Arnaldo Cruz Igartua MD General and Addiction Psychiatry, October 17, 2016 CMCPR Culture; from word cultivate; shared values, attitudes, Traditions=patterns of process, folklore habits, believes and paradigms that defines and unify a particular group. Transmitted by costumes, language, achievements and arts across several generations.
Is a living process of continuous changes. Changes in the behavior, relations and meaning of persons, places, things, situations.
The Substance Industry (Legal and Illegal) try to associate intoxication with culture to sell more. Legal use publicity- money and illegal use gang culture, design drugs and diversion from legal drugs. The Prohibition-Legalization Paradigm Change to Wellness: Harm Reduction-Control-Prevention- Treatment-Mainteinance PROHIBITION IS FAILING IN PR AND USA: generating black market, design drugs and criminality (till less damage than legalization) LEGALIZATION IS ALSO FAILING IN USA and COLORADO Lose of Medicine standards. Generating Health and Productivity problems CONTROL: do not distribute Marihuana but standardized purified-dosified Cannabinoids. Prohibit commercials of any substance. Harm Reduction-Prevention: “Housing First” harm reduction programs for homeless and prevention programs for at risk children “Treatment Wellness- Second”: Therapeutic communities with evidence- based treatment “Maintenance Third”: Long term maintenance or recovery HARM TO: ADOLESCENT AND PUBLIC HEALTH Adolescent Substance Use: America’s #1 Public Health Problem The CASA Study, The National Center on Addiction and Substance Abuse at Columbia University, 2011
---The total federal costs of substance (that usually start in adolescents) use are $468 Billions each year ($1,500 dollars for each person in America). ---The media glorification and normalization of substances specially harm adolescents (Also Partnership Attitude Tracking Study by
Met Life, 2011) 4 GOOD BUSINESS FOR WHOM? Who pays Damage Costs?
Legal costs 485 Billions VS 193 Billions Costos Tabaco 300 Billones 2012 Ilegal National Drug Theat Assesment Dep Justice 2011; . Impact of Alcoholism and Alcohol Induced disease on America 2011; Research Society on Alcoholism; Alcohol and Tobaco Tax and Trade Bureau Annual Report 2011 Cuidados Medicos Productividad o Muerte Costos de Sustancias Ilegales 2007 Costos de Alcohol 185 Billones al 193 Billones al Año año 2011
Productividad120.3 Criminlidad Salud Perdida de Ingresos Tratamiento 15 Muerte Prematura GOOD BUSINESS FOR WHOM? Who pays Damage Costs? Tax Revenues/year Vs Costs Of Legalization
350 TOBACO Tax 26 300 300 ALCOHOL Tax 65 Billion-Cost 300 Billon- Cost185 Billon Billion 250
200 185
150
100 [VALUE]
50 26.6
0 Alcohol Tabaco Ganancia Costos Need to Redefine Several Paradigms
From a cultural paradigm of fighting illness and disease (ANTY-Prohibition/Legalization) to a culture of promoting wellness and happiness From a paradigm of legalization and prohibition to a culture of control, prevention and treatment- wellness Wellness elevate goals above the basics of: Seeking Immediate pleasure or escaping imminent pain or difficulties to defining a new meaning of A DAY BY DAY PROCESS of little changes seeking long term wellness. SAMSA: Eight dimensions of Wellness 1. Physical by educating our eating habits, exercise and sleep; Eat healthy and avoid using toxins and excesses. 2. Emotional psychological dimension by cultivating optimism, gratitude and appropriately channeling emotions; 3. Educational and work grow in the capacity and efficiency 4. Economic learning to prioritize and plan for the future the expenses and savings 5. The social learning to select and cultivate positive friendships developing membership and networks of friends to support our changes. Make at least one social work a day. SAMSA: Eight dimensions of Wellness
6. The spiritual dimension improves our connection to our deep nature and the nature that surrounds us gives us peace, balance and hope developing new human values. 7. Try to do something that you are passionate about in your work or sport or volunteer services. Opt for healthy and positive environments by moving away from those who are behind or activating insane patterns. 8. Be an eternal student expanding your interest in knowing something new home day. Write, create and compose small works each day that reflect you as co- creator of your life and your present. Effect of a drug (legal or illegal)in health (Volkow et al. 2014, MJ and Mental Health p30 )
“NOT ONLY determined by its pharmacological properties” “Also by availability and social acceptance” “Legal drugs (alcohol and tobacco) use are associated to greatest burden of disease associated to drugs NOT because they are more dangerous than illegal drugs but because their legal status allows for MORE WIDESPREAD EXPOSSURE” In Public Health the “hard drug” = the most used substance. The term soft and strong drug is misleading. Addiction Severity (and vulnerability) is not necessary related to the Substance Abused (ASI)
1. Family Marital Social 2. Legal 3. Alcohol 4. Drugs 5. Psychiatric Symptoms- Comorbidity 6. Medical-physical Comorbidity 7. Vocational-Study Suport DSM-V Substance Use Disdorder
Use: compulsive or reducing functioning, withdrawal or tolerance, mild, moderate, severe (Dependance) Intoxication: with or perception disorder, tachycardia, dry mouth, red conjunctiva Abstinence: irritable, aggressiveness, anxiety, depression Larger amounts or over a longer period than was intended by the user Persistent desire to cut down or control use/unsuccessful efforts to do so Failure to fulfill major role obligations at work, school or home as a result of marijuana use
12 Cannabis is not the same as cannabinoids
National Institute of Medicine position, 1999; "If there is any future for marijuana as medicine is in its isolated components, the cannabinoids and their synthetic derivatives. Isolated cannabinoids provide more reliable effects than mixtures of raw vegetables. Therefore, the purpose of clinical trials smoked marijuana would not be to develop marijuana as a licensed drug but rather to serve as a first step towards the development of non smoked cannabinoid and rapid effect. REF ."Marijuana and Medicine: Assessing the science base; Institute of Medicine Preface ix In Joy JE, JA Benson, SJ Watson, eds, Washington, DC: Institute of Medicine, National Academy Press, 1999 Cannabis is not the same as cannabinoids Word Health Organization November 2016 The Expert Committee continues to recommend that cannabis is not to be used medically despite growing evidence of considerable medical use world-wide, including the availability of a pharmaceutical preparation with a marketing authorization in multiple countries.
When describing these studies, it is not always easy to distinguish between cannabis, its preparations (e.g. nabiximols) and other cannabinoids (e.g. dronabinol), which is a constituent of cannabis, but has also its own listing in the United Nations Convention on Psychoactive Substances). Moreover, some synthetic cannabinoids, such as nabilone, are sometimes included in the study designs. Cannabis and Cannabis Resin
Pre-Review Report A document prepared for the World Health Organization Expert Committee on Drug Dependence Thirty-eight Meeting Geneva, 14 – 18 November 2016 Part of Conclusions: Degradation of Medicine Standards by 8766 Industry Ruling CANNABIS IS NOT THE SAME AS CANNABINOIDS HUNDREDS OF DIFFERENT CANNABIS INBREEDING STRAINS RAW =500 substances; Unrealiable; TOXIC SMOKED= 4000 SUBSTANCES; TOXIC
15 16 Ruling 8766 exchange Science and Medicine Standards to Industrial Terms
“INDUSTRIAL TRAINING" Do not give dosages or MEDICAL guidelines nor references Low follow up by MD (one card each year) No dosages in raw, but inhaled or smoked Easy diversion to smoked Do not mention sublingual drops in training Do not mention extraction of purified standardized cannabinoids High quantities each month 1.5 oz=60 cigarettes a day (was 2.5 oz) IMPULSIVITY AND CRAVING SKINNER OPERANT CONDITIONING VTA-NA- AMYGDALA MOTIVATIONAL CIRCUITS DAMAGE TO CORTICAL INHIBITION & Executive Functions BRAKE -ACCELERATOR Neurocognitive Damages
Effects of Smoked Cannabis Sativa
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BRAIN HEALTH AND ADDICTIONSThis image cannot currently be displayed.
SPECT OF NORMAL BRAIN
26 27 28 Frontal Assessment Battery Scores in Early, Late, Control This image cannot currently be displayed.
IMPORTANT AREAS OF PREFRONTAL CORTEX Anatomical Area Excecutive Clinical Function Presentation Impairment DORSOLATERAL Attention, Priorities, Planning, inflexible Sequencing, behavioral patterns planning Irrational Ideas VENTRO-MEDIAL Motivation, Passivity, Apathy Emotions Alexithimia
ORBITAL Impulse control, Antisocial Emotions, Memory, deshinibition, Judgement, Insight Amnesia, Alexithimia 30 This image cannot currently be displayed. "Adolescent Substance Use: America's # 1 Public Health Problem"; June 2011 Funded by: Legacy Conrad N. Hilton Foundation Carnegie Corporation of New York Michael Alan Rosen Foundation
"90% of Americans with addiction started smoking, drinking or using other drugs before age 18. One in four (25%) Americans who began using any addictive substance before age 18 are addicted 1 in 25 (4%) started using at age 21 or older. The glorification of consumption of tobacco, drinking, marijuana and other substances in the media NORMALIZE consumption of these adolescents and ultimately undermine the health and future of adolescents across the country. " . This image cannot currently be displayed. DESIGNER DRUGS The lack of evidence based Prevention and Treatment "Puerto Rico Substance Abuse Needs Assessment Program"2002 Household Survey, Final Results (364k o 90k families) SA 7.1% of the population in Puerto Rico, 178,000 people, are in need of specialized treatment services for chemical dependency SD 7.5 % additional 186,000 people need help with their substance abuse SD 15.0% S Dependence received specialized treatment services in the previous year. SA 3.4% received some services, either in general or specializing in addiction or other informal service, due to their substance abuse. This image cannot currently be displayed. /month for INDUSTRY Long-term effects of adolescent-onset and persistent use of cannabis Raul Gonzalez Etal. University of Ca, 2012 ---Detrimental effects of cannabis may be specific to some neurocognitive functions (rather than general) such as episodic memory (monozygotic tween studies) cannabis associated deficits may recover with abstinence (rather than persist) ---Both adolescent onset and almost 2 decades of persistent cannabis use may be needed to obtain the magnitude and pervasiveness of long-term neuropsychological deficits reported by Meier et al. This image cannot currently be displayed. Effects and uses of Cannabis Sativa
37 Longitudinal study of cognition among adolescents marihuana users over 3 weeks of abstinence Karen L. Hanson et al Univ of Cincinati, 2010 ---Marihuana users perform worse than control on verbal learning and verbal working memory ---Learned fewer words after 3 days of abstinence and up to two weeks of abstinence ---Similar to control group in working memory after 3 weeks of abstinence ---Similar attention processing speeds but less accurate attention/vigilance tasks persisting throughout 3 weeks or more (Not ADD) ---Nearly half of USA twelve graders have used marihuana; 6% use daily. LEGAL = MORE USE = MORE DAMAGE
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39 "Prevalence of Marijuana Use Among US Adults Doubles Over Past Decade";National Institute of Health (NIH); October 21, 2015. Prevalence 3.4% 12-17 year old 4.4% to 7.5 increased in last decade 18-29 year old Life prevalence 11.8% men; 5.4 women (Khan et al 2013) 25%-50% of daily users are dependent (Hall 2015) 3 in 10 people who use marijuana meet the criteria for addiction. Given (George Koob, Ph.D., director of the NIAAA, part of the National Institute of Health) Use double 2001 from 4.1 to 9.5 in 2012 Dependence double from 2001 1.5 to 2.9 in 2012 100% Increased when used alone and 75% increase in combination Adolescent Substance Use: America’s #1 Public Health Problem The CASA Study, The National Center on Addiction and Substance Abuse at Columbia University, 2011 ---Adolescents addiction is the preventable most costly Public Health problem in USA ---26% of adolescents active users of substances develop addictions ---90% of USA patients with addictions started abusing substances before 18 year old ---25% of substance users that started before 18 year old become addicted in stead of 4% if started after 21 years old; 500% more risk42 Increase in marijuana use by teenagers in PR in recent years."The use of substances in Puerto Rican schools"; Youth Consultation 2010-2012 VIII, UCC
"The substance most commonly used by teenagers, after alcohol and tobacco, is marijuana (12.4%).
The use of marijuana showed the sharpest rise to double its prevalence of 6.1% in 2005-07 to 12.4% in 2010-12.
30,348 students on the island have smoked marijuana or hashish once in life and
30,222 (12.4%) have used it in the past year.
It is estimated that 21.745 (9.0%) of our youth have recently used marijuana (last month).
A 16.0% of youth who have tried marijuana said that during the past year have smoked this substance daily and almost half (46.5%) has done occasionally, but not regularly. In addition,
14.8 % of students reported smoking marijuana daily in the month before the survey. " The past year use of cannabis in adolescents increased from 6.1% on 2005-2007 to 12.4% 2010 to 2012
Addolescent Substance Use 60 Consulta Juvenil VIII 2010-2012 PR 50
40
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0 Alcohol 48.6 Tobacco 14.3 Marihuana 12.4 Pills 6.1 Solvents 6.1 Substance Column2 Column1 44 Marihuana Impact on Colorado Schools ---Drug related suspensions/expulsions increased 32 % from school years 2008/2009 through 2012/2013 ---The vast majority were for marihuana violations. ---74% of CO teens in addiction treatment in Dember Colorado said that they had used medical marijuana prescribed to other about 50 times (Cellia Vimont 2012)
47 Cannabis poisoning in children under 10: --0 in 2008 to --8 in 2013 - before recreational- and to --14 in 2014 in Children's Hospital Colorado Arrests of minors for marijuana jumped 5 percent from 2012 to 2014.
51 52 For Web resourses visit Facebook “Public Health Control” Referencias: 1. Reglamento 8766 para el uso, posesión, cultivo, manufactura, producción, fabricación, dispensación, distribución e investigación del cannabis medicinal; Puerto Rico, 8 de julio de 2016. 2. Medical Marijuana: ME Schatman, PhD, Feb 06, 2015. 3. Alerta a las familias sobre posibles daños por el uso de marihuana; Capítulo de Psiquiatría de Niños y Adolescentes del CMCPR con el Capítulo de PR de la Academia de Psiquiatría Americana; 2015. 4. Prevalence of Marijuana Use Among U.S. Adults Doubles Over Past Decade"; NIH; Oct 21, 2015. 5. Marijuana and medicine: Assessing the science base; Joy JE, Benson JA, Watson SJ: Institute of Medicine, Nat Acad Press, 1999. 6. Cannabis and Cannabinoids; Pharmacology, Toxicology and Therapeutic Potential; F Grotenhem, MD, E Russo, MD, 2002. 7. Drug Facts: Marijuana, NIH and NIDA, Revised Sept 2015. 8. Adolescent Substance Use: America's #1 Public Health Problem; Jun 2011, Funded by: Legacy® Conrad N. Hilton Foundation Carnegie Corporation of New York Michael Alan Rosen Foundation. 9. The effect of medical cannabis laws on juvenile cannabis use; L Stolzenberg Etal; FIU, USA; International J of Drug Policy, 2015. 10. Uso de substancias en escolares de PR; Consulta Juvenil VIII 2010-2012, UCC. 11. Puerto Rico Substance Abuse Needs Assessment Program; 2002. Referencias (cont.): 12. ¿Puede el uso de marihuana afectar la habilidad de conducir?; National Institute of Drug Abuse (NIDA y NIH), Sept 2015. 13. Adverse Health Effects of Marijuana Use Nora D. Volkow, MD Etal, N Engl J Med 2014;370:2219-27. DOI:10.1056/NEJMra1402309. 14. Clearing the Smoke on Cannabis Medical Use of Cannabis and Cannabinoids; Canadian Centre on Substance Abuse; 2014. 15. Cannabinoids in medicine: A review of their therapeutic potential, February 2006; Substance Abuse Program, U of Montreal. 16. Narrative review of the safety and efficacy of marijuana for the treatment of commonly state-approved medical and psychiatric disorders; KA Belendiuk et al; Addiction Scienc & Clin Pract. (2015). 17. Efficacy and adverse effects of medical marijuana for chronic non cancer pain; A Deshpande, MD, Canadian Family Physician. 2015. 18. Cannabinoids for Medical Use, A Systematic Review and Metaanalysis. PF Whiting, PHD JAMA. 2015. 19. Comprehensive Review of Medicinal Marijuana, Cannabinoids, and Therapeutic Implications in Medicine and Headache.EP Baron, DO. Headache Curr 2015. 20. DEA waives registration requirements for CBD research, Dec. 23, 2015; J Zinsmeister, [email protected]; +1 (415) 680-3993. 21. US Policy Responses to Calls for the Medical Use of Cannabis Wayne Hall, PhD, 2015. 22. Programa nacional de cuatro pilares integrados para la salud mental y las adicciones: Subcomité Científico CMCPR (Nov 2013). 23. Medical Marijuana: The State of the Science, Michael E. Schatman, PhD, www.medscape.com. 24. Alerta sobre el reglamento 155 (de 2015) que legaliza la marihuana cruda como si fuera un medicamento. Galenus; 2016 25. Lessons Learned after 4 years of Marihuana Legalization; SAM, University of Colorado, Johns Hopkins University, Harvard Med Shool, Childrens Hospital Boston, Univ of Kansas