The Other McCain

"One should either write ruthlessly what one believes to be the truth, or else shut up." — Arthur Koestler

‘Medical’ Marijuana: There Must Be an Epidemic of Glaucoma in the ‘Hood

Posted on | October 30, 2015 | 156 Comments

Want to read something laugh-out-loud funny? This woman’s account of a guy who bummed a ride home after her local college class is worth a read if you enjoy, uh, authentic urban dialect.

The highlight of the story — which occurs in Los Angeles, we can gather — is a visit to a legal “medical marijuana” vendor “off Crenshaw somewhere.” Da Tech Guy points out how this story shows the way in which California’s legalization of marijuana for “medical” purposes has basically allowed the state to gain tax revenue from a hitherto illegal market. It is obvious from the woman’s story that “medical” marijuana is being sold to people whose only disease is a desire to get high. Otherwise, we would have to imagine that there has been an epidemic of glaucoma in, uh, low-income urban communities.

 

Comments

156 Responses to “‘Medical’ Marijuana: There Must Be an Epidemic of Glaucoma in the ‘Hood”

  1. Southern Air Pirate
    October 30th, 2015 @ 11:14 pm

    There are folks who have been fired for perfume.
    http://nypost.com/2007/10/01/lost-job-over-my-perfume/
    others have imposed a no client policy on those that chose to wear fragrances
    http://www.nbcnews.com/id/23836093/ns/health-behavior/t/odor-tyrants-those-sensitive-scent-fight-back/
    It won’t stop because folks have extended the concept and idea of rights beyond the bubble of their own personal space. It has expanded as well that the only rights are those that have felt infringed and hated on the rest of the world needs to make accommodations for them.

  2. DeadMessenger
    October 30th, 2015 @ 11:17 pm

    As someone who received near fatal amounts of chemo and radiation to “treat” terminal cancer, I can tell you from VAST experience that, yes, there are anti-nausea drugs, and no, they do not work worth a crap. And yes, I’ll own this: I used mj at that time to treat both the nausea and lack of appetite, and it worked FAR better than any of the disgusting “medicines” I had fobbed on me by witch doctors.

    I am onboard with kids not using it at all, and I have read about permanent ill effects on kids and teenagers who are still developing. Recreational for adults? Not in favor of that, because I did experience some down sides, and I saw them in other people I knew. True medicinal, hell yeah. But trust the government to decide? Shyeah, right. Should be a doctor/patient thing.

  3. Finrod Felagund
    October 30th, 2015 @ 11:21 pm

    I agree with every word you wrote there.

  4. DeadMessenger
    October 30th, 2015 @ 11:22 pm

    Oh come ON! I used it when I had cancer. I was 99th percentile mensa before that, and now I’m still 99th percentile mensa. Plus, I’m here talking to you, aren’t I, not eating Twinkies and listening to Black Sabbath backwards!

    It’s like anything though; it can be abused. And when people abuse stuff, they get effed up.

  5. Finrod Felagund
    October 30th, 2015 @ 11:27 pm

    So how much of that has been proven scientifically?

  6. DeadMessenger
    October 30th, 2015 @ 11:38 pm

    QM is right. People here will gut you like a trout under certain circumstances. No one was gutted here today. This was more like a little spat; a lover’s quarrel. That analogy breaks down at this point, on account of no make-up se….uh….never mind.

  7. DeadMessenger
    October 30th, 2015 @ 11:41 pm

    Wait till they figure out a way to tax sex. That’s when the progs will go all small-government upside people’s heads.

  8. Jason Lee
    October 31st, 2015 @ 4:52 am

    Literature review current through: Sep 2015. | This topic last updated: Sep 22, 2014.

    INTRODUCTION — Cannabis is the most commonly used illegal substance worldwide [1]. Approximately 160 million people or approximately four percent of the world’s population between the ages of 15 and 64 years have been estimated to have used cannabis at least once in the past year.

    The psychoactive properties of cannabis are primarily due to delta-9-tetrahydrocannabinol (THC) [2]. The THC content of cannabis has increased significantly since the late 1960s from approximately 1 to 5 percent to as much as 10 to 15 percent [3]. This increased potency may contribute to increased rates of cannabis use disorder.

    The psychiatric diagnoses, cannabis abuse and cannabis dependence, in DSM-IV-TR were replaced by one diagnosis, cannabis use disorder, in DSM-5 [4]. Although the crosswalk between DSM-IV and DSM-5 disorders is imprecise, cannabis dependence is approximately comparable to cannabis use disorder, moderate to severe subtype, while cannabis abuse is similar to the mild subtype.

    The prognosis, treatment, and long-term medical effects of cannabis use disorder are reviewed here. Other issues related to cannabis use disorder are discussed separately. Treatment of medical conditions such as chemotherapy-induced emesis and cancer pain with cannabinoids are discussed separately. Other issues related to cannabis intoxication or addiction are discussed separately. (See “Cannabis use disorder: Clinical features and diagnosis” and “Characteristics of antiemetic drugs”, section on ‘Cannabinoids’ and “Cancer pain management: Adjuvant analgesics (coanalgesics)”, section on ‘Cannabis and cannabinoids’ and “Cannabis use disorder: Epidemiology, comorbidity, and pathogenesis” and “Cannabis (marijuana): Acute intoxication”, section on ‘Management’.)

    TREATMENT PRINCIPLES AND OVERVIEW — Treatment for cannabis use disorder usually occurs on an outpatient basis, but residential treatment may be required for patients who cannot remain abstinent in an ambulatory setting or those with multiple concurrent substance use disorders. Treatment may occur in a partial hospital or inpatient setting if the patient is psychotic, suicidal, or agitated, or has been hospitalized for another psychiatric disorder.

    The patient’s family should be involved in treatment, in order to provide additional history, learn about the disorder, and help monitor the patient’s progress.

    Patients should generally aim to achieve sustained abstinence from cannabis rather than a controlled level of use that does not impair functioning. It may be necessary to accept moderation as an initial goal in order to engage some patients in the treatment process. Patients may develop a series of goals along the way to abstinence, such as abstaining from cannabis but not nicotine, reducing the frequency or amount of cannabis used, or limiting cannabis use to low risk situations, for example, not driving while intoxicated. Other goals for treatment include improved psychological, social, and occupational functioning [5].

    Drug testing is useful for monitoring progress and early detection of relapse. A review found that intensive monitoring of substance use may increase recovery rates [5]. (See “Cannabis use disorder: Clinical features and diagnosis”.)

    Abstinence from cannabis for one or more consecutive days prior to the day of the intake assessment for treatment is associated with better treatment outcomes [6]. A study found that a significantly higher proportion of patients who abstained prior to treatment submitted one or more cannabis negative urine tests during treatment, compared to patients who did not abstain prior to treatment.

    Most clinical trials of the efficacy of interventions for cannabis use disorder studied patients with a DSM-IV diagnosis of cannabis dependence. Applying these findings to patients diagnosed under DSM-5 is imprecise, but the most closely comparable patients are those with cannabis use disorder, moderate to severe subtype (ie, patients with four or more symptoms within a 12-month period) [4]. DSM-5 criteria for cannabis use disorder are described in a table (table 1). (See “Cannabis use disorder: Clinical features and diagnosis”, section on ‘Diagnosis’.)

    We suggest psychosocial interventions over medication for first line treatment of cannabis use disorder. Randomized trials have shown several psychosocial programs to reduce cannabis use [5,7,8]. A single randomized trial found acetylcysteine to result in a greater proportion of negative urine tests compared to placebo [9].

    PSYCHOSOCIAL INTERVENTIONS — Psychosocial interventions with evidence of effectiveness in the treatment of cannabis use disorder attempt to stop compulsive use by one or more of the following strategies [5]:

    ?Enhance motivation to reduce or end cannabis use

    ?Improve social skills

    ?Improve social support and interpersonal functioning

    ?Change reinforcement contingencies

    ?Manage painful feelings

    ?Education about consequences of cannabis use

  9. Jason Lee
    October 31st, 2015 @ 4:53 am

    At minimum, we suggest addiction counseling incorporating these strategies. Based on availability and patient preference, participation in a psychosocial program with demonstrated effectiveness in cannabis use disorder is suggested, ie, cognitive behavioral therapy, motivational interviewing, or voucher-based incentives.

    No specific psychotherapy has been consistently shown to be superior to any other psychotherapy in treating cannabis use disorder [8]. Contingency management has been shown to effectively augment other forms of psychotherapy [8]. Longer therapies do not consistently lead to better outcomes than shorter therapies.

    A systematic review of randomized controlled trials concluded that psychotherapy is more likely to reduce cannabis use than lead to abstinence [7]. Many patients with cannabis use disorder do not complete treatment, do not achieve abstinence, or they resume cannabis use soon after completing these treatments [5,10,11]

    Cognitive behavioral therapy — Cognitive behavioral therapy (CBT) attempts to change maladaptive cognitive thoughts and to improve social skills and interpersonal relationships. Behavioral strategies to help patients cope with events that trigger cannabis use are based upon a functional analysis of cannabis use. This analysis helps patients recognize the antecedents and consequences of cannabis use (ABC: Antecedents, cannabis use Behavior, Consequences). Treatment sessions last approximately an hour and occur once per week.

    A systematic review reported that in multiple randomized trials, both group and individual CBT reduced cannabis use and associated problems in patients with cannabis dependence [7].

    Motivational interviewing — Motivational interviewing attempts to increase the patient’s motivation to stop addictive behaviors by eliciting the patient’s reasons for changing as well as ambivalence towards change. Motivational interviewing takes a less directive approach and includes such techniques as expression of empathy, reflection, summarization, and exploration of the pros and cons of cannabis use [12]. (See “Motivational interviewing for substance use disorder”.)

    Systematic reviews from 2006 and 2008 concluded motivational interviewing was efficacious in reducing cannabis use [7,13]. As an example, one study found the percentage of days that patients smoked cannabis was significantly less in the group assigned motivational enhancement compared to the control group (56 versus 76 percent of days smoking) [14].

    A review found that motivational interviewing may be especially efficient for treating cannabis dependence. Similar rates of abstinence occurred in patients receiving either three hours of motivational interviewing or 28 hours of cognitive behavioral therapy [13].

    Voucher based incentives — Vouchers are used in contingency management, which provides the patient with a tangible reward contingent upon a desired behavior, such as attending a treatment session or maintaining cannabis abstinence. These incentives are used in conjunction with psychotherapy, such as cognitive behavioral therapy or motivational enhancement therapy. Vouchers typically have a monetary value that escalates with each performance of the desired behavioral [12]. Patients can exchange vouchers for items or service.

    Voucher based incentives have been found to increase the efficacy of outpatient cognitive behavioral therapy or motivational enhancement therapy for adults [7]. As an example, a US study found the proportion of patients who completed a four week treatment program was significantly higher for the group assigned to motivational enhancement plus vouchers, compared to those assigned to motivational enhancement alone (64 versus 39 percent) [11].

    Peer support groups — The effectiveness of peer support groups, such as Marijuana Anonymous, has not been rigorously studied in patients with cannabis use disorder, but in our clinical experience, they are an effective adjunct to addiction counseling or other psychosocial interventions. (See “Psychosocial treatment of alcohol use disorder”, section on ‘Peer support groups’.)

    Family therapy — Family therapy for cannabis use disorder is based on the theory that specific processes within the family system, such as conflicts, communication, and affective issues, can influence cannabis use.

    A randomized trial of 600 adolescents with cannabis dependence found multidimensional family therapy to be associated with reduction in cannabis use [15], but these results require further testing using a placebo controlled designed.

    Twelve to 15 family therapy sessions (typically six with the cannabis dependent adolescent, three with the parents, and six with the whole family) resulted in reductions in cannabis use and negative consequences sustained through the 12 month follow-up. Adolescents assigned to family therapy, compared to adolescents assigned to treatment combining motivational enhancement therapy plus cognitive behavioral therapy, demonstrated similar improvements with regard to the proportion who recovered from cannabis dependence (19 versus 23 percent of adolescents), and total days abstinent over 12 months (257 versus 251 days).

    PHARMACOTHERAPY — No medications have been consistently shown to be effective for cannabis use disorder. A single randomized trial of N-acetylcysteine led to an increased likelihood of negative urine tests in patients with cannabis use disorder compared to patients receiving placebo. No other medications have shown consistently positive results in rigorous clinical trials.

    Acetylcysteine — The antioxidant acetylcysteine, an N-acetyl prodrug of the naturally occurring amino acid cysteine, is available over-the-counter as a dietary supplement and as a prescribed medication in the US and other countries.

    A single trial suggests that acetylcysteine (NAC) may be effective for cannabis use disorder. In an eight week trial, 116 adolescents (15 to 21 years old) with cannabis dependence were randomized to receive orally administered NAC capsules 1200 mg or placebo twice daily [9]. Both groups additionally received a contingency management intervention and brief (<10 minutes) weekly cessation counseling. Compared to those receiving placebo, participants receiving NAC had more than twice the odds of having negative urine cannabinoid test results during treatment, the primary outcome (odds ratio 2.4, 95% CI 1.1 to 5.2). A greater proportion of urine tests were negative for cannabis in patients receiving NAC compared to patients receiving placebo (41 versus 27 percent). NAC was well tolerated with minimal adverse events.

    Antidepressants — Neither bupropion nor nefazodone reduced cannabis use or associated symptoms in multiple randomized trials of patients with cannabis use disorder [5,16,17].

    Anticonvulsants — A 12-week, randomized trial compared gabapentin (1200?mg/day) to placebo in 50 adult outpatients with cannabis dependence [18]. All participants received manual-guided, abstinence-oriented individual counseling weekly. Gabapentin reduced cannabis use by self-report and urine toxicology, and led to decreased withdrawal symptoms. Study limitations included a high dropout out rate.

    Two trials found minimal evidence to support divalproex in cannabis dependence. A randomized, placebo-controlled trial showed that divalproex at a dose of 750 mg twice per day decreases cannabis craving but worsens other withdrawal symptoms [19]. A second controlled trial found no significant differences between divalproex and placebo with regard to abstinence [20].

    Cannabinoid agonists — These agents show promise in reducing symptoms of cannabis withdrawal and therefore may also prevent relapse, but further study is needed.

    Oral delta-9-tetrahydrocannabinol (THC) is the best candidate for a medication to treat cannabis withdrawal symptoms [19,21]. A double blind, placebo controlled trial showed that THC (10 mg taken five times per day) decreased withdrawal symptoms and craving during cannabis abstinence while producing no intoxication [19].

    A small cross-over study found that the combination of THC and lofexidine (an alpha-2 adrenergic agonist that is not currently available in the US) was superior to other treatments in preventing withdrawal and relapse [22]. Compared to placebo, THC (20 mg three times per day) alone significantly decreased only a small subset of withdrawal symptoms and did not decrease cannabis relapse while lofexidine (0.6 mg per four times per day) alone did not attenuate withdrawal symptoms but significantly decreased relapse. The combination of THC and lofexidine significantly decreased withdrawal symptoms including craving and significantly decreased relapse.

    THC is currently available for prescription in Canada as a spray that combines THC and another plant cannabinoid called cannabidiol. The spray is indicated for treatment of neuropathic pain due to multiple sclerosis or cancer. The spray is not available in the US.

    Dronabinol is a cannabinoid used to treat anorexia associated with the acquired immunodeficiency syndrome, and nausea and vomiting associated with chemotherapy. A review found that dronabinol was superior to placebo in reducing withdrawal symptoms for heavy cannabis users in doses ranging from 10 mg three times per day to 30 mg three times per day [23].

  10. Jason Lee
    October 31st, 2015 @ 4:53 am

    COURSE AND PROGNOSIS

    Cannabis use can vary greatly in adolescents and young adults over time. A ten-year study followed 311 subjects aged 14 to 24 years who had used cannabis one to four times in their lives, during which time [24]:

    ?69 percent stopped using cannabis

    ?17 percent used cannabis one to four times

    ?11 percent used cannabis five or more times

    ?2 percent developed cannabis abuse

    ?1 percent developed cannabis dependence.

    Approximately 60 percent of cannabis users between the ages of 23 to 30 stop using the drug [25].

    Predictors of continued cannabis use among include [26]:

    ?Early onset of use

    ?Frequent use

    ?Male sex

    ?Using cannabis to enhance positive feelings and reduce negative feelings

    ?Using other illegal substances

    Over 50 percent of adolescents and young adults with abuse or dependence spontaneously improve. A German epidemiologic study prospectively followed a sample aged 14 to 24 years at baseline for up to four years [25]. Among those who at any point during follow up met criteria for cannabis abuse, over the following 12 months, 57 percent improved and no longer met abuse criteria, 41 percent remained abusers, and 2 percent developed dependence.

    Among those 14 to 24 years old who at any point during four years of follow up ever met criteria for cannabis dependence, over the following 12 months, 60 percent improved and no longer met criteria for dependence or abuse, 21 percent improved to the point where they met only abuse criteria, and 19 percent remained dependent [25].

    An observational study followed 162 Australian adults 17 years and older who used cannabis at least weekly for a minimum of three years [26]:

    ?One year after baseline, the same level of use persisted in 66 percent, and criteria for cannabis dependence were met by approximately 70 percent. Cannabis use declined to less than weekly or not at all in 19 percent.

    ?The only predictor of quantity of cannabis used at follow up one year later, after adjusting for various confounders, was quantity used at baseline.

    ?Use of other substances in the past year was common, including alcohol (in 97 percent), tobacco (79 percent), hallucinogens (44 percent), amphetamines (34 percent), cocaine (27 percent), and benzodiazepines (24 percent).

    ?Only 5 percent of the cohort obtained treatment, whereas 92 percent of those who decreased or stopped using cannabis did so without professional help.

    Persistent withdrawal symptoms often contribute to relapse of cannabis use [10,16]. A study of 739 cannabis users found that 42 percent reported craving cannabis as one of the symptoms of withdrawal [27]. (See “Cannabis use disorder: Clinical features and diagnosis”, section on ‘Cannabis withdrawal’.)

    Maintaining abstinence is difficult for adults who chronically use cannabis in large doses. A study evaluated adult cannabis dependent patients who regularly used cannabis for a mean of 15 years, and 4 times per day in the month prior to initiating a 14 week outpatient psychotherapy program [28]. Of the 82 patients who achieved at least two weeks of abstinence (confirmed by a negative urine screen), 71 percent subsequently resumed use at least once during the following six months. The mean time to use was 74 days. Relapse with at least four days of use within any seven day period occurred in 50 percent of the patients, with a mean of 83 days until relapse.

    Psychosocial functioning and health

    Short-term outcomes — Cannabis use is associated with a number of adverse psychosocial problems in the short term, including school dropout, using other illicit drugs, crime, and unemployment [29]. Many of the associations remain significant after controlling for various confounders.

    A longitudinal study followed a New Zealand birth cohort of 1265 children until age 21, and found a direct and significant relationship between frequency of cannabis use and the number of crimes committed, controlling for numerous known confounders [29]. As an example, individuals aged 14 to 15 years who used cannabis less than monthly committed 1.6 times more crimes compared with those who never used cannabis, while those who used at least weekly committed 3.7 times more crimes. These relationships declined with age but remained significant.

    An observational study of 162 Australian adults who used cannabis at least weekly for a minimum of three years found that one year after baseline, problems related to cannabis in the past year were reported by 44 percent of the cohort, including problems with family, friends, study, work, and the law [26].

    Long-term outcomes — Adverse consequences of cannabis use may diminish or disappear with sustained abstinence or reductions in use. As an example, a study of 56 monozygotic male twins discordant for cannabis use found that previous heavy cannabis use was not associated with adverse effects on physical and mental health, quality of life, and sociodemographic measures [30]. Cannabis using twins consumed cannabis for a mean of 1085 days, and had last used cannabis a mean of 20 years earlier. The control co-twins used cannabis for a maximum of five days in their lifetime. No significant differences between cannabis-using and non-using twins were seen in:

    ?Current level of education and household income

    ?Proportion who were married and employed

    ?Current level of health related quality of life

    ?Lifetime nicotine abuse or dependence

    ?Lifetime alcohol abuse or dependence

    ?Lifetime risk of various mood or anxiety disorders

    ?Medication use for medical problems in the past five years

    ?Number of outpatient or emergency room visits in the past five years

    ?Number of hospitalizations in the past five years

    LONG TERM MEDICAL EFFECTS OF CANNABIS USE

    Pulmonary — Cannabis smoke contains many of the same combusted particles found in tobacco smoke [31]. As an example, cannabis smoke contains approximately three times the amount of tar found in tobacco smoke and 50 percent more carcinogens [32]. In addition, hand rolled cannabis cigarettes are not filtered and the smoke is inhaled deeply [1]. However, individuals typically smoke far less cannabis than tobacco.

    Cannabis smoke irritates the airways and is associated with cough, sputum production, wheezing, bronchodilatation, and bronchitis, as well as dyspnea, pharyngitis, exacerbation of asthma, and exacerbation of cystic fibrosis [31]. An epidemiologic survey of a nationally representative US sample found that cannabis smokers have significantly higher rates of chronic inflammatory changes compared to those who do not smoke, after controlling for sex, age, current asthma, and tobacco use [33]. Longer-term use is associated with increased respiratory symptoms suggestive of obstructive lung disease [31].

    Long-term cannabis smoking has not been found to be associated with measures of pulmonary function or airflow obstruction [31]. As an example, a longitudinal study of 5,115 people over a 20-year period found that occasional and low, cumulative cannabis use was not associated with reduced pulmonary function (forced expiratory volume and forced vital capacity) [34].

    Cancer — Molecular, cellular, and histopathological evidence indicate that cannabis smoking may cause cancer [35,36], though research is inconclusive [35]. Many methodologic problems of existing studies, such as inadequate sample sizes and not accounting for important confounding factors, especially cigarette smoking, limit the ability to detect an association.

    ?Lung cancer — Cannabis smokers are probably at increased risk for lung cancer; the magnitude of risk has not been well quantified [37]. (See “Cigarette smoking and other risk factors for lung cancer”, section on ‘Marijuana and cocaine’.)

    ?Head and neck cancer — A pooled analysis of five case control studies did not find an association between cannabis use and cancer of the head and neck [38]. (See “Epidemiology and risk factors for head and neck cancer”, section on ‘Smoking’.)

    ?Bladder cancer — A case control study found that patients with transitional cell carcinoma of the bladder were significantly more likely to be habitual cannabis users, compared to the controls without transitional cell carcinoma (89 versus 69 percent) [39]. However, the clinical significance of this finding is unclear, especially in light of the fact that tobacco use was a potential confounding variable. (See “Epidemiology and etiology of urothelial (transitional cell) carcinoma of the bladder”.)

    Neuropsychological effects — Evidence of an association between cannabis use and long-term neurocognitive deficits is mixed.

    ?A 2003 meta-analysis including more than 600 cannabis users found no evidence that cannabis causes significant long term effects on neurocognitive processes [40]. These results were consistent with an epidemiologic study [41].

    ?In studies completed after the metaanalysis:

    •A comprehensive neuropsychological test battery was administered to monozygotic twin pairs discordant for regular cannabis use, in which neither twin used any other illicit substance regularly [42]. Testing was completed a minimum of one year after cannabis had last been used, with a mean of almost 20 years since last regular use. A total of 56 tests assessed the domains of general intelligence, attention, memory, executive functioning, and motor skills. Cannabis users performed significantly worse on only one of the tests compared with those who did not use cannabis.

    •In a prospective study of 1,037 individuals in New Zealand followed from birth to age 38 years, persistent cannabis use was associated with neuropsychological decline, across domains of functioning, controlling for education and other factors [43]. Impairment was seen principally among adolescent-onset cannabis users, with more persistent use associated with greater decline. Participants received serial neuropsychological testing beginning at age 13 years, prior to initiation of cannabis use, and at age 38 years

    While other studies have found evidence of deficits in attention, memory, executive functioning, and psychomotor speed related to dose and cumulative exposure to cannabis, these studies have involved smaller patient groups as well as potential confounding by ongoing or recent cannabis use and other factors [44-46].

    Neuroimaging studies have attempted to correlate structural and neurophysiologic changes with long-term cannabis use. In one study, magnetic resonance imaging showed that long term, heavy use is associated with significantly reduced volumes in the hippocampus and amygdala (two regions of the brain rich in cannabinoid receptors) [47]. In addition, a greater cumulative cannabis exposure is associated with more severe volume reductions. Other investigations using positron emission tomography, transcranial Doppler sonography, and EEG, have all suggested neurophysiologic changes in chronic cannabis users [48-50].

    Psychotic disorders — Substantial evidence indicates that cannabis use causes psychosis, beyond the transient psychosis sometime seen during intoxication:

    ?A meta-analysis of 83 observational studies found that onset of psychosis (schizophrenia-related illness) occurred significantly earlier (2.7 years) in patients who used cannabis, compared with patients who did not [51]. By contrast, alcohol use was not associated with a significantly earlier age of onset of psychosis.

    ?A systematic review of 35 longitudinal studies found a significantly increased risk of psychosis for those who ever used cannabis compared to those who did not (adjusted OR 1.41, 95% CI 1.20-1.65) [52]. The review also found a dose response relationship, with a two-fold increase in risk of psychosis for people who used cannabis most frequently (OR 2.09, 1.54-2.84). The outcome of psychosis ranged from self reported symptoms to clinical diagnoses of schizophrenia, and the study adjusted for confounding factors and excluded cohorts with identified mental illness or substance use problems.

    ?A review of neurochemical studies suggested cannabis use may cause psychosis through its effects on dopamine release [53].

    ?There is evidence that genetic factors may influence the risk of psychosis in adults who used cannabis as adolescents [54,55]. This may help explain why the vast majority of cannabis users do not develop psychosis.

    Cannabis use may exacerbate symptoms in patients with established psychotic illnesses such as schizophrenia. A systematic review of longitudinal studies (albeit with limitations) found cannabis use was consistently associated with increased relapse of psychosis, rehospitalization, and poor compliance with treatment [56].

    Depression — Cannabis use does not appear to cause depression.

    ?A systematic review of longitudinal studies did not find a significantly increased risk of depression for those who ever used cannabis compared to those who did not [52].

    ?A twin study concluded that comorbidity of cannabis dependence and major depressive disorder is probably due to genetic and environmental factors that predispose to both outcomes [57].

    Cardiovascular — Cannabis intoxication usually causes an increase in sympathetic activity and a decrease in parasympathetic activity, resulting in tachycardia and an increase in cardiac output with little or no increase in blood pressure [58]. High doses of cannabis inhibit sympathetic activity and increase parasympathetic activity, leading to bradycardia and hypotension. There have been reports of reversible EKG abnormalities affecting the P and T waves and the ST segment, and an increase in supraventricular and ventricular ectopic activity.

    Cannabis smoking may pose a risk of cardiovascular events for older people with coronary artery or cerebrovascular disease, because of increased catecholamines, increased carboxyhemoglobin levels, increased cardiac work, and possible episodes of intense postural hypotension [59].

    A large study found that smoking cannabis rarely triggered a myocardial infarction. Among cannabis users who did experience an acute myocardial infarction, the risk was nearly five times higher within the first hour after smoking compared to periods of nonuse (relative risk 4.8, 95% CI 2.9-9.5) [60]. The elevated risk rapidly declined thereafter.

    Immune system — Cannabis use appears to suppress aspects of immunological function, but it is not clear whether this causes increased rates of infection or other problems [50,61].

    Cannabinoid hyperemesis syndrome — Chronic heavy cannabis use can cause recurrent episodes of severe nausea, intractable vomiting, and abdominal pain, which resolves when cannabis use is stopped [62].

    Reproductive — Cannabis use suppresses secretion of testosterone in men [63], which may decrease libido and lead to impotence and gynecomastia. Cannabis use also causes decreased sperm count and motility. Changes in semen characteristics seen with heavy cannabis smoking may cause increased infertility [64].

    Chronic cannabis use increases prolactin levels in women [65], which may cause galactorrhea.

    The impact of prenatal cannabis use on the infant is not clear. Perinatal outcome and cannabis use are discussed separately. (See “Overview of substance misuse in pregnant women”, section on ‘Marijuana’.)

    Dental — Cannabis smoking may be associated with increased periodontal disease. In a prospective cohort study of 903 subjects, cannabis use was associated with a significantly higher incidence of periodontitis at age 32 years after controlling for tobacco smoking and a number of other potential confounders related to dental hygiene and regular dental care (OR 2.2, 95% CI 1.2-3.9) [66].

    Ophthalmologic effects — Smoking cannabis causes corneal vasodilation (red eyes) and reduction of intraocular pressure [67].

    INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12thgrade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

    Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

    ?Basics topics (see “Patient information: Marijuana use and addiction (The Basics)”)

    SUMMARY AND RECOMMENDATIONS

    ?Relatively few patients with cannabis use disorders pursue treatment, despite the availability of efficacious treatments. Typically, 10 years elapse between onset of cannabis use and contact with treatment services. (See ‘Treatment principles and overview’ above.)

    ?Treatment should generally aim to provide sustained abstinence from cannabis, but the goal of moderation in use may be needed to engage some patients in the treatment process. On average, even the most effective treatments for cannabis use disorder lead to a reduction in use rather than abstinence. (See ‘Treatment principles and overview’ above.)

    ?We suggest a psychosocial intervention over medication as first line treatment for patients seeking treatment for cannabis use disorder (Grade 2B). At minimum, we suggest addiction counseling incorporating strategies listed below. Based on availability and patient preference, participation in a psychosocial program with demonstrated effectiveness in cannabis use disorder is suggested, ie, cognitive behavioral therapy, motivational interviewing, or voucher-based incentives. No one of these therapies is clearly better than another. (See ‘Psychosocial interventions’ above.)

    •Enhance motivation to reduce or end cannabis use

    •Improve social skills

    •Improve social support and interpersonal functioning

    •Change reinforcement contingencies

    •Manage painful feelings

    •Education about consequences of cannabis use

    ?We suggest participation of patients with cannabis use disorder in a peer support group, such as Marijuana Anonymous, as an adjunct to treatment. (See ‘Peer support groups’ above.) (Grade 2C)

    ?In patients with cannabis use disorder who did not adequately respond to a psychosocial intervention, we suggest augmentation of the psychosocial intervention with acetylcysteine (NAC) (Grade 2B). Acetylcysteine 1200 mg is taken orally twice daily. (See ‘Acetylcysteine’ above.)

    ?Many patients treated for cannabis use disorder do not complete treatment, do not achieve abstinence, or they relapse soon after completion. Reduced use is more common than continuous abstinence. (See ‘Psychosocial interventions’ above.)

    ?While awaiting better evidence on the need for treatment and its effectiveness, we suggest not treating symptoms of withdrawal from cannabis use disorder (Grade 2C). (See ‘Cannabinoid agonists’ above.)

    ?Most adolescents or young adults using cannabis or suffering from cannabis use disorder spontaneously improve over time. (See ‘Course and prognosis’ above.)

    ?Cannabis use disorder in adults is fairly stable over the short term. Maintaining abstinence is difficult for adults who chronically use cannabis in large doses. Discontinuation of cannabis can lead to a withdrawal syndrome that can contribute to relapse of cannabis use. Drug testing is useful for monitoring progress and early detection of relapse, and can increase recovery rates. (See “Cannabis use disorder: Clinical features and diagnosis”.)

    ?Cannabis use is associated with a number of adverse psychosocial problems in the short term, including school dropout, using other illicit drugs, interpersonal problems with family and friends, crime, unemployment. These adverse consequences diminish or disappear with sustained abstinence or reductions in cannabis use. (See ‘Psychosocial functioning and health’above.)

    ?Cannabis affects multiple organ systems, but it is not clear whether continuous use causes long-term medical consequences. (See ‘Long term medical effects of cannabis use’ above.)

  11. Jason Lee
    October 31st, 2015 @ 4:54 am

    REFERENCES

    Leggett T, United Nations Office on Drugs and Crime. A review of the world cannabis situation. Bull Narc 2006; 58:1.

    Ashton CH. Pharmacology and effects of cannabis: a brief review. Br J Psychiatry 2001; 178:101.

    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, American Psychiatric Association, Washington, DC, 2000.

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  12. Peggy Higginbotham
    October 31st, 2015 @ 5:29 am

    ???

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    2qnb…….
    ??
    ??? http://GlobalEmploymentReportsTopStarJobsLine/Get/$97hourly… ?????????????????????????????????????????????????

  13. Peggy Higginbotham
    October 31st, 2015 @ 5:30 am

    ???

    .…my companion’s relative makes $97 working on a PC onIine……..A few days ago new McLaren F1 subsequent after earning 18,512$,,,this was my previous month’s paycheck ,and-a little over, $17k Last month ..3-5 h/r of work a day ..with extra open doors & weekly paychecks.. it’s realy the easiest work I have ever Do.. I Joined This 7 months ago and now making over $83, p/h..Learn More right Here….
    2qnb……..
    ??
    ??? http://GlobalEmploymentReportsTopStarJobsLine/Get/$97hourly… ?????????????????????????????????????????????????

  14. teapartydoc
    October 31st, 2015 @ 5:47 am

    Abolish occupational licensing.

  15. SouthOhioGipper
    October 31st, 2015 @ 7:08 am

    So what if alcohol is legal? Democracies are allowed to have such double standards if they so wish.

  16. SouthOhioGipper
    October 31st, 2015 @ 7:09 am

    Alcohol has far deeper cultural roots in the west than Marijuana.

  17. NeoWayland
    October 31st, 2015 @ 7:49 am

    I think we need to draw a line between public and private action. An employer should be able to fire someone if that employee costs them business or incurs extra costs.

    Legally forbidding something is entirely different.

    I do agree with you about the bubble of personal space and the special accommodations thing.

  18. NeoWayland
    October 31st, 2015 @ 7:53 am

    “That to secure these rights, Governments are instituted among Men, deriving their just Powers from the consent of the governed, — That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect.”

  19. NeoWayland
    October 31st, 2015 @ 7:58 am

    Moderation is a good thing.

    I think when government intervenes, it excuses people from taking responsibility for their actions.

    Many promote their own freedom, but only at the expense of someone else. Others don’t want to face the consequences of the things that they have done.

    You should be free to choose as long as your choice doesn’t interfere with another, BUT you should accept responsibility for your actions and words.

    Put individual freedom and personal responsibility together and the result is an incredibly potent catalyst that has been known to shake nations.

    One of mine. You can find the whole thing here. http://www.paganvigil.com/files/PaganVigilFAQ050512.html

  20. NeoWayland
    October 31st, 2015 @ 8:09 am

    Personally, I’m not into clowns…

  21. NeoWayland
    October 31st, 2015 @ 8:11 am

    Might be a good start.

    I like the idea of insurance companies taking that over. If they had all the liability, they’d make sure that there were some strong standards.

  22. SouthOhioGipper
    October 31st, 2015 @ 8:17 am

    The Founding Fathers never intended for the United States to become an anarchocapitalistic hedonist state ruled by vice. Vice is not worth a revolution over.

  23. NeoWayland
    October 31st, 2015 @ 8:19 am

    Pardon, but that’s not necessarily so.

    The DOI and the Constitution are both written on hemp paper. Hemp was used in most ropes, many fabrics, and soil cleanup,

    Washington and Jefferson both wrote about growing hemp for recreational use.

  24. NeoWayland
    October 31st, 2015 @ 8:24 am

    What the Founders intended was a new type of nation that might work, they didn’t know.

    Since then there have been many things that they didn’t foresee, some good, some bad. We’re still working our way through.

    The purpose of government shouldn’t be the institution, it should be protecting liberty.

  25. Quartermaster
    October 31st, 2015 @ 9:16 am

    That would be an amusing rumor to start.

  26. Quartermaster
    October 31st, 2015 @ 9:27 am

    I don’t think Matt is saying FedGov does those studies. If there appears to be evidence that MJ has some good medicinal effects, then such studies should be done.

    I think there is enough out there to allow such studies to proceed. As to allowing recreational use, no dice. As long as there is a welfare state that puts people on the roles after they have destroyed their lives, everyone else gets a say on the recreational biz. I’ve seen the bad effects that prolonged use has had on my younger brother and such use is simply idiotic.

  27. DeadMessenger
    October 31st, 2015 @ 9:29 am

    Um. Probably I missed something here. ‘Cause I don’t get it. But speaking of clowns, and considering the date, one year I was a juggalo. And when teenagers too old for trick or treating came to the door, I offered them either a can of lima beans or creamed corn. Probably lucky my house didn’t get burned down.

  28. Quartermaster
    October 31st, 2015 @ 9:33 am

    The welfare state is the biggest barrier to allowing general drug use. They allow drunks on welfare and SSI simply because they are drunks. They’ve done the same with druggies. As long as the costs of the behavior are socialized, then society gets a say on whether something is going to be deemed legal. The arguments about Gov not having a place in denying people their pleasures are empty as long as the welfare state exists.

  29. DeadMessenger
    October 31st, 2015 @ 9:36 am

    I personally know that it does have good medicinal effects. But has bad effects when people abuse it. This is all common sense. Not sure that srudies are required. But, you know, somebody will be looking for a grant, so whatever; the gubmint is getting involved one way or another. I’m not sure that any unbiased studies can be done on this topic.

  30. Quartermaster
    October 31st, 2015 @ 9:41 am

    If you want it legalized as a part of our pharmacy, you’re going to have to jump through the hoops as you would for any pharmaceutical.

  31. Matthew W
    October 31st, 2015 @ 10:28 am

    CRIKEYS !!!!!!
    The first sane response !!!
    Yes studies could/should be done. But as of right now there is no scientific proof that MJ is medicinal.

  32. Matthew W
    October 31st, 2015 @ 10:28 am

    YEAH !!!!!!!!!!!!!!!!!!
    You got it !!!!

  33. Matthew W
    October 31st, 2015 @ 10:30 am

    What a maroon !!
    Yeah, I’m a big gov fan because I don’t accept medical Mj based on the fact that there is no proof.
    Good night Gracie.

  34. NeoWayland
    October 31st, 2015 @ 10:37 am

    Clowns, make-up s…

  35. Mike G.
    October 31st, 2015 @ 4:55 pm

    Thanks for that. I have been on the road and couldn’t respond, plus I would have just given more anecdotal evidence.

  36. DeadMessenger
    October 31st, 2015 @ 5:52 pm

    Oh yes, those pharmaceutical hoops are sooooo rigorous, which is why a year after a new drug is released, the lawsuits start. This is my point. Hemp isn’t a new thing. It’s been used for centuries. The problem comes when people abuse it. Plus, pharma can’t patent it, so there will never even be the half-a$$ed “testing” that is normally done.

    In fact, getting back to testing, they don’t do any kind of longitudinal studies, which is where the real information is. That’s why teenage girls were dropping dead after taking those cervical cancer shots. To Big Pharma, you gotta break a few eggs, and that includes your children and spouse, then so be it.

  37. Quartermaster
    October 31st, 2015 @ 6:02 pm

    Whether I agree or not isn’t relevant. Whether you like it or not isn’t relevant either. That’s the way it is.

    The studies will have to be done, or the law will have to be changed. That’s the way it is.

  38. Quartermaster
    October 31st, 2015 @ 6:04 pm

    I likes apples and bananas. Got something agin ’em?

  39. Prime Director
    October 31st, 2015 @ 8:50 pm

    Look, I smoke a lot of weed. Lots and lots of it. Like, 2 zips a week of the good shit; literally, the best weed in the world. Straight from the bay area grow-rooms to my door (my friends supply the clubs). I smoke mostly blunts, swishers. Like, 4 or 5 a day. Why do I smoke so much? Pppbbbtttt… why do you drink so much? Respite, respite and nepenthe.

    Life is good.

    Yes, weed slows down cognition a bit, particulary memory. And reading comprehension; and forget quantitative reasoning, man…

    Plus, it fucks with your memory.

  40. DeadMessenger
    October 31st, 2015 @ 9:25 pm

    There’s money for greedy and corrupt governments – and more importantly, greedy and corrupt politicians – so I expect that MM will ultimately be a thing everywhere, bypassing any kind of need for “studies”. Especially in a state like FL, where there’s no state tax. If that’s going to be the case, I’d rather it got dispensed from a regular pharmacy via actual Rx in order to keep it away from kids, but instead, there will simply be a different kind of pusher. Then it’ll be as if we’re all living in Amsterdam. : )

  41. Matt_SE
    November 1st, 2015 @ 12:47 am

    The government is now a drug pusher. When Social Security goes bankrupt, they’ll probably legalize cocaine for the extra revenue.

  42. Matt_SE
    November 1st, 2015 @ 12:49 am

    Oh fuck…here we go. THIS IS NOT THE EIGHTEENTH FUCKING CENTURY! We don’t need hemp for rope, sailor.

  43. Erica Tilton
    November 1st, 2015 @ 3:36 am

    ?

    .like Margaret answered I didn’t realize that somebody can make $25678 in 4 weeks on the web….A few days ago new McLaren F1 subsequent after earning 18,512$,,,this was my previous month’s paycheck ,and-a little over, $17k Last month ..3-5 h/r of work a day ..with extra open doors & weekly paychecks.. it’s realy the easiest work I have ever Do.. I Joined This 7 months ago and now making over $83, p/h..Learn More right Here….
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  44. Erica Tilton
    November 1st, 2015 @ 3:36 am

    ?

    .like Margaret answered I didn’t realize that somebody can make $25678 in 4 weeks on the web….A few days ago new McLaren F1 subsequent after earning 18,512$,,,this was my previous month’s paycheck ,and-a little over, $17k Last month ..3-5 h/r of work a day ..with extra open doors & weekly paychecks.. it’s realy the easiest work I have ever Do.. I Joined This 7 months ago and now making over $83, p/h..Learn More right Here….
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    ??
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  45. NeoWayland
    November 1st, 2015 @ 7:17 am

    You should look at what Irenée du Pont (as in that du Pont) did and why.

    It would be like if Coca-Cola and Disney conspired to tell you that milk brought out psychotic and uncontrollable behavior, all while Coca-Cola was introducing a new line of wellness drinks.

  46. NeoWayland
    November 1st, 2015 @ 7:24 am

    One other thing, whether we need rope or not should have nothing to do with if government regulates it and tries to suppress it.

    If people choose to buy one product over another, that’s the free market. If government takes one product away so others can benefit, that’s crony capitalism and only a step or two removed from fascism.

  47. Matt_SE
    November 1st, 2015 @ 9:17 am

    If everyone goes their own way, we’ll all end by going the same way.

  48. NeoWayland
    November 1st, 2015 @ 1:17 pm

    Not sure if we’ll go the same way, but choosing without government interference sounds pretty good to me.

    People should make their own choices and accept responsibility.

  49. Robert What?
    November 1st, 2015 @ 7:14 pm

    Even with everything bad you might say about legalization of marijuana, I would still take it over the disastrous “drug wars” that have turned us into a police state, destroyed countless lives, and consumed untold billions of national wealth.

  50. Matt_SE
    November 1st, 2015 @ 7:52 pm

    People should also be nice to each other so we won’t have wars.