Petros Levounis MD MA Chair
Department of Psychiatry Rutgers ndash New Jersey Medical School
Rutgers ndash New Jersey Medical School Fundamentals of Addiction Medicine Summer Series
Newark NJ ndash August 7 2013
TOBACCO and CANNABIS
2
1 Tobacco Basics 2 Tobacco Treatments 3 Cannabis Basics 4 Cannabis Treatments 5 Cannabis Special Topics 6 Conclusions
Outline
2
1 Tobacco Basics
3
Wikipediaorg
The Molecular Structure
4 4
Benowitz Med Clin N Am 1992
The Nicotine Cycle
5
Serotonin
GABA
Acetylcholine
β-Endorphins
Glutamate
Norepinephrine
Dopamine
Mood Elevation (appetite)
Anxiety Relief
Arousal and Cognition
Reduction of Tension
Learning and Memory
Arousal ( appetite)
Pleasure ( appetite)
Benowitz N Engl J Med 2010
Intoxication
6
Serotonin
GABA
Acetylcholine
β-Endorphins
Glutamate
Norepinephrine
Dopamine
Depressed Mood
Anxiety
Insomnia
Irritability
Difficulty Concentrating
Decreased Heart Rate
Appetite (and Cravings)
Withdrawal
7
Benowitz N Engl J Med 2010
Carbon monoxide Hydrogen cyanide Ammonia Benzene Formaldehyde
Nicotine Nitrosamines Lead Cadmium Polonium-210
An estimated 4800 compounds in tobacco smoke including 11 proven human carcinogens
Gases Particles
Nicotine is the addictive component of tobacco products but it does NOT cause the ill health effects of tobacco use
Compounds in Tobacco Smoke
8
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
bull Cancers ndash Acute myeloid leukemia ndash Bladder and kidney ndash Cervical ndash Esophageal ndash Gastric ndash Laryngeal ndash Lung ndash Oral cavity and pharyngeal ndash Pancreatic
bull Pulmonary diseases ndash Acute (eg pneumonia) ndash Chronic (eg COPD)
bull Cardiovascular diseases ndash Abdominal aortic aneurysm ndash Coronary heart disease ndash Cerebrovascular disease ndash Peripheral arterial disease
bull Reproductive effects ndash Reduced fertility in women ndash Poor pregnancy outcomes
(eg low birth weight preterm delivery)
ndash Infant mortality
bull Other effects cataract osteoporosis periodontitis poor surgical outcomes
Health Consequences
9
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Lung cilia regain normal function Ability to clear lungs of mucus increases Coughing fatigue shortness of breath decrease
Excess risk of CHD decreases to half that of a
continuing smoker Risk of stroke is reduced to that of people who have never smoked
Lung cancer death rate drops to half that of a
continuing smoker Risk of cancer of mouth
throat esophagus bladder kidney pancreas
decrease
Risk of CHD is similar to that of people who have never smoked
2 weeks to
3 months 1 to 9
months
1 year
5 years
10 years
after 15 years
Time Since Quit Date
Circulation improves walking becomes easier Lung function increases
up to 30
Quitting Health Benefits
10
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Caffeine Clozapine
Olanzapine Haloperidol
Chlorpromazine Fluvoxamine
Tacrine Theophyline
Drugs that may have a decreased effect due to induction of CYP1A2 by tobacco smoke
Smoking cessation may reverse the effect
Drug Interactions 1
11
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Drug Interactions 2
Smokers who use oral combined contraceptives (estrogen and progestin) have an increased risk of serious cardiovascular adverse effects including
Stroke Myocardial infarction Thromboembolism
Experts do not recommend oral contraceptives for women who are
Over 35 and Heavy (gt15 cigarettes per day) smokers
12
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
0
50
100
150
200
250
300
350
400
450
AIDS Obesity Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced
Individuals with mental illness or substance use
disorders
Causes of Annual Deaths in the US
13 Centers for Disease Control and Prevention NHIS 2007 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Laser National Comorbidity Survey 1991-1992 JAMA 2000 slide courtesy of Judith J Prochaska PhD ndash UCSF
225
348
0
10
20
30
40
50
60
70
80
90
100
None History
Panic Disorder
PTSD
GAD
Dysthymia
Major Depression
Bipolar Disorder
Nonaffect Psychosis
ASPD
Alcohol AbuseDep
Drug abusedep
410 Overall
Active
Psychiatric History
14
2 Tobacco Treatments
15
1 Physician advice
2 Individual counseling
3 Telephone counseling
4 Group programs
5 Aversion therapy
6 Hypnotherapy
7 NRT bupropion varenicline nortriptyline clonidine
Evidence-Based Practices
16
1 SSRIs and SNRI
2 Anxiolytics benzodiazepines buspirone
3 Homeopathic treatments
4 Herbal supplements
5 Massage Therapy
6 Acupuncture
7 Nicotine Anonymous
Practices Lacking Evidence-Base
17
0
10
20
30
No clinician Self-helpmaterial
Nonphysicianclinician
Physicianclinician
Type of Clinician
Est
ima
ted
ab
stin
en
ce a
t 5
+ m
on
ths
10 11 17
22 n = 29 studies
Fiore Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline 2008 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Compared to patients who receive no assistance from a clinician patients who receive assistance are 17ndash22 times as likely to quit successfully for 5 or more months
Clinician Interventions
18
Nicotine Replacement
Therapy 19
1 Patients with underlying CVD Recent MI (within past 2 weeks) Serious arrhythmias Serious or worsening angina
2 Patients under 18 years of age
3 Pregnant women
General Precautions
20
1 Patch provides consistent nicotine levels
2 Patch is easy to use and conceal
3 Gumlozengeinhalerspray can titrate therapy to manage withdrawal and may satisfy oral cravings
4 Inhaler mimics hand-to-mouth ritual of smoking
5 Spray is most rapidly absorbed form of nicotine replacement
Advantages
21
1 Allergic reactions to patch adhesive
2 Vivid or disturbing dreams with nocturnal patch use
3 Gum may be socially unacceptable and difficult to use with dentures
4 Patients with underlying bronchospastic disease must use inhaler with caution
5 Spray may be addictive and patients must wait 5 min before driving
Disadvantages
22
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
2
1 Tobacco Basics 2 Tobacco Treatments 3 Cannabis Basics 4 Cannabis Treatments 5 Cannabis Special Topics 6 Conclusions
Outline
2
1 Tobacco Basics
3
Wikipediaorg
The Molecular Structure
4 4
Benowitz Med Clin N Am 1992
The Nicotine Cycle
5
Serotonin
GABA
Acetylcholine
β-Endorphins
Glutamate
Norepinephrine
Dopamine
Mood Elevation (appetite)
Anxiety Relief
Arousal and Cognition
Reduction of Tension
Learning and Memory
Arousal ( appetite)
Pleasure ( appetite)
Benowitz N Engl J Med 2010
Intoxication
6
Serotonin
GABA
Acetylcholine
β-Endorphins
Glutamate
Norepinephrine
Dopamine
Depressed Mood
Anxiety
Insomnia
Irritability
Difficulty Concentrating
Decreased Heart Rate
Appetite (and Cravings)
Withdrawal
7
Benowitz N Engl J Med 2010
Carbon monoxide Hydrogen cyanide Ammonia Benzene Formaldehyde
Nicotine Nitrosamines Lead Cadmium Polonium-210
An estimated 4800 compounds in tobacco smoke including 11 proven human carcinogens
Gases Particles
Nicotine is the addictive component of tobacco products but it does NOT cause the ill health effects of tobacco use
Compounds in Tobacco Smoke
8
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
bull Cancers ndash Acute myeloid leukemia ndash Bladder and kidney ndash Cervical ndash Esophageal ndash Gastric ndash Laryngeal ndash Lung ndash Oral cavity and pharyngeal ndash Pancreatic
bull Pulmonary diseases ndash Acute (eg pneumonia) ndash Chronic (eg COPD)
bull Cardiovascular diseases ndash Abdominal aortic aneurysm ndash Coronary heart disease ndash Cerebrovascular disease ndash Peripheral arterial disease
bull Reproductive effects ndash Reduced fertility in women ndash Poor pregnancy outcomes
(eg low birth weight preterm delivery)
ndash Infant mortality
bull Other effects cataract osteoporosis periodontitis poor surgical outcomes
Health Consequences
9
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Lung cilia regain normal function Ability to clear lungs of mucus increases Coughing fatigue shortness of breath decrease
Excess risk of CHD decreases to half that of a
continuing smoker Risk of stroke is reduced to that of people who have never smoked
Lung cancer death rate drops to half that of a
continuing smoker Risk of cancer of mouth
throat esophagus bladder kidney pancreas
decrease
Risk of CHD is similar to that of people who have never smoked
2 weeks to
3 months 1 to 9
months
1 year
5 years
10 years
after 15 years
Time Since Quit Date
Circulation improves walking becomes easier Lung function increases
up to 30
Quitting Health Benefits
10
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Caffeine Clozapine
Olanzapine Haloperidol
Chlorpromazine Fluvoxamine
Tacrine Theophyline
Drugs that may have a decreased effect due to induction of CYP1A2 by tobacco smoke
Smoking cessation may reverse the effect
Drug Interactions 1
11
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Drug Interactions 2
Smokers who use oral combined contraceptives (estrogen and progestin) have an increased risk of serious cardiovascular adverse effects including
Stroke Myocardial infarction Thromboembolism
Experts do not recommend oral contraceptives for women who are
Over 35 and Heavy (gt15 cigarettes per day) smokers
12
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
0
50
100
150
200
250
300
350
400
450
AIDS Obesity Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced
Individuals with mental illness or substance use
disorders
Causes of Annual Deaths in the US
13 Centers for Disease Control and Prevention NHIS 2007 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Laser National Comorbidity Survey 1991-1992 JAMA 2000 slide courtesy of Judith J Prochaska PhD ndash UCSF
225
348
0
10
20
30
40
50
60
70
80
90
100
None History
Panic Disorder
PTSD
GAD
Dysthymia
Major Depression
Bipolar Disorder
Nonaffect Psychosis
ASPD
Alcohol AbuseDep
Drug abusedep
410 Overall
Active
Psychiatric History
14
2 Tobacco Treatments
15
1 Physician advice
2 Individual counseling
3 Telephone counseling
4 Group programs
5 Aversion therapy
6 Hypnotherapy
7 NRT bupropion varenicline nortriptyline clonidine
Evidence-Based Practices
16
1 SSRIs and SNRI
2 Anxiolytics benzodiazepines buspirone
3 Homeopathic treatments
4 Herbal supplements
5 Massage Therapy
6 Acupuncture
7 Nicotine Anonymous
Practices Lacking Evidence-Base
17
0
10
20
30
No clinician Self-helpmaterial
Nonphysicianclinician
Physicianclinician
Type of Clinician
Est
ima
ted
ab
stin
en
ce a
t 5
+ m
on
ths
10 11 17
22 n = 29 studies
Fiore Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline 2008 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Compared to patients who receive no assistance from a clinician patients who receive assistance are 17ndash22 times as likely to quit successfully for 5 or more months
Clinician Interventions
18
Nicotine Replacement
Therapy 19
1 Patients with underlying CVD Recent MI (within past 2 weeks) Serious arrhythmias Serious or worsening angina
2 Patients under 18 years of age
3 Pregnant women
General Precautions
20
1 Patch provides consistent nicotine levels
2 Patch is easy to use and conceal
3 Gumlozengeinhalerspray can titrate therapy to manage withdrawal and may satisfy oral cravings
4 Inhaler mimics hand-to-mouth ritual of smoking
5 Spray is most rapidly absorbed form of nicotine replacement
Advantages
21
1 Allergic reactions to patch adhesive
2 Vivid or disturbing dreams with nocturnal patch use
3 Gum may be socially unacceptable and difficult to use with dentures
4 Patients with underlying bronchospastic disease must use inhaler with caution
5 Spray may be addictive and patients must wait 5 min before driving
Disadvantages
22
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
1 Tobacco Basics
3
Wikipediaorg
The Molecular Structure
4 4
Benowitz Med Clin N Am 1992
The Nicotine Cycle
5
Serotonin
GABA
Acetylcholine
β-Endorphins
Glutamate
Norepinephrine
Dopamine
Mood Elevation (appetite)
Anxiety Relief
Arousal and Cognition
Reduction of Tension
Learning and Memory
Arousal ( appetite)
Pleasure ( appetite)
Benowitz N Engl J Med 2010
Intoxication
6
Serotonin
GABA
Acetylcholine
β-Endorphins
Glutamate
Norepinephrine
Dopamine
Depressed Mood
Anxiety
Insomnia
Irritability
Difficulty Concentrating
Decreased Heart Rate
Appetite (and Cravings)
Withdrawal
7
Benowitz N Engl J Med 2010
Carbon monoxide Hydrogen cyanide Ammonia Benzene Formaldehyde
Nicotine Nitrosamines Lead Cadmium Polonium-210
An estimated 4800 compounds in tobacco smoke including 11 proven human carcinogens
Gases Particles
Nicotine is the addictive component of tobacco products but it does NOT cause the ill health effects of tobacco use
Compounds in Tobacco Smoke
8
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
bull Cancers ndash Acute myeloid leukemia ndash Bladder and kidney ndash Cervical ndash Esophageal ndash Gastric ndash Laryngeal ndash Lung ndash Oral cavity and pharyngeal ndash Pancreatic
bull Pulmonary diseases ndash Acute (eg pneumonia) ndash Chronic (eg COPD)
bull Cardiovascular diseases ndash Abdominal aortic aneurysm ndash Coronary heart disease ndash Cerebrovascular disease ndash Peripheral arterial disease
bull Reproductive effects ndash Reduced fertility in women ndash Poor pregnancy outcomes
(eg low birth weight preterm delivery)
ndash Infant mortality
bull Other effects cataract osteoporosis periodontitis poor surgical outcomes
Health Consequences
9
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Lung cilia regain normal function Ability to clear lungs of mucus increases Coughing fatigue shortness of breath decrease
Excess risk of CHD decreases to half that of a
continuing smoker Risk of stroke is reduced to that of people who have never smoked
Lung cancer death rate drops to half that of a
continuing smoker Risk of cancer of mouth
throat esophagus bladder kidney pancreas
decrease
Risk of CHD is similar to that of people who have never smoked
2 weeks to
3 months 1 to 9
months
1 year
5 years
10 years
after 15 years
Time Since Quit Date
Circulation improves walking becomes easier Lung function increases
up to 30
Quitting Health Benefits
10
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Caffeine Clozapine
Olanzapine Haloperidol
Chlorpromazine Fluvoxamine
Tacrine Theophyline
Drugs that may have a decreased effect due to induction of CYP1A2 by tobacco smoke
Smoking cessation may reverse the effect
Drug Interactions 1
11
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Drug Interactions 2
Smokers who use oral combined contraceptives (estrogen and progestin) have an increased risk of serious cardiovascular adverse effects including
Stroke Myocardial infarction Thromboembolism
Experts do not recommend oral contraceptives for women who are
Over 35 and Heavy (gt15 cigarettes per day) smokers
12
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
0
50
100
150
200
250
300
350
400
450
AIDS Obesity Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced
Individuals with mental illness or substance use
disorders
Causes of Annual Deaths in the US
13 Centers for Disease Control and Prevention NHIS 2007 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Laser National Comorbidity Survey 1991-1992 JAMA 2000 slide courtesy of Judith J Prochaska PhD ndash UCSF
225
348
0
10
20
30
40
50
60
70
80
90
100
None History
Panic Disorder
PTSD
GAD
Dysthymia
Major Depression
Bipolar Disorder
Nonaffect Psychosis
ASPD
Alcohol AbuseDep
Drug abusedep
410 Overall
Active
Psychiatric History
14
2 Tobacco Treatments
15
1 Physician advice
2 Individual counseling
3 Telephone counseling
4 Group programs
5 Aversion therapy
6 Hypnotherapy
7 NRT bupropion varenicline nortriptyline clonidine
Evidence-Based Practices
16
1 SSRIs and SNRI
2 Anxiolytics benzodiazepines buspirone
3 Homeopathic treatments
4 Herbal supplements
5 Massage Therapy
6 Acupuncture
7 Nicotine Anonymous
Practices Lacking Evidence-Base
17
0
10
20
30
No clinician Self-helpmaterial
Nonphysicianclinician
Physicianclinician
Type of Clinician
Est
ima
ted
ab
stin
en
ce a
t 5
+ m
on
ths
10 11 17
22 n = 29 studies
Fiore Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline 2008 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Compared to patients who receive no assistance from a clinician patients who receive assistance are 17ndash22 times as likely to quit successfully for 5 or more months
Clinician Interventions
18
Nicotine Replacement
Therapy 19
1 Patients with underlying CVD Recent MI (within past 2 weeks) Serious arrhythmias Serious or worsening angina
2 Patients under 18 years of age
3 Pregnant women
General Precautions
20
1 Patch provides consistent nicotine levels
2 Patch is easy to use and conceal
3 Gumlozengeinhalerspray can titrate therapy to manage withdrawal and may satisfy oral cravings
4 Inhaler mimics hand-to-mouth ritual of smoking
5 Spray is most rapidly absorbed form of nicotine replacement
Advantages
21
1 Allergic reactions to patch adhesive
2 Vivid or disturbing dreams with nocturnal patch use
3 Gum may be socially unacceptable and difficult to use with dentures
4 Patients with underlying bronchospastic disease must use inhaler with caution
5 Spray may be addictive and patients must wait 5 min before driving
Disadvantages
22
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Wikipediaorg
The Molecular Structure
4 4
Benowitz Med Clin N Am 1992
The Nicotine Cycle
5
Serotonin
GABA
Acetylcholine
β-Endorphins
Glutamate
Norepinephrine
Dopamine
Mood Elevation (appetite)
Anxiety Relief
Arousal and Cognition
Reduction of Tension
Learning and Memory
Arousal ( appetite)
Pleasure ( appetite)
Benowitz N Engl J Med 2010
Intoxication
6
Serotonin
GABA
Acetylcholine
β-Endorphins
Glutamate
Norepinephrine
Dopamine
Depressed Mood
Anxiety
Insomnia
Irritability
Difficulty Concentrating
Decreased Heart Rate
Appetite (and Cravings)
Withdrawal
7
Benowitz N Engl J Med 2010
Carbon monoxide Hydrogen cyanide Ammonia Benzene Formaldehyde
Nicotine Nitrosamines Lead Cadmium Polonium-210
An estimated 4800 compounds in tobacco smoke including 11 proven human carcinogens
Gases Particles
Nicotine is the addictive component of tobacco products but it does NOT cause the ill health effects of tobacco use
Compounds in Tobacco Smoke
8
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
bull Cancers ndash Acute myeloid leukemia ndash Bladder and kidney ndash Cervical ndash Esophageal ndash Gastric ndash Laryngeal ndash Lung ndash Oral cavity and pharyngeal ndash Pancreatic
bull Pulmonary diseases ndash Acute (eg pneumonia) ndash Chronic (eg COPD)
bull Cardiovascular diseases ndash Abdominal aortic aneurysm ndash Coronary heart disease ndash Cerebrovascular disease ndash Peripheral arterial disease
bull Reproductive effects ndash Reduced fertility in women ndash Poor pregnancy outcomes
(eg low birth weight preterm delivery)
ndash Infant mortality
bull Other effects cataract osteoporosis periodontitis poor surgical outcomes
Health Consequences
9
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Lung cilia regain normal function Ability to clear lungs of mucus increases Coughing fatigue shortness of breath decrease
Excess risk of CHD decreases to half that of a
continuing smoker Risk of stroke is reduced to that of people who have never smoked
Lung cancer death rate drops to half that of a
continuing smoker Risk of cancer of mouth
throat esophagus bladder kidney pancreas
decrease
Risk of CHD is similar to that of people who have never smoked
2 weeks to
3 months 1 to 9
months
1 year
5 years
10 years
after 15 years
Time Since Quit Date
Circulation improves walking becomes easier Lung function increases
up to 30
Quitting Health Benefits
10
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Caffeine Clozapine
Olanzapine Haloperidol
Chlorpromazine Fluvoxamine
Tacrine Theophyline
Drugs that may have a decreased effect due to induction of CYP1A2 by tobacco smoke
Smoking cessation may reverse the effect
Drug Interactions 1
11
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Drug Interactions 2
Smokers who use oral combined contraceptives (estrogen and progestin) have an increased risk of serious cardiovascular adverse effects including
Stroke Myocardial infarction Thromboembolism
Experts do not recommend oral contraceptives for women who are
Over 35 and Heavy (gt15 cigarettes per day) smokers
12
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
0
50
100
150
200
250
300
350
400
450
AIDS Obesity Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced
Individuals with mental illness or substance use
disorders
Causes of Annual Deaths in the US
13 Centers for Disease Control and Prevention NHIS 2007 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Laser National Comorbidity Survey 1991-1992 JAMA 2000 slide courtesy of Judith J Prochaska PhD ndash UCSF
225
348
0
10
20
30
40
50
60
70
80
90
100
None History
Panic Disorder
PTSD
GAD
Dysthymia
Major Depression
Bipolar Disorder
Nonaffect Psychosis
ASPD
Alcohol AbuseDep
Drug abusedep
410 Overall
Active
Psychiatric History
14
2 Tobacco Treatments
15
1 Physician advice
2 Individual counseling
3 Telephone counseling
4 Group programs
5 Aversion therapy
6 Hypnotherapy
7 NRT bupropion varenicline nortriptyline clonidine
Evidence-Based Practices
16
1 SSRIs and SNRI
2 Anxiolytics benzodiazepines buspirone
3 Homeopathic treatments
4 Herbal supplements
5 Massage Therapy
6 Acupuncture
7 Nicotine Anonymous
Practices Lacking Evidence-Base
17
0
10
20
30
No clinician Self-helpmaterial
Nonphysicianclinician
Physicianclinician
Type of Clinician
Est
ima
ted
ab
stin
en
ce a
t 5
+ m
on
ths
10 11 17
22 n = 29 studies
Fiore Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline 2008 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Compared to patients who receive no assistance from a clinician patients who receive assistance are 17ndash22 times as likely to quit successfully for 5 or more months
Clinician Interventions
18
Nicotine Replacement
Therapy 19
1 Patients with underlying CVD Recent MI (within past 2 weeks) Serious arrhythmias Serious or worsening angina
2 Patients under 18 years of age
3 Pregnant women
General Precautions
20
1 Patch provides consistent nicotine levels
2 Patch is easy to use and conceal
3 Gumlozengeinhalerspray can titrate therapy to manage withdrawal and may satisfy oral cravings
4 Inhaler mimics hand-to-mouth ritual of smoking
5 Spray is most rapidly absorbed form of nicotine replacement
Advantages
21
1 Allergic reactions to patch adhesive
2 Vivid or disturbing dreams with nocturnal patch use
3 Gum may be socially unacceptable and difficult to use with dentures
4 Patients with underlying bronchospastic disease must use inhaler with caution
5 Spray may be addictive and patients must wait 5 min before driving
Disadvantages
22
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Benowitz Med Clin N Am 1992
The Nicotine Cycle
5
Serotonin
GABA
Acetylcholine
β-Endorphins
Glutamate
Norepinephrine
Dopamine
Mood Elevation (appetite)
Anxiety Relief
Arousal and Cognition
Reduction of Tension
Learning and Memory
Arousal ( appetite)
Pleasure ( appetite)
Benowitz N Engl J Med 2010
Intoxication
6
Serotonin
GABA
Acetylcholine
β-Endorphins
Glutamate
Norepinephrine
Dopamine
Depressed Mood
Anxiety
Insomnia
Irritability
Difficulty Concentrating
Decreased Heart Rate
Appetite (and Cravings)
Withdrawal
7
Benowitz N Engl J Med 2010
Carbon monoxide Hydrogen cyanide Ammonia Benzene Formaldehyde
Nicotine Nitrosamines Lead Cadmium Polonium-210
An estimated 4800 compounds in tobacco smoke including 11 proven human carcinogens
Gases Particles
Nicotine is the addictive component of tobacco products but it does NOT cause the ill health effects of tobacco use
Compounds in Tobacco Smoke
8
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
bull Cancers ndash Acute myeloid leukemia ndash Bladder and kidney ndash Cervical ndash Esophageal ndash Gastric ndash Laryngeal ndash Lung ndash Oral cavity and pharyngeal ndash Pancreatic
bull Pulmonary diseases ndash Acute (eg pneumonia) ndash Chronic (eg COPD)
bull Cardiovascular diseases ndash Abdominal aortic aneurysm ndash Coronary heart disease ndash Cerebrovascular disease ndash Peripheral arterial disease
bull Reproductive effects ndash Reduced fertility in women ndash Poor pregnancy outcomes
(eg low birth weight preterm delivery)
ndash Infant mortality
bull Other effects cataract osteoporosis periodontitis poor surgical outcomes
Health Consequences
9
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Lung cilia regain normal function Ability to clear lungs of mucus increases Coughing fatigue shortness of breath decrease
Excess risk of CHD decreases to half that of a
continuing smoker Risk of stroke is reduced to that of people who have never smoked
Lung cancer death rate drops to half that of a
continuing smoker Risk of cancer of mouth
throat esophagus bladder kidney pancreas
decrease
Risk of CHD is similar to that of people who have never smoked
2 weeks to
3 months 1 to 9
months
1 year
5 years
10 years
after 15 years
Time Since Quit Date
Circulation improves walking becomes easier Lung function increases
up to 30
Quitting Health Benefits
10
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Caffeine Clozapine
Olanzapine Haloperidol
Chlorpromazine Fluvoxamine
Tacrine Theophyline
Drugs that may have a decreased effect due to induction of CYP1A2 by tobacco smoke
Smoking cessation may reverse the effect
Drug Interactions 1
11
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Drug Interactions 2
Smokers who use oral combined contraceptives (estrogen and progestin) have an increased risk of serious cardiovascular adverse effects including
Stroke Myocardial infarction Thromboembolism
Experts do not recommend oral contraceptives for women who are
Over 35 and Heavy (gt15 cigarettes per day) smokers
12
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
0
50
100
150
200
250
300
350
400
450
AIDS Obesity Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced
Individuals with mental illness or substance use
disorders
Causes of Annual Deaths in the US
13 Centers for Disease Control and Prevention NHIS 2007 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Laser National Comorbidity Survey 1991-1992 JAMA 2000 slide courtesy of Judith J Prochaska PhD ndash UCSF
225
348
0
10
20
30
40
50
60
70
80
90
100
None History
Panic Disorder
PTSD
GAD
Dysthymia
Major Depression
Bipolar Disorder
Nonaffect Psychosis
ASPD
Alcohol AbuseDep
Drug abusedep
410 Overall
Active
Psychiatric History
14
2 Tobacco Treatments
15
1 Physician advice
2 Individual counseling
3 Telephone counseling
4 Group programs
5 Aversion therapy
6 Hypnotherapy
7 NRT bupropion varenicline nortriptyline clonidine
Evidence-Based Practices
16
1 SSRIs and SNRI
2 Anxiolytics benzodiazepines buspirone
3 Homeopathic treatments
4 Herbal supplements
5 Massage Therapy
6 Acupuncture
7 Nicotine Anonymous
Practices Lacking Evidence-Base
17
0
10
20
30
No clinician Self-helpmaterial
Nonphysicianclinician
Physicianclinician
Type of Clinician
Est
ima
ted
ab
stin
en
ce a
t 5
+ m
on
ths
10 11 17
22 n = 29 studies
Fiore Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline 2008 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Compared to patients who receive no assistance from a clinician patients who receive assistance are 17ndash22 times as likely to quit successfully for 5 or more months
Clinician Interventions
18
Nicotine Replacement
Therapy 19
1 Patients with underlying CVD Recent MI (within past 2 weeks) Serious arrhythmias Serious or worsening angina
2 Patients under 18 years of age
3 Pregnant women
General Precautions
20
1 Patch provides consistent nicotine levels
2 Patch is easy to use and conceal
3 Gumlozengeinhalerspray can titrate therapy to manage withdrawal and may satisfy oral cravings
4 Inhaler mimics hand-to-mouth ritual of smoking
5 Spray is most rapidly absorbed form of nicotine replacement
Advantages
21
1 Allergic reactions to patch adhesive
2 Vivid or disturbing dreams with nocturnal patch use
3 Gum may be socially unacceptable and difficult to use with dentures
4 Patients with underlying bronchospastic disease must use inhaler with caution
5 Spray may be addictive and patients must wait 5 min before driving
Disadvantages
22
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Serotonin
GABA
Acetylcholine
β-Endorphins
Glutamate
Norepinephrine
Dopamine
Mood Elevation (appetite)
Anxiety Relief
Arousal and Cognition
Reduction of Tension
Learning and Memory
Arousal ( appetite)
Pleasure ( appetite)
Benowitz N Engl J Med 2010
Intoxication
6
Serotonin
GABA
Acetylcholine
β-Endorphins
Glutamate
Norepinephrine
Dopamine
Depressed Mood
Anxiety
Insomnia
Irritability
Difficulty Concentrating
Decreased Heart Rate
Appetite (and Cravings)
Withdrawal
7
Benowitz N Engl J Med 2010
Carbon monoxide Hydrogen cyanide Ammonia Benzene Formaldehyde
Nicotine Nitrosamines Lead Cadmium Polonium-210
An estimated 4800 compounds in tobacco smoke including 11 proven human carcinogens
Gases Particles
Nicotine is the addictive component of tobacco products but it does NOT cause the ill health effects of tobacco use
Compounds in Tobacco Smoke
8
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
bull Cancers ndash Acute myeloid leukemia ndash Bladder and kidney ndash Cervical ndash Esophageal ndash Gastric ndash Laryngeal ndash Lung ndash Oral cavity and pharyngeal ndash Pancreatic
bull Pulmonary diseases ndash Acute (eg pneumonia) ndash Chronic (eg COPD)
bull Cardiovascular diseases ndash Abdominal aortic aneurysm ndash Coronary heart disease ndash Cerebrovascular disease ndash Peripheral arterial disease
bull Reproductive effects ndash Reduced fertility in women ndash Poor pregnancy outcomes
(eg low birth weight preterm delivery)
ndash Infant mortality
bull Other effects cataract osteoporosis periodontitis poor surgical outcomes
Health Consequences
9
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Lung cilia regain normal function Ability to clear lungs of mucus increases Coughing fatigue shortness of breath decrease
Excess risk of CHD decreases to half that of a
continuing smoker Risk of stroke is reduced to that of people who have never smoked
Lung cancer death rate drops to half that of a
continuing smoker Risk of cancer of mouth
throat esophagus bladder kidney pancreas
decrease
Risk of CHD is similar to that of people who have never smoked
2 weeks to
3 months 1 to 9
months
1 year
5 years
10 years
after 15 years
Time Since Quit Date
Circulation improves walking becomes easier Lung function increases
up to 30
Quitting Health Benefits
10
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Caffeine Clozapine
Olanzapine Haloperidol
Chlorpromazine Fluvoxamine
Tacrine Theophyline
Drugs that may have a decreased effect due to induction of CYP1A2 by tobacco smoke
Smoking cessation may reverse the effect
Drug Interactions 1
11
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Drug Interactions 2
Smokers who use oral combined contraceptives (estrogen and progestin) have an increased risk of serious cardiovascular adverse effects including
Stroke Myocardial infarction Thromboembolism
Experts do not recommend oral contraceptives for women who are
Over 35 and Heavy (gt15 cigarettes per day) smokers
12
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
0
50
100
150
200
250
300
350
400
450
AIDS Obesity Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced
Individuals with mental illness or substance use
disorders
Causes of Annual Deaths in the US
13 Centers for Disease Control and Prevention NHIS 2007 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Laser National Comorbidity Survey 1991-1992 JAMA 2000 slide courtesy of Judith J Prochaska PhD ndash UCSF
225
348
0
10
20
30
40
50
60
70
80
90
100
None History
Panic Disorder
PTSD
GAD
Dysthymia
Major Depression
Bipolar Disorder
Nonaffect Psychosis
ASPD
Alcohol AbuseDep
Drug abusedep
410 Overall
Active
Psychiatric History
14
2 Tobacco Treatments
15
1 Physician advice
2 Individual counseling
3 Telephone counseling
4 Group programs
5 Aversion therapy
6 Hypnotherapy
7 NRT bupropion varenicline nortriptyline clonidine
Evidence-Based Practices
16
1 SSRIs and SNRI
2 Anxiolytics benzodiazepines buspirone
3 Homeopathic treatments
4 Herbal supplements
5 Massage Therapy
6 Acupuncture
7 Nicotine Anonymous
Practices Lacking Evidence-Base
17
0
10
20
30
No clinician Self-helpmaterial
Nonphysicianclinician
Physicianclinician
Type of Clinician
Est
ima
ted
ab
stin
en
ce a
t 5
+ m
on
ths
10 11 17
22 n = 29 studies
Fiore Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline 2008 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Compared to patients who receive no assistance from a clinician patients who receive assistance are 17ndash22 times as likely to quit successfully for 5 or more months
Clinician Interventions
18
Nicotine Replacement
Therapy 19
1 Patients with underlying CVD Recent MI (within past 2 weeks) Serious arrhythmias Serious or worsening angina
2 Patients under 18 years of age
3 Pregnant women
General Precautions
20
1 Patch provides consistent nicotine levels
2 Patch is easy to use and conceal
3 Gumlozengeinhalerspray can titrate therapy to manage withdrawal and may satisfy oral cravings
4 Inhaler mimics hand-to-mouth ritual of smoking
5 Spray is most rapidly absorbed form of nicotine replacement
Advantages
21
1 Allergic reactions to patch adhesive
2 Vivid or disturbing dreams with nocturnal patch use
3 Gum may be socially unacceptable and difficult to use with dentures
4 Patients with underlying bronchospastic disease must use inhaler with caution
5 Spray may be addictive and patients must wait 5 min before driving
Disadvantages
22
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Serotonin
GABA
Acetylcholine
β-Endorphins
Glutamate
Norepinephrine
Dopamine
Depressed Mood
Anxiety
Insomnia
Irritability
Difficulty Concentrating
Decreased Heart Rate
Appetite (and Cravings)
Withdrawal
7
Benowitz N Engl J Med 2010
Carbon monoxide Hydrogen cyanide Ammonia Benzene Formaldehyde
Nicotine Nitrosamines Lead Cadmium Polonium-210
An estimated 4800 compounds in tobacco smoke including 11 proven human carcinogens
Gases Particles
Nicotine is the addictive component of tobacco products but it does NOT cause the ill health effects of tobacco use
Compounds in Tobacco Smoke
8
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
bull Cancers ndash Acute myeloid leukemia ndash Bladder and kidney ndash Cervical ndash Esophageal ndash Gastric ndash Laryngeal ndash Lung ndash Oral cavity and pharyngeal ndash Pancreatic
bull Pulmonary diseases ndash Acute (eg pneumonia) ndash Chronic (eg COPD)
bull Cardiovascular diseases ndash Abdominal aortic aneurysm ndash Coronary heart disease ndash Cerebrovascular disease ndash Peripheral arterial disease
bull Reproductive effects ndash Reduced fertility in women ndash Poor pregnancy outcomes
(eg low birth weight preterm delivery)
ndash Infant mortality
bull Other effects cataract osteoporosis periodontitis poor surgical outcomes
Health Consequences
9
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Lung cilia regain normal function Ability to clear lungs of mucus increases Coughing fatigue shortness of breath decrease
Excess risk of CHD decreases to half that of a
continuing smoker Risk of stroke is reduced to that of people who have never smoked
Lung cancer death rate drops to half that of a
continuing smoker Risk of cancer of mouth
throat esophagus bladder kidney pancreas
decrease
Risk of CHD is similar to that of people who have never smoked
2 weeks to
3 months 1 to 9
months
1 year
5 years
10 years
after 15 years
Time Since Quit Date
Circulation improves walking becomes easier Lung function increases
up to 30
Quitting Health Benefits
10
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Caffeine Clozapine
Olanzapine Haloperidol
Chlorpromazine Fluvoxamine
Tacrine Theophyline
Drugs that may have a decreased effect due to induction of CYP1A2 by tobacco smoke
Smoking cessation may reverse the effect
Drug Interactions 1
11
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Drug Interactions 2
Smokers who use oral combined contraceptives (estrogen and progestin) have an increased risk of serious cardiovascular adverse effects including
Stroke Myocardial infarction Thromboembolism
Experts do not recommend oral contraceptives for women who are
Over 35 and Heavy (gt15 cigarettes per day) smokers
12
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
0
50
100
150
200
250
300
350
400
450
AIDS Obesity Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced
Individuals with mental illness or substance use
disorders
Causes of Annual Deaths in the US
13 Centers for Disease Control and Prevention NHIS 2007 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Laser National Comorbidity Survey 1991-1992 JAMA 2000 slide courtesy of Judith J Prochaska PhD ndash UCSF
225
348
0
10
20
30
40
50
60
70
80
90
100
None History
Panic Disorder
PTSD
GAD
Dysthymia
Major Depression
Bipolar Disorder
Nonaffect Psychosis
ASPD
Alcohol AbuseDep
Drug abusedep
410 Overall
Active
Psychiatric History
14
2 Tobacco Treatments
15
1 Physician advice
2 Individual counseling
3 Telephone counseling
4 Group programs
5 Aversion therapy
6 Hypnotherapy
7 NRT bupropion varenicline nortriptyline clonidine
Evidence-Based Practices
16
1 SSRIs and SNRI
2 Anxiolytics benzodiazepines buspirone
3 Homeopathic treatments
4 Herbal supplements
5 Massage Therapy
6 Acupuncture
7 Nicotine Anonymous
Practices Lacking Evidence-Base
17
0
10
20
30
No clinician Self-helpmaterial
Nonphysicianclinician
Physicianclinician
Type of Clinician
Est
ima
ted
ab
stin
en
ce a
t 5
+ m
on
ths
10 11 17
22 n = 29 studies
Fiore Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline 2008 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Compared to patients who receive no assistance from a clinician patients who receive assistance are 17ndash22 times as likely to quit successfully for 5 or more months
Clinician Interventions
18
Nicotine Replacement
Therapy 19
1 Patients with underlying CVD Recent MI (within past 2 weeks) Serious arrhythmias Serious or worsening angina
2 Patients under 18 years of age
3 Pregnant women
General Precautions
20
1 Patch provides consistent nicotine levels
2 Patch is easy to use and conceal
3 Gumlozengeinhalerspray can titrate therapy to manage withdrawal and may satisfy oral cravings
4 Inhaler mimics hand-to-mouth ritual of smoking
5 Spray is most rapidly absorbed form of nicotine replacement
Advantages
21
1 Allergic reactions to patch adhesive
2 Vivid or disturbing dreams with nocturnal patch use
3 Gum may be socially unacceptable and difficult to use with dentures
4 Patients with underlying bronchospastic disease must use inhaler with caution
5 Spray may be addictive and patients must wait 5 min before driving
Disadvantages
22
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Carbon monoxide Hydrogen cyanide Ammonia Benzene Formaldehyde
Nicotine Nitrosamines Lead Cadmium Polonium-210
An estimated 4800 compounds in tobacco smoke including 11 proven human carcinogens
Gases Particles
Nicotine is the addictive component of tobacco products but it does NOT cause the ill health effects of tobacco use
Compounds in Tobacco Smoke
8
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
bull Cancers ndash Acute myeloid leukemia ndash Bladder and kidney ndash Cervical ndash Esophageal ndash Gastric ndash Laryngeal ndash Lung ndash Oral cavity and pharyngeal ndash Pancreatic
bull Pulmonary diseases ndash Acute (eg pneumonia) ndash Chronic (eg COPD)
bull Cardiovascular diseases ndash Abdominal aortic aneurysm ndash Coronary heart disease ndash Cerebrovascular disease ndash Peripheral arterial disease
bull Reproductive effects ndash Reduced fertility in women ndash Poor pregnancy outcomes
(eg low birth weight preterm delivery)
ndash Infant mortality
bull Other effects cataract osteoporosis periodontitis poor surgical outcomes
Health Consequences
9
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Lung cilia regain normal function Ability to clear lungs of mucus increases Coughing fatigue shortness of breath decrease
Excess risk of CHD decreases to half that of a
continuing smoker Risk of stroke is reduced to that of people who have never smoked
Lung cancer death rate drops to half that of a
continuing smoker Risk of cancer of mouth
throat esophagus bladder kidney pancreas
decrease
Risk of CHD is similar to that of people who have never smoked
2 weeks to
3 months 1 to 9
months
1 year
5 years
10 years
after 15 years
Time Since Quit Date
Circulation improves walking becomes easier Lung function increases
up to 30
Quitting Health Benefits
10
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Caffeine Clozapine
Olanzapine Haloperidol
Chlorpromazine Fluvoxamine
Tacrine Theophyline
Drugs that may have a decreased effect due to induction of CYP1A2 by tobacco smoke
Smoking cessation may reverse the effect
Drug Interactions 1
11
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Drug Interactions 2
Smokers who use oral combined contraceptives (estrogen and progestin) have an increased risk of serious cardiovascular adverse effects including
Stroke Myocardial infarction Thromboembolism
Experts do not recommend oral contraceptives for women who are
Over 35 and Heavy (gt15 cigarettes per day) smokers
12
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
0
50
100
150
200
250
300
350
400
450
AIDS Obesity Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced
Individuals with mental illness or substance use
disorders
Causes of Annual Deaths in the US
13 Centers for Disease Control and Prevention NHIS 2007 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Laser National Comorbidity Survey 1991-1992 JAMA 2000 slide courtesy of Judith J Prochaska PhD ndash UCSF
225
348
0
10
20
30
40
50
60
70
80
90
100
None History
Panic Disorder
PTSD
GAD
Dysthymia
Major Depression
Bipolar Disorder
Nonaffect Psychosis
ASPD
Alcohol AbuseDep
Drug abusedep
410 Overall
Active
Psychiatric History
14
2 Tobacco Treatments
15
1 Physician advice
2 Individual counseling
3 Telephone counseling
4 Group programs
5 Aversion therapy
6 Hypnotherapy
7 NRT bupropion varenicline nortriptyline clonidine
Evidence-Based Practices
16
1 SSRIs and SNRI
2 Anxiolytics benzodiazepines buspirone
3 Homeopathic treatments
4 Herbal supplements
5 Massage Therapy
6 Acupuncture
7 Nicotine Anonymous
Practices Lacking Evidence-Base
17
0
10
20
30
No clinician Self-helpmaterial
Nonphysicianclinician
Physicianclinician
Type of Clinician
Est
ima
ted
ab
stin
en
ce a
t 5
+ m
on
ths
10 11 17
22 n = 29 studies
Fiore Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline 2008 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Compared to patients who receive no assistance from a clinician patients who receive assistance are 17ndash22 times as likely to quit successfully for 5 or more months
Clinician Interventions
18
Nicotine Replacement
Therapy 19
1 Patients with underlying CVD Recent MI (within past 2 weeks) Serious arrhythmias Serious or worsening angina
2 Patients under 18 years of age
3 Pregnant women
General Precautions
20
1 Patch provides consistent nicotine levels
2 Patch is easy to use and conceal
3 Gumlozengeinhalerspray can titrate therapy to manage withdrawal and may satisfy oral cravings
4 Inhaler mimics hand-to-mouth ritual of smoking
5 Spray is most rapidly absorbed form of nicotine replacement
Advantages
21
1 Allergic reactions to patch adhesive
2 Vivid or disturbing dreams with nocturnal patch use
3 Gum may be socially unacceptable and difficult to use with dentures
4 Patients with underlying bronchospastic disease must use inhaler with caution
5 Spray may be addictive and patients must wait 5 min before driving
Disadvantages
22
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
bull Cancers ndash Acute myeloid leukemia ndash Bladder and kidney ndash Cervical ndash Esophageal ndash Gastric ndash Laryngeal ndash Lung ndash Oral cavity and pharyngeal ndash Pancreatic
bull Pulmonary diseases ndash Acute (eg pneumonia) ndash Chronic (eg COPD)
bull Cardiovascular diseases ndash Abdominal aortic aneurysm ndash Coronary heart disease ndash Cerebrovascular disease ndash Peripheral arterial disease
bull Reproductive effects ndash Reduced fertility in women ndash Poor pregnancy outcomes
(eg low birth weight preterm delivery)
ndash Infant mortality
bull Other effects cataract osteoporosis periodontitis poor surgical outcomes
Health Consequences
9
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Lung cilia regain normal function Ability to clear lungs of mucus increases Coughing fatigue shortness of breath decrease
Excess risk of CHD decreases to half that of a
continuing smoker Risk of stroke is reduced to that of people who have never smoked
Lung cancer death rate drops to half that of a
continuing smoker Risk of cancer of mouth
throat esophagus bladder kidney pancreas
decrease
Risk of CHD is similar to that of people who have never smoked
2 weeks to
3 months 1 to 9
months
1 year
5 years
10 years
after 15 years
Time Since Quit Date
Circulation improves walking becomes easier Lung function increases
up to 30
Quitting Health Benefits
10
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Caffeine Clozapine
Olanzapine Haloperidol
Chlorpromazine Fluvoxamine
Tacrine Theophyline
Drugs that may have a decreased effect due to induction of CYP1A2 by tobacco smoke
Smoking cessation may reverse the effect
Drug Interactions 1
11
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Drug Interactions 2
Smokers who use oral combined contraceptives (estrogen and progestin) have an increased risk of serious cardiovascular adverse effects including
Stroke Myocardial infarction Thromboembolism
Experts do not recommend oral contraceptives for women who are
Over 35 and Heavy (gt15 cigarettes per day) smokers
12
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
0
50
100
150
200
250
300
350
400
450
AIDS Obesity Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced
Individuals with mental illness or substance use
disorders
Causes of Annual Deaths in the US
13 Centers for Disease Control and Prevention NHIS 2007 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Laser National Comorbidity Survey 1991-1992 JAMA 2000 slide courtesy of Judith J Prochaska PhD ndash UCSF
225
348
0
10
20
30
40
50
60
70
80
90
100
None History
Panic Disorder
PTSD
GAD
Dysthymia
Major Depression
Bipolar Disorder
Nonaffect Psychosis
ASPD
Alcohol AbuseDep
Drug abusedep
410 Overall
Active
Psychiatric History
14
2 Tobacco Treatments
15
1 Physician advice
2 Individual counseling
3 Telephone counseling
4 Group programs
5 Aversion therapy
6 Hypnotherapy
7 NRT bupropion varenicline nortriptyline clonidine
Evidence-Based Practices
16
1 SSRIs and SNRI
2 Anxiolytics benzodiazepines buspirone
3 Homeopathic treatments
4 Herbal supplements
5 Massage Therapy
6 Acupuncture
7 Nicotine Anonymous
Practices Lacking Evidence-Base
17
0
10
20
30
No clinician Self-helpmaterial
Nonphysicianclinician
Physicianclinician
Type of Clinician
Est
ima
ted
ab
stin
en
ce a
t 5
+ m
on
ths
10 11 17
22 n = 29 studies
Fiore Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline 2008 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Compared to patients who receive no assistance from a clinician patients who receive assistance are 17ndash22 times as likely to quit successfully for 5 or more months
Clinician Interventions
18
Nicotine Replacement
Therapy 19
1 Patients with underlying CVD Recent MI (within past 2 weeks) Serious arrhythmias Serious or worsening angina
2 Patients under 18 years of age
3 Pregnant women
General Precautions
20
1 Patch provides consistent nicotine levels
2 Patch is easy to use and conceal
3 Gumlozengeinhalerspray can titrate therapy to manage withdrawal and may satisfy oral cravings
4 Inhaler mimics hand-to-mouth ritual of smoking
5 Spray is most rapidly absorbed form of nicotine replacement
Advantages
21
1 Allergic reactions to patch adhesive
2 Vivid or disturbing dreams with nocturnal patch use
3 Gum may be socially unacceptable and difficult to use with dentures
4 Patients with underlying bronchospastic disease must use inhaler with caution
5 Spray may be addictive and patients must wait 5 min before driving
Disadvantages
22
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Lung cilia regain normal function Ability to clear lungs of mucus increases Coughing fatigue shortness of breath decrease
Excess risk of CHD decreases to half that of a
continuing smoker Risk of stroke is reduced to that of people who have never smoked
Lung cancer death rate drops to half that of a
continuing smoker Risk of cancer of mouth
throat esophagus bladder kidney pancreas
decrease
Risk of CHD is similar to that of people who have never smoked
2 weeks to
3 months 1 to 9
months
1 year
5 years
10 years
after 15 years
Time Since Quit Date
Circulation improves walking becomes easier Lung function increases
up to 30
Quitting Health Benefits
10
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Caffeine Clozapine
Olanzapine Haloperidol
Chlorpromazine Fluvoxamine
Tacrine Theophyline
Drugs that may have a decreased effect due to induction of CYP1A2 by tobacco smoke
Smoking cessation may reverse the effect
Drug Interactions 1
11
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Drug Interactions 2
Smokers who use oral combined contraceptives (estrogen and progestin) have an increased risk of serious cardiovascular adverse effects including
Stroke Myocardial infarction Thromboembolism
Experts do not recommend oral contraceptives for women who are
Over 35 and Heavy (gt15 cigarettes per day) smokers
12
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
0
50
100
150
200
250
300
350
400
450
AIDS Obesity Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced
Individuals with mental illness or substance use
disorders
Causes of Annual Deaths in the US
13 Centers for Disease Control and Prevention NHIS 2007 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Laser National Comorbidity Survey 1991-1992 JAMA 2000 slide courtesy of Judith J Prochaska PhD ndash UCSF
225
348
0
10
20
30
40
50
60
70
80
90
100
None History
Panic Disorder
PTSD
GAD
Dysthymia
Major Depression
Bipolar Disorder
Nonaffect Psychosis
ASPD
Alcohol AbuseDep
Drug abusedep
410 Overall
Active
Psychiatric History
14
2 Tobacco Treatments
15
1 Physician advice
2 Individual counseling
3 Telephone counseling
4 Group programs
5 Aversion therapy
6 Hypnotherapy
7 NRT bupropion varenicline nortriptyline clonidine
Evidence-Based Practices
16
1 SSRIs and SNRI
2 Anxiolytics benzodiazepines buspirone
3 Homeopathic treatments
4 Herbal supplements
5 Massage Therapy
6 Acupuncture
7 Nicotine Anonymous
Practices Lacking Evidence-Base
17
0
10
20
30
No clinician Self-helpmaterial
Nonphysicianclinician
Physicianclinician
Type of Clinician
Est
ima
ted
ab
stin
en
ce a
t 5
+ m
on
ths
10 11 17
22 n = 29 studies
Fiore Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline 2008 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Compared to patients who receive no assistance from a clinician patients who receive assistance are 17ndash22 times as likely to quit successfully for 5 or more months
Clinician Interventions
18
Nicotine Replacement
Therapy 19
1 Patients with underlying CVD Recent MI (within past 2 weeks) Serious arrhythmias Serious or worsening angina
2 Patients under 18 years of age
3 Pregnant women
General Precautions
20
1 Patch provides consistent nicotine levels
2 Patch is easy to use and conceal
3 Gumlozengeinhalerspray can titrate therapy to manage withdrawal and may satisfy oral cravings
4 Inhaler mimics hand-to-mouth ritual of smoking
5 Spray is most rapidly absorbed form of nicotine replacement
Advantages
21
1 Allergic reactions to patch adhesive
2 Vivid or disturbing dreams with nocturnal patch use
3 Gum may be socially unacceptable and difficult to use with dentures
4 Patients with underlying bronchospastic disease must use inhaler with caution
5 Spray may be addictive and patients must wait 5 min before driving
Disadvantages
22
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Caffeine Clozapine
Olanzapine Haloperidol
Chlorpromazine Fluvoxamine
Tacrine Theophyline
Drugs that may have a decreased effect due to induction of CYP1A2 by tobacco smoke
Smoking cessation may reverse the effect
Drug Interactions 1
11
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Drug Interactions 2
Smokers who use oral combined contraceptives (estrogen and progestin) have an increased risk of serious cardiovascular adverse effects including
Stroke Myocardial infarction Thromboembolism
Experts do not recommend oral contraceptives for women who are
Over 35 and Heavy (gt15 cigarettes per day) smokers
12
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
0
50
100
150
200
250
300
350
400
450
AIDS Obesity Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced
Individuals with mental illness or substance use
disorders
Causes of Annual Deaths in the US
13 Centers for Disease Control and Prevention NHIS 2007 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Laser National Comorbidity Survey 1991-1992 JAMA 2000 slide courtesy of Judith J Prochaska PhD ndash UCSF
225
348
0
10
20
30
40
50
60
70
80
90
100
None History
Panic Disorder
PTSD
GAD
Dysthymia
Major Depression
Bipolar Disorder
Nonaffect Psychosis
ASPD
Alcohol AbuseDep
Drug abusedep
410 Overall
Active
Psychiatric History
14
2 Tobacco Treatments
15
1 Physician advice
2 Individual counseling
3 Telephone counseling
4 Group programs
5 Aversion therapy
6 Hypnotherapy
7 NRT bupropion varenicline nortriptyline clonidine
Evidence-Based Practices
16
1 SSRIs and SNRI
2 Anxiolytics benzodiazepines buspirone
3 Homeopathic treatments
4 Herbal supplements
5 Massage Therapy
6 Acupuncture
7 Nicotine Anonymous
Practices Lacking Evidence-Base
17
0
10
20
30
No clinician Self-helpmaterial
Nonphysicianclinician
Physicianclinician
Type of Clinician
Est
ima
ted
ab
stin
en
ce a
t 5
+ m
on
ths
10 11 17
22 n = 29 studies
Fiore Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline 2008 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Compared to patients who receive no assistance from a clinician patients who receive assistance are 17ndash22 times as likely to quit successfully for 5 or more months
Clinician Interventions
18
Nicotine Replacement
Therapy 19
1 Patients with underlying CVD Recent MI (within past 2 weeks) Serious arrhythmias Serious or worsening angina
2 Patients under 18 years of age
3 Pregnant women
General Precautions
20
1 Patch provides consistent nicotine levels
2 Patch is easy to use and conceal
3 Gumlozengeinhalerspray can titrate therapy to manage withdrawal and may satisfy oral cravings
4 Inhaler mimics hand-to-mouth ritual of smoking
5 Spray is most rapidly absorbed form of nicotine replacement
Advantages
21
1 Allergic reactions to patch adhesive
2 Vivid or disturbing dreams with nocturnal patch use
3 Gum may be socially unacceptable and difficult to use with dentures
4 Patients with underlying bronchospastic disease must use inhaler with caution
5 Spray may be addictive and patients must wait 5 min before driving
Disadvantages
22
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Drug Interactions 2
Smokers who use oral combined contraceptives (estrogen and progestin) have an increased risk of serious cardiovascular adverse effects including
Stroke Myocardial infarction Thromboembolism
Experts do not recommend oral contraceptives for women who are
Over 35 and Heavy (gt15 cigarettes per day) smokers
12
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
0
50
100
150
200
250
300
350
400
450
AIDS Obesity Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced
Individuals with mental illness or substance use
disorders
Causes of Annual Deaths in the US
13 Centers for Disease Control and Prevention NHIS 2007 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Laser National Comorbidity Survey 1991-1992 JAMA 2000 slide courtesy of Judith J Prochaska PhD ndash UCSF
225
348
0
10
20
30
40
50
60
70
80
90
100
None History
Panic Disorder
PTSD
GAD
Dysthymia
Major Depression
Bipolar Disorder
Nonaffect Psychosis
ASPD
Alcohol AbuseDep
Drug abusedep
410 Overall
Active
Psychiatric History
14
2 Tobacco Treatments
15
1 Physician advice
2 Individual counseling
3 Telephone counseling
4 Group programs
5 Aversion therapy
6 Hypnotherapy
7 NRT bupropion varenicline nortriptyline clonidine
Evidence-Based Practices
16
1 SSRIs and SNRI
2 Anxiolytics benzodiazepines buspirone
3 Homeopathic treatments
4 Herbal supplements
5 Massage Therapy
6 Acupuncture
7 Nicotine Anonymous
Practices Lacking Evidence-Base
17
0
10
20
30
No clinician Self-helpmaterial
Nonphysicianclinician
Physicianclinician
Type of Clinician
Est
ima
ted
ab
stin
en
ce a
t 5
+ m
on
ths
10 11 17
22 n = 29 studies
Fiore Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline 2008 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Compared to patients who receive no assistance from a clinician patients who receive assistance are 17ndash22 times as likely to quit successfully for 5 or more months
Clinician Interventions
18
Nicotine Replacement
Therapy 19
1 Patients with underlying CVD Recent MI (within past 2 weeks) Serious arrhythmias Serious or worsening angina
2 Patients under 18 years of age
3 Pregnant women
General Precautions
20
1 Patch provides consistent nicotine levels
2 Patch is easy to use and conceal
3 Gumlozengeinhalerspray can titrate therapy to manage withdrawal and may satisfy oral cravings
4 Inhaler mimics hand-to-mouth ritual of smoking
5 Spray is most rapidly absorbed form of nicotine replacement
Advantages
21
1 Allergic reactions to patch adhesive
2 Vivid or disturbing dreams with nocturnal patch use
3 Gum may be socially unacceptable and difficult to use with dentures
4 Patients with underlying bronchospastic disease must use inhaler with caution
5 Spray may be addictive and patients must wait 5 min before driving
Disadvantages
22
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
0
50
100
150
200
250
300
350
400
450
AIDS Obesity Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced
Individuals with mental illness or substance use
disorders
Causes of Annual Deaths in the US
13 Centers for Disease Control and Prevention NHIS 2007 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Laser National Comorbidity Survey 1991-1992 JAMA 2000 slide courtesy of Judith J Prochaska PhD ndash UCSF
225
348
0
10
20
30
40
50
60
70
80
90
100
None History
Panic Disorder
PTSD
GAD
Dysthymia
Major Depression
Bipolar Disorder
Nonaffect Psychosis
ASPD
Alcohol AbuseDep
Drug abusedep
410 Overall
Active
Psychiatric History
14
2 Tobacco Treatments
15
1 Physician advice
2 Individual counseling
3 Telephone counseling
4 Group programs
5 Aversion therapy
6 Hypnotherapy
7 NRT bupropion varenicline nortriptyline clonidine
Evidence-Based Practices
16
1 SSRIs and SNRI
2 Anxiolytics benzodiazepines buspirone
3 Homeopathic treatments
4 Herbal supplements
5 Massage Therapy
6 Acupuncture
7 Nicotine Anonymous
Practices Lacking Evidence-Base
17
0
10
20
30
No clinician Self-helpmaterial
Nonphysicianclinician
Physicianclinician
Type of Clinician
Est
ima
ted
ab
stin
en
ce a
t 5
+ m
on
ths
10 11 17
22 n = 29 studies
Fiore Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline 2008 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Compared to patients who receive no assistance from a clinician patients who receive assistance are 17ndash22 times as likely to quit successfully for 5 or more months
Clinician Interventions
18
Nicotine Replacement
Therapy 19
1 Patients with underlying CVD Recent MI (within past 2 weeks) Serious arrhythmias Serious or worsening angina
2 Patients under 18 years of age
3 Pregnant women
General Precautions
20
1 Patch provides consistent nicotine levels
2 Patch is easy to use and conceal
3 Gumlozengeinhalerspray can titrate therapy to manage withdrawal and may satisfy oral cravings
4 Inhaler mimics hand-to-mouth ritual of smoking
5 Spray is most rapidly absorbed form of nicotine replacement
Advantages
21
1 Allergic reactions to patch adhesive
2 Vivid or disturbing dreams with nocturnal patch use
3 Gum may be socially unacceptable and difficult to use with dentures
4 Patients with underlying bronchospastic disease must use inhaler with caution
5 Spray may be addictive and patients must wait 5 min before driving
Disadvantages
22
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Laser National Comorbidity Survey 1991-1992 JAMA 2000 slide courtesy of Judith J Prochaska PhD ndash UCSF
225
348
0
10
20
30
40
50
60
70
80
90
100
None History
Panic Disorder
PTSD
GAD
Dysthymia
Major Depression
Bipolar Disorder
Nonaffect Psychosis
ASPD
Alcohol AbuseDep
Drug abusedep
410 Overall
Active
Psychiatric History
14
2 Tobacco Treatments
15
1 Physician advice
2 Individual counseling
3 Telephone counseling
4 Group programs
5 Aversion therapy
6 Hypnotherapy
7 NRT bupropion varenicline nortriptyline clonidine
Evidence-Based Practices
16
1 SSRIs and SNRI
2 Anxiolytics benzodiazepines buspirone
3 Homeopathic treatments
4 Herbal supplements
5 Massage Therapy
6 Acupuncture
7 Nicotine Anonymous
Practices Lacking Evidence-Base
17
0
10
20
30
No clinician Self-helpmaterial
Nonphysicianclinician
Physicianclinician
Type of Clinician
Est
ima
ted
ab
stin
en
ce a
t 5
+ m
on
ths
10 11 17
22 n = 29 studies
Fiore Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline 2008 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Compared to patients who receive no assistance from a clinician patients who receive assistance are 17ndash22 times as likely to quit successfully for 5 or more months
Clinician Interventions
18
Nicotine Replacement
Therapy 19
1 Patients with underlying CVD Recent MI (within past 2 weeks) Serious arrhythmias Serious or worsening angina
2 Patients under 18 years of age
3 Pregnant women
General Precautions
20
1 Patch provides consistent nicotine levels
2 Patch is easy to use and conceal
3 Gumlozengeinhalerspray can titrate therapy to manage withdrawal and may satisfy oral cravings
4 Inhaler mimics hand-to-mouth ritual of smoking
5 Spray is most rapidly absorbed form of nicotine replacement
Advantages
21
1 Allergic reactions to patch adhesive
2 Vivid or disturbing dreams with nocturnal patch use
3 Gum may be socially unacceptable and difficult to use with dentures
4 Patients with underlying bronchospastic disease must use inhaler with caution
5 Spray may be addictive and patients must wait 5 min before driving
Disadvantages
22
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
2 Tobacco Treatments
15
1 Physician advice
2 Individual counseling
3 Telephone counseling
4 Group programs
5 Aversion therapy
6 Hypnotherapy
7 NRT bupropion varenicline nortriptyline clonidine
Evidence-Based Practices
16
1 SSRIs and SNRI
2 Anxiolytics benzodiazepines buspirone
3 Homeopathic treatments
4 Herbal supplements
5 Massage Therapy
6 Acupuncture
7 Nicotine Anonymous
Practices Lacking Evidence-Base
17
0
10
20
30
No clinician Self-helpmaterial
Nonphysicianclinician
Physicianclinician
Type of Clinician
Est
ima
ted
ab
stin
en
ce a
t 5
+ m
on
ths
10 11 17
22 n = 29 studies
Fiore Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline 2008 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Compared to patients who receive no assistance from a clinician patients who receive assistance are 17ndash22 times as likely to quit successfully for 5 or more months
Clinician Interventions
18
Nicotine Replacement
Therapy 19
1 Patients with underlying CVD Recent MI (within past 2 weeks) Serious arrhythmias Serious or worsening angina
2 Patients under 18 years of age
3 Pregnant women
General Precautions
20
1 Patch provides consistent nicotine levels
2 Patch is easy to use and conceal
3 Gumlozengeinhalerspray can titrate therapy to manage withdrawal and may satisfy oral cravings
4 Inhaler mimics hand-to-mouth ritual of smoking
5 Spray is most rapidly absorbed form of nicotine replacement
Advantages
21
1 Allergic reactions to patch adhesive
2 Vivid or disturbing dreams with nocturnal patch use
3 Gum may be socially unacceptable and difficult to use with dentures
4 Patients with underlying bronchospastic disease must use inhaler with caution
5 Spray may be addictive and patients must wait 5 min before driving
Disadvantages
22
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
1 Physician advice
2 Individual counseling
3 Telephone counseling
4 Group programs
5 Aversion therapy
6 Hypnotherapy
7 NRT bupropion varenicline nortriptyline clonidine
Evidence-Based Practices
16
1 SSRIs and SNRI
2 Anxiolytics benzodiazepines buspirone
3 Homeopathic treatments
4 Herbal supplements
5 Massage Therapy
6 Acupuncture
7 Nicotine Anonymous
Practices Lacking Evidence-Base
17
0
10
20
30
No clinician Self-helpmaterial
Nonphysicianclinician
Physicianclinician
Type of Clinician
Est
ima
ted
ab
stin
en
ce a
t 5
+ m
on
ths
10 11 17
22 n = 29 studies
Fiore Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline 2008 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Compared to patients who receive no assistance from a clinician patients who receive assistance are 17ndash22 times as likely to quit successfully for 5 or more months
Clinician Interventions
18
Nicotine Replacement
Therapy 19
1 Patients with underlying CVD Recent MI (within past 2 weeks) Serious arrhythmias Serious or worsening angina
2 Patients under 18 years of age
3 Pregnant women
General Precautions
20
1 Patch provides consistent nicotine levels
2 Patch is easy to use and conceal
3 Gumlozengeinhalerspray can titrate therapy to manage withdrawal and may satisfy oral cravings
4 Inhaler mimics hand-to-mouth ritual of smoking
5 Spray is most rapidly absorbed form of nicotine replacement
Advantages
21
1 Allergic reactions to patch adhesive
2 Vivid or disturbing dreams with nocturnal patch use
3 Gum may be socially unacceptable and difficult to use with dentures
4 Patients with underlying bronchospastic disease must use inhaler with caution
5 Spray may be addictive and patients must wait 5 min before driving
Disadvantages
22
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
1 SSRIs and SNRI
2 Anxiolytics benzodiazepines buspirone
3 Homeopathic treatments
4 Herbal supplements
5 Massage Therapy
6 Acupuncture
7 Nicotine Anonymous
Practices Lacking Evidence-Base
17
0
10
20
30
No clinician Self-helpmaterial
Nonphysicianclinician
Physicianclinician
Type of Clinician
Est
ima
ted
ab
stin
en
ce a
t 5
+ m
on
ths
10 11 17
22 n = 29 studies
Fiore Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline 2008 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Compared to patients who receive no assistance from a clinician patients who receive assistance are 17ndash22 times as likely to quit successfully for 5 or more months
Clinician Interventions
18
Nicotine Replacement
Therapy 19
1 Patients with underlying CVD Recent MI (within past 2 weeks) Serious arrhythmias Serious or worsening angina
2 Patients under 18 years of age
3 Pregnant women
General Precautions
20
1 Patch provides consistent nicotine levels
2 Patch is easy to use and conceal
3 Gumlozengeinhalerspray can titrate therapy to manage withdrawal and may satisfy oral cravings
4 Inhaler mimics hand-to-mouth ritual of smoking
5 Spray is most rapidly absorbed form of nicotine replacement
Advantages
21
1 Allergic reactions to patch adhesive
2 Vivid or disturbing dreams with nocturnal patch use
3 Gum may be socially unacceptable and difficult to use with dentures
4 Patients with underlying bronchospastic disease must use inhaler with caution
5 Spray may be addictive and patients must wait 5 min before driving
Disadvantages
22
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
0
10
20
30
No clinician Self-helpmaterial
Nonphysicianclinician
Physicianclinician
Type of Clinician
Est
ima
ted
ab
stin
en
ce a
t 5
+ m
on
ths
10 11 17
22 n = 29 studies
Fiore Treating Tobacco Use and Dependence 2008 Update Clinical Practice Guideline 2008 slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Compared to patients who receive no assistance from a clinician patients who receive assistance are 17ndash22 times as likely to quit successfully for 5 or more months
Clinician Interventions
18
Nicotine Replacement
Therapy 19
1 Patients with underlying CVD Recent MI (within past 2 weeks) Serious arrhythmias Serious or worsening angina
2 Patients under 18 years of age
3 Pregnant women
General Precautions
20
1 Patch provides consistent nicotine levels
2 Patch is easy to use and conceal
3 Gumlozengeinhalerspray can titrate therapy to manage withdrawal and may satisfy oral cravings
4 Inhaler mimics hand-to-mouth ritual of smoking
5 Spray is most rapidly absorbed form of nicotine replacement
Advantages
21
1 Allergic reactions to patch adhesive
2 Vivid or disturbing dreams with nocturnal patch use
3 Gum may be socially unacceptable and difficult to use with dentures
4 Patients with underlying bronchospastic disease must use inhaler with caution
5 Spray may be addictive and patients must wait 5 min before driving
Disadvantages
22
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Nicotine Replacement
Therapy 19
1 Patients with underlying CVD Recent MI (within past 2 weeks) Serious arrhythmias Serious or worsening angina
2 Patients under 18 years of age
3 Pregnant women
General Precautions
20
1 Patch provides consistent nicotine levels
2 Patch is easy to use and conceal
3 Gumlozengeinhalerspray can titrate therapy to manage withdrawal and may satisfy oral cravings
4 Inhaler mimics hand-to-mouth ritual of smoking
5 Spray is most rapidly absorbed form of nicotine replacement
Advantages
21
1 Allergic reactions to patch adhesive
2 Vivid or disturbing dreams with nocturnal patch use
3 Gum may be socially unacceptable and difficult to use with dentures
4 Patients with underlying bronchospastic disease must use inhaler with caution
5 Spray may be addictive and patients must wait 5 min before driving
Disadvantages
22
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
1 Patients with underlying CVD Recent MI (within past 2 weeks) Serious arrhythmias Serious or worsening angina
2 Patients under 18 years of age
3 Pregnant women
General Precautions
20
1 Patch provides consistent nicotine levels
2 Patch is easy to use and conceal
3 Gumlozengeinhalerspray can titrate therapy to manage withdrawal and may satisfy oral cravings
4 Inhaler mimics hand-to-mouth ritual of smoking
5 Spray is most rapidly absorbed form of nicotine replacement
Advantages
21
1 Allergic reactions to patch adhesive
2 Vivid or disturbing dreams with nocturnal patch use
3 Gum may be socially unacceptable and difficult to use with dentures
4 Patients with underlying bronchospastic disease must use inhaler with caution
5 Spray may be addictive and patients must wait 5 min before driving
Disadvantages
22
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
1 Patch provides consistent nicotine levels
2 Patch is easy to use and conceal
3 Gumlozengeinhalerspray can titrate therapy to manage withdrawal and may satisfy oral cravings
4 Inhaler mimics hand-to-mouth ritual of smoking
5 Spray is most rapidly absorbed form of nicotine replacement
Advantages
21
1 Allergic reactions to patch adhesive
2 Vivid or disturbing dreams with nocturnal patch use
3 Gum may be socially unacceptable and difficult to use with dentures
4 Patients with underlying bronchospastic disease must use inhaler with caution
5 Spray may be addictive and patients must wait 5 min before driving
Disadvantages
22
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
1 Allergic reactions to patch adhesive
2 Vivid or disturbing dreams with nocturnal patch use
3 Gum may be socially unacceptable and difficult to use with dentures
4 Patients with underlying bronchospastic disease must use inhaler with caution
5 Spray may be addictive and patients must wait 5 min before driving
Disadvantages
22
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Park between cheek amp gum
Stop chewing at first sign of peppery taste or tingling sensation
Chew slowly
Chew again when peppery taste or tingle fades
Do not eat or drink 15 min before or
after use
Gum Chewing Technique
23
Slide courtesy of Judith J Prochaska PhD MPH - University of California San Francisco
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Bupropion
24
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
1 Easy to use
2 Can be used with NRT or varenicline
3 May delay cessation-related weight gain
4 May be beneficial in patients with coexisting depression
Advantages
25
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
1 Common side effects Dry mouth
Anxiety
Insomnia (avoid bedtime dosing)
2 Should be avoided in patients with an increased risk for seizures
Disadvantages
26
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Varenicline
27
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
1 Oral formulation with twice-a-day dosing
2 Offers a new mechanism of action for persons who previously failed using other medications
3 Early industry-sponsored trials suggest this agent is superior to bupropion SR
Advantages
28
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
1 Common side effects Nausea (in up to 33 of patients)
Sleep disturbances (insomnia abnormal dreams)
Constipation
Flatulence
Vomiting
2 Psychiatric Risks
3 Cardiovascular Risks
Disadvantages
29
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
ldquoStimulated Reportingrdquo
Gunnell BMJ 2009
30
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Data adapted from Silagy et al (2004) Cochrane Database Syst Rev Hughes et al (2004) Cochrane Database Syst Rev Gonzales et al (2006) JAMA and Jorenby et al (2006) JAMA
195
146
115
86
164
88
239
118
171
91
200
102 94
225
gt 6 Month Quit Rates
31
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
32
Long WSJ May 3 2011 LeSage American Association of Pharmaceutical Scientists Journal 2006
NicVax 2006
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
33
NicVax 2013
Genetic Engineering amp Biotechnology News July 19 2011 Hartmann-Boyce Cochrane Database Sys Rev 2012
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
3 Cannabis Basics
34
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
35
StreetDrugscom 35
Enwikipediaorg 35
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
ldquoWhy drink and drive when you can smoke and flyrdquo
ldquoIf we all had a bong wersquod all get alongrdquo
36
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
bull Mild euphoria and relaxation bull The giggles bull Increased sensitivity to external stimuli Colors seem brighter Smells are more pungent
bull Distortion of time perception
Pleasurable Effects
37
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
The Molecular Structure
ApiFreebasecom 38
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
bull THC activates the CB1 and CB2 cannabinoid receptors CB1 has high density in cerebellum basal
ganglia hippocampus cerebral cortex CB1 has low density in the brainstem hence low
risk of respiratory depression CB2 is found in spleen hematopoietic cell lines
mast cells
bull Anandamide is the endogenous ligand
The Cannabinoid System
39
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Routes of Administration
bull Smoked marijuana Reaches the brain in minutes Effects last 1 - 3 hours Delivers a lot of THC into the bloodstream
bull Eating or drinking marijuana Takes frac12 - 1 hour to have an effect Effects last up to 4 hours Delivers significantly less THC into the bloodstream
40
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Biphasic Distribution
Heather British Journal of Psychiatry 2001
41
41
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
bull Casual use Up to 10 days in urine 50 positive in hair samples
bull Heavy use Up to 30 days in urine 85 positive in hair samples
bull Weight loss gives serial UTox spike bull Dronabinol gives positive test bull Passive inhalation gives negative test
Toxicology Testing
42
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Cannabis Potency
NSDUH TEDS National Seizure System
43
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
If drunk ndash you run the RED lights If stoned ndash you stop at the GREEN lights
Cannabis Intoxication
44
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
bull Irritability and restlessness bull Aggression bull Insomnia bull Appetite decrease bull Withdrawal syndrome is not As painful as heroin withdrawal As dangerous as alcohol withdrawal or As long-lasting as cocaine withdrawal
bull No indication for treatment
Cannabis Withdrawal
45
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Neurocognitive Decline ndash 8 IQ points
Meier PNAS 2012
46
46
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Tobacco 32
Heroin 23
Cocaine 17
Alcohol 15
Sedatives 9
Cannabis 9
Addictive Potential
47
Anthony Exp Clin Psychopharmacol 1994
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
4 Cannabis Treatments
48
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
49
V CBT CBT + V
V CBT CBT + V
Wee
ks of
Con
tinuo
us A
bstin
ence
3 Month Abstinence Rate
69
35 (a)
53 17 20
43 (bc)
(a) V vs CBT comparison p lt 05 (b) CBT+V vs CBT comparison p lt 05 (c) CBT+V vs V comparison p lt 05
Vouchers and CBT
Budney J Consult Clinical Psychology 2006 slide courtesy of Dr Frances Levin
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
50
0 1 2 3 4 5 6 7 8 0
01
02
03
04
05
06
07
08
09
1
Ret
entio
n Pr
obab
ility
Log Rank Wilcoxon P= 00249 Time to drop
Placebo
Marinol
Week
Dronabinol
Levin Drug Alcohol Depend 2011 slide courtesy of Dr Frances Levin
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
5 Cannabis
Special Topics 51
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
The Schizophrenia-Marijuana Link
Caspi Biol Psychiatry 2005
52
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Adolescence
MonitoringTheFutureorg
53
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
bull Therapeutic potential for Pain (cancer multiple sclerosis) Nausea (cancer) Loss of appetite (HIVAIDS) Increased occular pressure (glaucoma)
bull Savitex reg (available only in UK and Canada) is a mouth spray Plant-derived THC ndash 50 Cannabidiol ndash 50
Medical Marijuana
54
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
55 55
Enwikipediaorg
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Synthetic Cannabinoids
Enwikipediaorg 56
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Cannabidiol
57
Morgan British Journal of Psychiatry 2008
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
6 Summary
58
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
1 Smoking rates are 40 to 70 among those with mental illness 2 to 3 times that of the general population
2 Marijuana is addictive but not as addictive as tobacco heroin cocaine or alcohol
3 Psychotherapy works well for both tobacco and cannabis addiction
4 Pharmacotherapy is proven to be effective for addiction to tobacco but not cannabis
59
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-
Thank you
60
- TOBACCO and CANNABIS
- Slide Number 2
- Slide Number 3
- Slide Number 4
- Slide Number 5
- Slide Number 6
- Slide Number 7
- Slide Number 8
- Slide Number 9
- Slide Number 10
- Slide Number 11
- Slide Number 12
- Slide Number 13
- Slide Number 14
- Slide Number 15
- Slide Number 16
- Slide Number 17
- Slide Number 18
- Slide Number 19
- Slide Number 20
- Slide Number 21
- Slide Number 22
- Slide Number 23
- Slide Number 24
- Slide Number 25
- Slide Number 26
- Slide Number 27
- Slide Number 28
- Slide Number 29
- Slide Number 30
- Slide Number 31
- Slide Number 32
- Slide Number 33
- Slide Number 34
- Slide Number 35
- Slide Number 36
- Pleasurable Effects
- Slide Number 38
- The Cannabinoid System
- Slide Number 40
- Biphasic Distribution
- Toxicology Testing
- Slide Number 43
- Cannabis Intoxication
- Cannabis Withdrawal
- Neurocognitive Decline ndash 8 IQ points
- Addictive Potential
- Slide Number 48
- Vouchers and CBT
- Dronabinol
- Slide Number 51
- The Schizophrenia-Marijuana Link
- Adolescence
- Medical Marijuana
- Slide Number 55
- Slide Number 56
- Cannabidiol
- Slide Number 58
- Slide Number 59
- Thank you
-