Christian Thurstone, M.D.Associate Professor of PsychiatryUniversity of Colorado Denver

September 19, 2012

Marijuana: The Blunt Truth

Recovery Month Conference

Trends in use Why adolescent MJ use mattersPrevention and Treatment

Trends

Son, if you’re going to smoke pot, let me know so that

I can get you a “green card.”

Thanks, dad.

Please don’t tell your mother

Change in adolescent past month MJ use in Los Angeles

0

5

10

15

20

25

30

22.5%

Youth Risk Behavior Survey, 2012

%22.2% 18.1

%

21.4% 19.3

%

22.4%

Limitations of CDC data

Does not include teens not in school

Still awaiting data on availability, norms, attitudes

No statistically significant changes

School Expulsions for Drugs - CO

0

2

4

6

8

10

1276

7

53

4

75

3

#

http://www.cde.state.co.us/cdereval/rv2011sdiincidents.htm

0

2

4

6

8

10

12

Year

# of + DREs for THC

Drugged Driving

300 304335

429

391

599

0

2

4

6

8

10

12

Year

# fatalities with driver +

for THC

Drugged Driving

2729

39

41

47

Teens in substance tx (N=80)

“Have you ever obtained MJ from someone with a MMJ license?”

0

25

50

75

100

N = 38/8049%

N = 42/8051%

Thurstone et al.,

“Have you ever obtained MJ from someone with a MMJ license?”

Primary Care Sample (N=66)

0

25

50

75

100

N = 12/6618%

N = 44/6682%

VariableUsed

someone’s MMJn=122

Not used someone’s MMJ

n=42p-value

Male (%) 80.3% 64.3% 0.035

# days of MJ use in past 6 months

102.7 days 81.6 days 0.047

# MJ use d/o sx’s 5.52 3.29 0.0005

Salomonsen-Sautel et al., 2012

N = 137 Yes or unsure No

Is MJ safe for children < 13 yrs?

11.7% 88.3%

Is MJ safe for teens 13-18 yrs?

38.2% 61.8%

Is MJ safe for pregnant women?

27.9% 72.1%

Shuman et al., 2012

Hall and Degenhardt, 2009; NSDUH, 2011

Epidemiology Marijuana and the adolescent brain

17% who try MJ before 18 years develop abuse/dep, compared to 4% for >18 yrs

58% of new users are <18 years

67% of teens substance tx admits are for MJ

20% of all substance tx admits are for MJ

40% of all MJ substance tx admits are teens

Hall and Degenhardt, 2009; NSDUH, 2011

Adolescent exposure to MJ may be toxic to brain development

Age

Functional Development

Limbic system

Prefrontal system

Adolescence

Casey et al., 2008

Adolescent MJ use increases the odds of other ilicit substance use 2-3 times by young

adulthood

Agrawal et al., 2004; Fergusson et al., 2000; Fergusson et al., 2005; Grau et

al., 2007; Kandel et al., 1986; Lessem et al., 2006; Lynskey et al., 2003; Mayet

et al., 2011; van Ours et al., 2003; Yamaguchi and Kandel, 1984

Adolescent MJ use is toxic to adolescent brain development: psychosis

7 cohorts confirm adolescent exposure to MJ predicts psychosis (OR=0.72-3.0)

The risk is dose-dependent

Risk is not accounted for by intoxication effect, reverse-causation or confounds

Andreasson et al., 1987; Arseneault et al., 2002; Fergusson et al., 2003; Henquet

et al., 2005; Tien et al., 1990; van Os et al., 2002; Wiles et al., 2006

Adolescent MJ use may be toxic to adolescent brain development: cognition

Those using MJ before 17 compared to after have:

↓VIQ (103.5 vs 115.6, p<0.001) (Pope et al., 2003)

↓ verbal fluency (# of objects in a category named) (Pope et

al., 2003)

• ↓ word recall in 30 minutes (Pope et al., 2003)

• ↓ visual scanning ability (but not divided attention, working memory, flexibility) (Ehrenreich et al., 1999)

• ↓ visual scanning reaction time (but not for the other measures) (Ehrenreich et al., 1999)

• ↑ ↓difficulty learning, remembering and focus at age 27 with MJ expsure between 14-22 yrs (Brook et al., 2008)

• ↓ Whole brain volume, % cortical gray matter (Wilson et al.,

2000)

• ↑ CBF (Wilson et al., 2000)

Animal Studies - adolescent exposure is toxic to brain development

Domain Outcome

Motivation ↓

Social interaction ↑ anxiety

Memory ↓ short-term recognition

Attention ↓ filtering of unnecessary stimuli

Hippocampus ↓ ↓neurons, synaptic density

Jager and Ramsey, 2008, Rubino et al., 2009

Dunedin StudyN=1,037

0 3818 21 26 327 9 11

13

WISC-R{

Cannabis dependence

Cannabis >3X/wk

At age 38, WAIS-IV and

Attention and Memory

Meier et al., 2012

Dunedin Study

Meier et al., 2012

•Results:• ↓Cannabis dependence predicted in IQ

•↓ was dose-dependent

•Decline in IQ accounted for by adolescent onset users

• ↓Cessation of use at age 38 did not change in IQ

•↓ in all four indices of IQ: working memory, processing speed, perceptual reasoning, verbal comprehension

•Friends/family noticed significantly more memory/attention problems

Dunedin Study

Meier et al., 2012

• ↓ in IQ not accounted for by:

•past 24 hour cannabis use

•past week cannabis use

•tobacco dependence

•alcohol dependence

•other substance dependence

•schizophrenia

Fergusson et al., 2010

Adolescent MJ use predicts less educational achievement

Teens using MJ for the first time after 18 years (or never) compared to those using by 15 years are:

• 3.6 times more likely to get a HS degree

• 2.3 times more likely to enroll in college

• 3.7 times more likely to get a college degree

MJ and School

0

2

4

6

8

10

12

-17%

-5%-3%

Fergusson et al., 2010

Adolescent MJ use predicts aggression

⇒ ↑Low dose THC (0.1 mg/kg) aggression (Taylor et al., 1976)

• ⇒ ↓High dose THC (0.25-0.4 mg/kg) aggression (Salzman

et al., 1976)

• ⇒ ↑Marijuana withdrawal aggression on days 3, 7 but baseline on day 28 (Kouri et al., 1999)

Adolescent MJ use and HIV, STD, teen pregnancy

early onset sex (mean=13.1 years)

↑ lifetime partners (mean=6.2)

↓ condom use (55% report sometimes or never)

↑ rates of STD’s (14%)

Adolescent MJ use is associated with:

Among 656 Denver teens on probation at 12-month f/u:

freq. of MJ use predicts STD diagnosis

# of dep. sx’s predicts non-condom use in last 6 months

Bellis et al., 2008; Brodbeck et al., 2006; Crosby et al., 2003; Guo et al., 2005; Hendershot et

al., 2010; Malow et al., 2001; Mertz et al., 2000; Shrier et al., 1997; Wu et al., 2009; Yan et al.,

2007

Marketing1966: “We do not favor smoking by young people.” - J. Cullman,

president Philip Morris

2009: “We have made a significant effort ... to connect only to

adult smokers.” spokesperson for Philip Morris

1991: 31% of 3-year-olds and 91% of 6-year-olds match Joe

Camel with a picture of a cigarette - Fischer et al., 1991

2012: “...despite claims from cigarette manufacturers...,the evidence is sufficient to conclude that marketing efforts...by tobacco companies show a consistent dose-response relationship in the initiation and progression of tobacco use among young people.” U.S. Surgeon general

Conclusions Some indicators of teen MJ use increasing but more data needed

Teens have easy access to MMJ

Teens are especially vulnerable to the effects of MJ

Difficult to protect youth in a legalized, regulated environment

UN Rights of a Child: “State parties shall take all appropriate measures...to protect children from the illicit use of

narcotic drugs and psychotropic substances...”

www.DrThurstone.com

Christian Thurstone, M.D.Associate Professor of PsychiatryUniversity of Colorado Denver

September 19, 2012

Marijuana: Treatment Update

Recovery Month Conference

Treatment

Conduct d/o 53%

ADHD 38%

GAD 23%

MDD 18%

PTSD or acute stress d/o 14%

Past-year assault 66%

Suicidal acts/thoughts 9%

Dennis et al., 2004

Treatment

Condition Treatment

SUD Family therapy, CBT

Conduct d/o Family therapy, CBT

ADHD Medications, CBT

GAD CBT

MDD CBT

PTSD or acute stress d/o CBT

Integrated MH/Substance tx

Contingency management

Case managementCBT

Continuing care

ENCOMPASS

New Treatment Research

Study Methods Results

Riggs et al., 2011

303 13-18 yo’s with ADHD and SUD

OROS/PBO + CBT for 16 weeks

OROS>PBO for ADHD

OROS had more - UDS (3.8 v 2.8)

Riggs et al., 2007

126 12-19 yo’s with MDD, CD and SUD

FLX/PBO + CBT for 16 weeks

FLX>PBO for MDD

⇒MDD remission SUD response

New Treatment Research

Study Methods Results

Stanger et al., 2009

69 14-18 yo’s in tx for MJ

MI/CBT +/- CM for 14 wks

CM>no CM DURING tx

Ramo et al., 2005

90 teens followed for 6 months after inpt tx

88% relapsed in 6 mo’s, MJ involved in 58% of relapses

Waldron and Turner, 2008

Review of 17 RCT’s since 1998 for adolescent substance tx

FT≈CBTMaintained ES at f/u:CBT: 10/12FT: 6/13

Earlier Intervention

•Before court-involvement

•Primary care

•School-based

•Treating substance misuse

NAC

Patients: 116 15-21 yo’sMethods: 8 weeks, NAC/PBO 1200mg bid + CMResults: 41% v 27% negative UDS, p=NS, well-tolerated, OR=2.4 of - UDSLimitations: 8 weeks, 40% drop-out

Gray et al., 2012

Gabapentin

50 adults in tx for cannabis dependence for 12 weeks

Gabapentin (1200 mg/day) v placebo

Gabapentin had greater decrease in grams and days per week (5 days to 0.75 for gabapentin or 1 for PBO) and

urine THC levels

Mason et al., 2012

Summary

MI/CBT

Need to increase accessibility

Need to provide continuing care

Need to provide integrated treatment

www.DrThurstone.com