains • Sativa • Sativa • THC > CBD • THC > CBD • Energizing • Energizing • Euphoria • Euphoria • Mind > Body • Mind > Body • Indica • Indica • CBD > THC • CBD > THC • Sedating • Sedating • “Body Melt” • “Body Melt” • Body > Mind • Body > Mind • Ruderalis • Ruderalis • Hybridization • Hybridization Joy et al, 1999 Joy et al, 1999 2 2/11/2016 BACKGROUND OF CANNABIS BACKGROUND OF CANNABIS • Preparations • Preparations • Marijuana • Marijuana • Kief • Kief • Hashish • Hashish • Tincture • Tincture • Infusions • Infusions www.thesmokingbud.com www.theweedblog.com BACKGROUND OF CANNABIS BACKGROUND OF CANNABIS • Preparations • Preparations • Marijuana • Marijuana • Kief • Kief • Hashish • Hashish • Oil • Oil • Shatter • Shatter • Dabs • Dabs • Wax • Wax • Tincture • Tincture • Infusions • Infusions www.flikr.com www.wired.com BACKGROUND OF CANNABIS BACKGROUND OF CANNABIS • Preparations • Preparations • Marijuana • Marijuana • Kief • Kief • Hashish • Hashish • Oil • Oil • Shatter • Shatter • Dabs • Dabs • Wax • Wax • Tincture • Tincture • Infusions • Infusions www.slate.com www.grasscity.com 3 2/11/2016 BACKGROUND OF CANNABIS BACKGROUND OF CANNABIS • Preparations • Marijuana • Preparations • Kief • Marijuana • Hashish • Kief • Oil • Hashish • Shatter • Dabs • Tincture • Wax • Infusions • Tincture • Infusions www.rollingstone.com www.lilly.com BACKGROUND OF CANNABIS BACKGROUND OF CANNABIS • Preparations • Relative THC concentration by preparation: • Marijuana: ~ 5% THC • Marijuana • Resins: ~ 20% THC • Kief • Oils: ≥ 60% THC • Hashish • Tincture • Infusions • Butters www.eatyourcannabis.com United Nations Office on Drugs & Crime (UNODC), 2009 EFFECTS OF CANNABIS ON THE BODY EFFECTS OF CANNABIS ON THE BRAIN ........... ............................... ................................................ ......................... ................ ................. ................................... ........................... ................ .............. ..... ............... ....... ...... .......... .............. ......... .......... .... .......... ..... .......... ..... ........ .. ...... .... ...... ........ ... .......... Brain Development, Appetite, Immunological Function, Reproduction, Pain Regulation/Analgesia www.sciencekids.co.nz Adapted from Compton 2014 & www.drugabuse.gov 4 2/11/2016 In utero Infancy Childhood Adolescence Adulthood In utero Infancy Childhood Adolescence Adulthood • ~ 33% THC crosses placenta (Gray et al, 2005) • ↓ IQ by 5 points at age 6 (Goldschmidt et al, 2012) • Affects fetal oxygen delivery (Marroun et al, 2010) • ↑ depression at age 10 (Gray et al, 2005) • Possible effects on fetal growth similar to tobacco • ↑ hyperactivity, impulsivity, inattention at age 10 (Marroun et al, 2009) (Goldschmidt et al, 2000) • Endocannabanoid, immune systems, cytoskeletal • ↑ odds of cannabis use by age 14 & possibly heavier dynamics (axonal connections) (Volkow et al, 2014) cannabis use later in life (Day et al, 2006) • Concern for consequences comparable to lead • ↓ achievement at age 14 (Goldschmidt et al, 2012) exposure (Canfield et al, 2003; CDC 2013) www.cdc.gov/nceh/lead In utero Infancy Childhood Adolescence Adulthood In utero Infancy Childhood Adolescence Adulthood • Second-hand exposure primarily • Low birth weight (LBW), prematurity, poor sleep, • Edibles & packaging 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 In utero Infancy Childhood Adolescence Adulthood • 1 in 6 develop addiction • Inadvertent ingestion of marijuana edibles in Colorado • ↓ IQ by 8 points when heavy use occurs from age 13- • Infants-12 year olds 38 • 15 hospital observations/admissions from 2009-2011 • Confers a 2-fold increased risk of psychosis in • NONE from 2007-2009 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 Wang et al, 2013 Meier et al., (2012), Proc Natl Acad Sci USA 109:E2657-E2664 5 2/11/2016 In utero Infancy Childhood Adolescence Adulthood 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 Brain reward circuit • 3.7x less likely to obtain a university degree • Cannabis before sex: 50% less likely to use a condom • Association with aggression Prefrontal system • 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 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 In utero Infancy Childhood Adolescence Adulthood 1 in 9-11 develop addiction • • Chronic use: • 4x ↑ risk of MI in the hour after using • Cognitive impairment for up to 1 month • Doubles risk of bronchitis, wheezing, & chronic cough • Psychomotor impairment for up to 3 weeks • May increase risk of head/neck, lung, & testicular • Decreased fertility cancers • Disrupts menstrual cycle in women • Decreased testosterone, sperm quality/quantity in men Lacson et al. (2012), Cancer 118:5734-5783 Hall and Degenhardt (2009), Lancet 374:1383-1391 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 Bosker et al. (2013), PLoS One 8:e53127 Mittleman et al. (2001), Circulation 103:2805-2809 Bosker et al. (2013), PLoS One 8:e53127 6 2/11/2016 In utero Infancy Childhood Adolescence Adulthood THE STORY OF CANNABIS • If THC > 1ng/ml: • 2.5x more likely to be involved in a car crash REGULATION • 3.3x more likely to be involved in a fatal car crash IN THE UNITED STATES • 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 THE STORY OF CANNABIS REGULATION IN THE UNITED STATES REGULATION IN THE UNITED STATES • Pure Food & Drug Act (1906) • International Opium Convention (1925) • Banned exportation of Indian hemp (hashish) & • Required special drugs, including derivatives to countries prohibiting its use cannabis, to be accurately labeled with contents • Required importing countries to issues certificates approving importation • Restricted sales of narcotics, including • Cannabis remains legal in the United States cannabis, to pharmacies with physician’s
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