Marijuana - Association for Academic Psychiatry

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Transcript Marijuana - Association for Academic Psychiatry

West Virginia University
School of Medicine
Department of Behavioral Medicine and Psychiatry
Ehab Abdallah M.D.
Marijuana
Medical Friend or Foe
Classifying Marijuana
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Marijuana produces some excitatory effects but it is not
generally regarded as a stimulant.
Marijuana produces sedative effects, but a person faces no risk
of slipping into a coma or dying.
Marijuana produces mild analgesic effects, but it is not related
pharmacologically to opiates like drugs.
Marijuana produces hallucinations at high doses, but its
structure does not resemble LSD or any other drug formally
categorized as hallucinogen.
So marijuana
is clearly a
hybrid drug in
a league of its
own.
Basic Terminology
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Marijuana is
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Cannabis is the
frequently a synonym
for cannabis but
technically the two
terms are separate.
botanical term for the
hemp plant cannabis
sativa.
Brief History
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Cannabis sativa have been commercially
valuable for thousands of years in the
manufacture of rope, shoes, sailcloth,
and containers of all kinds.
Pots made of hemp fiber discovered at
archeological sites in China date the
origins of cannabis as far back as the
Stone Age.
Cannabis sativa is arguably the oldest
cultivated plant not used for food.
Spaniards brought
cannabis to the
New World in
1545.
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English settlers brought it to Jamestown,
Virginia in 1611 as a major commercial crop
along with tobacco.
In the eighteenth-century George
Washington grew cannabis on his farm.
Entries in his diary indicated that he
maintained a keen interest in cultivating
better strains of cannabis, but there is no
reason to believe he was interested in
anything more than a better quality of rope.
Marijuana – The Plant
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Marijuana is obtained from serrated
leaves from the cannabis plant.
The key psychoactive factor is
contained in a sticky substance, or
resin, that accumulates on these leaves.
Depending on the growing conditions,
cannabis will produce either a greater
amount of resin or greater amount of
fibers.
Marijuana – The Plant
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In hot, dry climates such as North Africa
the fiber content is weak but so much
resin is produced that the plant looks as
if it is covered with dew.
In cooler more humid climates such as
North America less resin is produced
but the fiber is stronger and more
durable.
Definitions
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Cannabinoids: Any of the several dozen active
substances in marijuana and other cannabis
products.
Delta-9-tetrahydrocannainol (THC): The
active psychoactive ingredient in marijuana
and hashish.
Marijuana: The most commonly available
psychoactive drug originated from the
cannabis plant. The THC concentration
ranges from approximately 1 to 4 percent.
Definitions
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Sinsemilla: A form of marijuana
obtained from the un-pollinated or
seedless portion of the cannabis plant,
it has a higher THC concentration than
regular marijuana, as high as 6 percent.
Hashish: A drug containing the resin of
cannabis flowers, the THC
concentration ranges from
approximately 8 to 14 percent.
Definitions
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Hashish Oil: A drug produced by boiling
hashish, leaving the potent
psychoactive residue, the THC
concentration ranges from
approximately 15 to 60 percent.
Hashish oil crystals: Solid form of
hashish oil.
Bhang: A liquid form of marijuana,
popular in India.
The History of
Marijuana and Hashish
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The first direct reference to a cannabis
product as a psychoactive agent dates from
2737 B.C. in the writings of the Chinese
emperor Shen Nung. The focus was on its
powers as a medication for rheumatism,
gout, malaria, and strangely enough absentmindedness.
In India the use was clearly recreational as
the most popular form is liquid made from
cannabis leaves called Bhang.
History
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The Muslim world also grew to appreciate the
psychoactive potential of cannabis,
encouraged by the fact that ,in contrast to its
stern prohibition of alcohol consumption, The
Koran did not specifically ban its use.
In Iran, because of the hot dry climate and
high resin content of the cannabis, hashish
was born and its popularity spread quickly
during the twelfth century from the east to
North Africa in the West.
Hashish in the
Nineteenth Century
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Before the nineteenth century hashish was not
known in Europe, Pope Innocent VIII in 1484
condemned witchcraft and the use of hemp in the
Black Mass .
By 1800 marijuana was widely used for two reasons:
1) French soldiers who had served in Napoleon’s
campaigns in Egypt brought hashish back with them
to their homes in France. 2) The wave of romanticism
that swept over Europe, including an increased
interest in exotic stories of the East, such as Arabian
Nights and The Tales of Marco Polo which contained
references to hashish.
Hashish in the
Nineteenth Century
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In Paris during 1840’s a small group of
prominent French artists, writers and
intellectuals formed the Club des Hachichins
(Club of Hashish-Eaters), members included
Victor Hugo.
They gather “to take of literature, art and love”
while consuming large quantities of hashish.
The mixture consisted of a concentrated hemp
paste, mixed with butter, sweeteners, and
flavoring such as vanilla and cinnamon.
Marijuana and Hashish
in the Twentieth Century
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By 1890, cotton had replaced hemp as a major
cash crop in southern states although cannabis
plant continued to grow wild along road sides
and in the fields.
It was not until the 1920’s that marijuana began
to be a noticeable phenomenon.
Some authors had related the appearance of
marijuana as a recreational drug to social
changes brought on by prohibition when it was
difficult to obtain good quality liquor at
affordable prices.
At first its recreational use was restricted to Jazz
musicians and people in show business.
Marijuana and Hashish
in the Twentieth Century
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Famous mainstream clarinetist and band leader
Benny Goodman had his popular hit “Sweet
Marihuana Brown”.
Marijuana by that time was tolerated by
authorities because it was not illegal.
Marijuana was not considered as a social threat.
In late the 1920’s and the early 1930’s there was
a large migration of Mexicans to the United
States, they entered the country through towns
along the Mexican border and along the Gulf
Coast.
Marijuana and Hashish
in the Twentieth Century
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In Mexican communities marijuana was, in the
words of one historian “a casual adjunct to life
… a relaxant, a remedy for headaches, a mild
euphoric cheaply obtained for two cigarettes for
the dollar.
Rumors about the violent behavioral
consequences of marijuana smoking among
Mexicans began to spread. The idea was
unchallenged by objective data.
Considering the hysteria against marijuana
smoking and cannabis use in general Congress
passed the Marijuana tax act of 1937.
Marijuana and Hashish
in the Twentieth Century
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The marijuana regulation was accomplished indirectly as
the act did not ban marijuana; it merely required
everyone connected with marijuana, from growers to
buyers to pay a tax.
It was a simple procedure that, in effect, made it
virtually impossible to comply with the law.
In absence of compliance, a person was in violation of
the act and therefore subject to arrest.
During the 1940’s and 1950’s the theory that marijuana
was connected to violence slowly faded away, only to be
replaced by a new notion, the gateway theory.
According to the gateway theory marijuana is dangerous
because its abuse will lead to the abuse of heroin,
cocaine, or other illicit drugs.
Marijuana and Hashish
in the Twentieth Century
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Penalties for involvement with marijuana increased, in
certain states the penalties were harsh. Judges had the
option of sentencing a marijuana seller or user to life
imprisonment. In Georgia, a second offence of selling
marijuana to a minor could be punishable by death.
In 1969, the U.S. Supreme Court ruled the 1937
Marijuana Tax Act to be unconstitutional. The argument
was made that requiring a person to pay tax in order to
possess an illegal substance is a form of selfincrimination, which would be a specific violation of the
fifth amendment to the constitution.
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Reefer – A common name for a marijuana
cigarette.
Joint – a marijuana cigarette.
Psychiatric Symptoms in
Marijuana Users
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Effects of moderate intoxication (Zinberg et al) attitude
and expectations or mental “set” and environmental
combine with pharmacological effects to produce
subjective experience of intoxication.
Euphoria – well-being and peacefulness are universally
described in experimental studies in drug naïve and drug
experienced volunteers.
During cannabis intoxication an awareness of alteration
in thought processes is frequently reported. Subjects
may describe their thoughts as being fragmented (Ames,
1958) or more efficient than usual (Chopra & Smith,
1974).
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Some cannabis users claim that after taking the
drug they can recall distant memories to which
they would not ordinarily have access to. (Tart,
1970).
However experimental studies on the effect of
THC on memory did not show any measurable
effects on long term memory retrieval.
Suspiciousness and paranoia are common
experiences.
Subjects also reported that time seems to pass
more slowly.
Marijuana smokers reported increase awareness
of their surroundings as well as sharpened sense
of sight and sounds.
Adverse Reactions
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Anxiety provoking with mild intoxication.
Panic attacks – acute anxiety reactions to
Marijuana may include restlessness,
depersonalization, sense of loss of control,
fear of panic and paranoia.
Cannabis induced psychotic
reaction – Acute toxic confusion
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Toxic psychosis can follow ingestion of
cannabis.
Acute toxic psychosis is more common to
occur with higher doses of Delta-9-THC.
Typically symptoms are apprehension
suspiciousness, confusion, memory
impairment, depersonalization, derealization, and hallucination.
Psychiatric Symptoms in Cannabis Users: Table 1
Case reports of psychosis associated with cannabis use
YEAR
COUNTRY
NUMBER
OF CASES
COMMENTS
1955
Brazil
1
Mental confusion and hallucinations in a Brazilian Indian who had smoked 2g
cannabis.
1968
USA
3
First time users. Description of symptoms is scanty. Had extreme paranoid
reactions. No mention of outcome.
1969
India
3
Full report was of 6 cases – the other three experienced acute anxiety or
depersonalization only.
1969
Vietnam
12
First-time users. All had impaired cognitive function. Ten had paranoid symptoms.
Well (1970) comments that these may be true cases of toxic psychosis in view of
the soldiers exceptional circumstances.
(US soldiers)
1971
USA
8
Authors commented on the absence of previous psychosis of family history of
psychosis.
1973
India
4
Schizophrenia-like acute psychosis in long-term users of beverage containing
cannabis products (‘bhang’).
1982
Sweden
4
No pre-existing psychosis or abuse of other drugs. Marked confusion noted.
Reported also included seven cases of ‘subacute’ and ‘chronic’ psychosis.
1983
UK
1
Subject had a history of other drug abuse including ‘magic mushrooms’.
1984
Anguilla
5
Three schizophreniform psychoses, two manic.
1984
UK
9
Various clinical pictures – those with schizophreniform features had family histories
of psychosis. None had abused alcohol or other drugs. One patient had features
suggesting an acute toxic psychosis.
1986
UK
1
Psychiatric Symptoms in Cannabis Users: Table 2
Clinical studies of psychosis associated with cannabis use
YEAR
COUNTRY
NUMBER OF
SUBJECTS (type)
DESIGN
COMMENTS
1972
USA
100
(Cannabis Users)
Comparative
Psychiatric problems precede cannabis use.
1972
Germany
36,000
(US soldiers)
Descriptive
Confounded by use of other drugs and
alcohol. Symptoms included disorientation
and confusion.
1974
India
200
(Patients)
Descriptive
Symptoms included disorientation, amnesia
and confusion.
1976
Jamaica
88
(In-patients)
Descriptive
37.5% of patients diagnosed as having a
‘schizophreniform’ reaction had a history of
cannabis use, while the figure was lower for
all other diagnostic groups.
1982
S. Africa
20
(In-patients)
Retrospective
Case-control
Cannabis-using psychotics had a shorter
course and more hypomanic symptoms than
non-using psychotics.
Acute psychotic reaction in clear
consciousness
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An acute psychotic reaction may follow
cannabis use, clinical picture is
characterized by rapid onset and mixture
of affective and schizophrenic like
symptoms.
Mood Disturbances
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Self-limiting, dysphoric reactions are well
recognized consequences of cannabis use.
Serious mood disturbances can occur with
prolonged marijuana use, however this has not
been supported by controlled studies.
The increased risk of suicide found in one large
study needs further consideration.
Clinical reports have suggested that cannabis
use may precipitate relapse in patients with preexisting depressive disorder.
Relationship to Schizophrenia
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Some authors found causative role for the drug use in
the aetiology of chronic functional psychosis on the basis
that drug using schizophrenic patients had better premorbid personalities and earlier age of onset than the
non-users.
Andreasson et al 1987 reported the result of prospective
study of 45,570 Swedish patients over 15 year follow-up
period the relative risk for developing schizophrenia was
2.4 for cannabis users compared to non-users and 6.0
for heavy users.
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Marijuana appears to enhance or magnify positive
symptoms of schizophrenia in established cases.
Some patients use marijuana to counteract the side
effects of neuroleptics, or to counteract the sense of loss
or emptiness a schizophrenic may feel when his/her
delusions or hallucinations are suppressed by
medication.
Peralta & Cuesta 1992 published a Spanish study of 95
schizophrenic patients, 23 were marijuana users, and
found no difference in positive symptoms, but a
significantly higher rate of negative symptoms among
non-users.
The Residual Cognitive Effects of Heavy Marijuana
Use in College Students Harrison G. Pope Jr. MD et al JAMA 1996
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Design – Single-blind comparison of regular
users vs infrequent users of marijuana.
Participants – Two samples of college
undergraduates: 65 heavy users, and 64 light
users.
Intervention – Neuropsychological tests were
administered to all subjects , all subjects were
abstinent from marijuana and other drugs for a
minimum of 19 hours before testing.
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Results – Heavy users displayed
significantly greater impairment than light
users on attentional/executive functions .
Conclusions – Heavy marijuana use is
associated with residual
neuropsychological effects even after a
day of supervised abstinence from the
drug.
Cognitive Functioning of Long-term Heavy
Cannabis Users Seeking Treatment
Solowij, PhD et al JAMA 2002
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Objective – To examine the effects of duration of
cannabis use on specific areas of cognitive
functioning .
Design, Setting, and Participants
Multisite retrospective cross-sectional
neuropsychological study conducted in the US
between 1997 and 2000 among 102 near-daily
cannabis users (51 long-term users and 51
shorter-term users) compared with 33 nonuser
controls.
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Results – Long-term cannabis users performed
significantly less well than shorter-term users
and controls on tests of memory and attention.
Long-term users showed impaired learning ,
retention , and retrieval compared with controls.
Conclusions – These results confirm that longterm heavy cannabis users show impairments in
memory and attention that endure beyond the
period of intoxication and worsen with increasing
years of regular cannabis use.
Amotivational Syndrome
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1986 William McGlothin, a psychologist, and Louis West,
a psychiatrist, proposed that chronic marijuana smoking
among young people was responsible for amotivational
syndrome.
Regular marijuana use may contribute to the
development of more passive, inward turning personality
characteristics, for numerous middle class students, the
subtly progressive change from conforming,
achievement-oriented behavior to a state of relaxed and
careless drifting has followed their use of significant
amount of Marijuana.
Such individuals exhibit greater introversion, become
totally involved with the present at the expense of their
future goals and demonstrate a strong tendency toward
regressive, childlike magical thinking.
Cardiovascular Effect
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“circulation 2001”
Smoking marijuana increase heart rate, supine
hypertension and postural hypotension.
Mittleman MD. reported triggering myocardial
infarction with marijuana.
Interviewed 3,882 patients with acute M.I an
average of 4 days after infarction onset.
Of the 3,882 patients 124 (3.2%) reported
smoking marijuana in the prior year, 37 within
24 hours and 9 within 1 hour of M.I. symptoms.
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Compared with non-users marijuana users were
more likely to be:
Men
 Current cigarette smokers
 Obese
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Marijuana smokers were less likely to:
Have history of angina
 Hypertension
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Risk of M.I. was elevated 4.8 times over baseline
in the 60 minutes after marijuana use, the
elevated risk rapidly decreases thereafter.
Conclusions – smoking marijuana is a rare
trigger of acute M.I.
Myocardial Infarction Following the
Combined Recreational Use of Viagra and
Marijuana
“clinical cardiology 2002”
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Viagra is widely prescribed treatment for male
erectile dysfunction.
Viagra is metabolized by the cytochrome P450
3A4 hepatic microsemal isoenzyme.
Marijuana is an inhibitor of the cytochrome P450
3A4 isoenzyme.
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Case report about myocardial infarction following
combined use of viagra and marijuana.
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Male age 41 years old
Non-smoker
No history of D.M. or HTN
No family history of premature coronary artery disease
No past history of impotence
Admit smoking marijuana the previous evening and
taking recreationally one tablet of viagra 12 hours before
onset of chest pain.
Myocardial infarction was confirmed by EKG and cardiac
enzymes.
Effects on sexual functioning
and reproduction
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Men
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Reduces level of testosterone
Reduces sperm count
Increases percentage of abnormally formed sperm.
Women
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Reduction in level of lutenizing hormone (LH), a hormone
necessary for fertilized egg to be implemented in the
uterus.
Medical Uses for Marijuana
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Glaucoma
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Asthma
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Smoking marijuana reduces I.O.P. in normal human
subjects.
THC eye drops reduce glaucoma symptoms.
Initial bronchodiltion, followed by bronchoconstriction.
Nausea
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Cancer treatment.
AIDS patient.
The End