Marijuana Dependence and Legalization

Making best guesses about pot.

One essential question about state marijuana legalization continues to dog the debate:  Namely, as marijuana becomes gradually legal, how do we estimate how many people will become dependent? How can we estimate the number of cannabis users who will become addicted under legalization, and who otherwise would not have succumbed?

Back in 2011, neuroscientist Michael Taffe of the Scripps Research Institute in San Diego, writing on the blog TL neuro, referenced this common question, noting that “the specific estimate of dependence rate will quite likely vary depending on what is used as the population of interest… Obviously, changing the size of the underlying population is going to change the estimated rate….”

But change it how, and by how much? The truth is, we don’t know. We can’t know in advance. There are sound arguments for both positions: Legal marijuana will lead to increased rates of cannabis addiction because of lower price and greater availability. On the other hand, almost everybody likely to become addicted to marijuana has probably already been exposed to it, including teens.

What we can start attempting to find out with greater rigor, however, is this: How many chronically addicted marijuana users are out there right now?

In The Pathophysiology of Addiction  by George Koob, Denise Kandel, and Nora Volkow (2008), the base rate of cannabis dependence was estimated to be 10.3% for male users and 8.7% for female users. Their data came from the National Survey on Drug Use and Health, and the rate is similar to common estimates for prescription stimulant addiction. The dependence rate for cigarettes is at least three times as high. However, an overall dependence rate of 9.7%, when men and women smokers are combined, is the origin of the highly contested figure of 10%.

Since then, other databases have been tapped for estimates of existing cannabis dependence. In October of 2013, using the Global Burden of Disease database maintained by the World Bank, British and Australian researchers, along with collaborators at the University of Washington in the U.S., published revised estimates in the open-access journal PLOS ONE, based on numbers from 2010.  The scientists culled and pooled a series of epidemiological estimates and concluded that roughly 11 million cases of cannabis dependence existed worldwide in 1990, compared to 13 million cases in 2010. This boost can be accounted for in part by population increases.

Are these dependent users distributed evenly across the globe? They are not. The PLOS ONE paper demonstrates that marijuana use is markedly more prevalent in certain regions: “Levels of cannabis dependence were significantly higher in a number of high income countries including Australia, New Zealand, the United States, Canada, and a number of Western European countries including the United Kingdom.” High income equals high marijuana usage and dependence—“Cannabis dependence in Australasia was about 8 times higher than prevalence in Sub-Saharan Africa West.” But there may be major holes in the epidemiological database: “This is particularly the case for low income countries, where there is typically limited information on use occurring, even less on levels of use, and usually no data on prevalence of dependence.”

In conclusion, the researchers found an age and sex-standardized cannabis addiction prevalence of 0.2%. “Prevalence was not estimated to have changed significantly from 1990, although increased population size produced an increase in the number of cases of cannabis dependence over the period.”

In another 2008 study, this one published in the Journal of Clinical Psychiatry, scientists at Columbia University and the New York State Psychiatric Institute looked at a set of 2,613 frequent cannabis users, using the development of significant withdrawal symptoms as the leading indicator. About 44% of regular dope smokers experienced two or more cannabis withdrawal symptoms, while about 35% reported three or more symptoms. The most prevalent symptoms in this study were fatigue, weakness, anxiety, and depressed mood. “Over two-thirds smoked more than 1 joint/day on days they smoked during their period of heaviest use; mean joints smoked/day was 3.9. About one-fifth had primary major depression….”

Age of onset was not predictive of withdrawal symptoms in this large study. The investigators suggest that “irritability and anxiety may receive great clinical consensus as regular features of cannabis withdrawal because they are subjectively and clinically striking compared to fatigue and related symptoms.” The researchers also speculate that somatic symptoms of weakness and fatigue might be attributed to varying levels of THC, compared to the presence of other cannabinoids such as CBD. The study is further evidence supporting an “association of primary panic disorder or major depression with cannabis depression/anxiety withdrawal symptoms,” suggesting a “possible common vulnerability, meriting further investigation.”

One of the reasons this matters is because of the very tight relationship between marijuana addiction and major depressive disorder. A 2008 study of young adults in the journal Addictive Behaviors  found that participants with comorbid cannabis dependence and major depressive disorder, the most commonly dependence symptom was withdrawal, reported by more than 90% of the subjects in the study. 73% of the subjects experienced four symptoms or more. After that, the most common symptoms were irritability (an underreported but significant behavioral problem), restlessness, anxiety, and a variety of somatic symptoms, including gastrointestinal problems, loss of appetite, and sleep disturbances, including night sweats and vivid dreaming. The authors, affiliated with University of Pittsburgh School of Medicine, concur with the conclusion of earlier researchers:  “Given the weight of evidence now supporting the clinical significance of a cannabis withdrawal syndrome, the burden of proof must rest with those who would exclude the syndrome….”

Clearly, cannabis does not contribute to the world disease burden in the same way that alcohol, nicotine, and opiods do. However, it’s fair to say that for a minority of users, cannabis dependence causes disabilities and liabilities that are not always trivial.

Mark A. R. Kleiman, a Professor of Public Policy at UCLA and a consultant to the state of Washington on marijuana legalization, told PBS:

The couple of million who stay stoned all day, every day, account for the vast bulk of the total marijuana consumed, and thus the total revenues of the illicit marijuana industry. That's typical. The money in any drug, including alcohol, is in the addicts, not the casual users. There was a big fuss during the 80s about how much casual middle-class drug use there was and how respectable folks were supporting the markets. It's certainly true that most people who are illicit drug users are employed, stable respectable citizens. But it doesn't follow that if we could get the employed, stable respectable citizens to stop using illicit drugs, the problem would mostly go away.

State Marijuana Legalization: The Opposing Voices

Repeating Our Alcohol Mistakes?

A recent article in the always insightful Alcoholism and Drug Abuse Weekly, edited by Alison Knopf, concerns itself with the voices speaking out against Attorney General Holder’s announcement that federal authorities would not interfere with state efforts to legalize marijuana. It’s no secret that we here at Addiction Inbox have been longtime advocates for decriminalization along Dutch lines. So it’s high time we heard from some prominent dissenters on this issue.

Kevin A. Sabet, Ph.D., director of Project SAM (Smart Approaches to Marijuana) and former White House advisor on marijuana policy: “It’s the same thing with alcohol:  The marijuana industry is giving lip service, saying that they don’t want kids to use.”

Sue Thau, public policy consultant for Community Anti-Drug Coalitions of America (CADCA): “This is the start of Big Marijuana the way we have Big Alcohol and Big Tobacco…. Anyone who cares about addiction has to care about this.”

Rafael Lemaitre, spokesman for the Office of National Drug Control Policy: “We know that marijuana use, particularly long-term, chronic use that began at a young age, can lead to dependence and addiction. Marijuana is not a benign drug, and we continue to oppose marijuana legalization because it runs counter to a public health approach to drug policy.”

Gen. Arthur T. Dean, CEO of Community Anti-Drug Coalitions of America (CADCA): "This decision sends a message to our citizens, youth, communities, states, and the international community at large that the enforcement of federal law related to marijuana is not a priority."

The article is entitled “Advocates dismayed as legalization moves forward.”

Here are a few I have come across recently from other sources:

Citizens Against Legalizing Marijuana (CALM): "After decades of study the FDA continues to reaffirm that there is no medical benefit provided by the use of smoked marijuana and that, in fact, considerable harm can be caused by such use. We affirm the 2006 FDA finding and vast scientific evidence that marijuana causes harm. The normalization, expanded use, and increased availability of marijuana in our communities are detrimental to our youth, to public health, and to the safety of our society."

Office of National Drug Control Policy: "The Office of National Drug Control Policy is working to reduce the use of marijuana and other illicit drugs through development of strategies that fully integrate the principles of prevention, treatment, recovery, and effective supply reduction efforts. Proposals such as legalization that would promote marijuana use are inconsistent with this public health and safety approach.... Marijuana use is associated with dependence, respiratory and mental illness, poor motor performance, and impaired cognitive and immune system functioning, among other negative effects."

CNBC: "Contrary to the beliefs of those who advocate the legalization of marijuana, the current balanced, restrictive, and bipartisan drug policies of the United States are working reasonably well and they have contributed to reductions in the rate of marijuana use in our nation.... The rate of current, past 30-day use of marijuana by Americans aged 12 and older in 1979 was 13.2 percent. In 2008 that figure stood at 6.1 percent. This 54-percent reduction in marijuana use over that 29-year period is a major public health triumph, not a failure."


Photo Credit: LARRY MAYER/Billings Gazette Staff

The Media and Drug Policy: Where’s the Science?

Groping blindly toward a new framework.

As states and the federal government clash at the legal, social, and political levels over legalizing marijuana, the science of drugs and addiction has taken a back seat. The dismal state of the addiction treatment business has recently been documented by Anne M. Fletcher in Inside Rehab, while over the past few years, drug policy officials in the U.S. have had to cope with three major developments: the medicalization and legalization of marijuana, the emergence of new synthetic drugs, and the abuse of potent prescription painkillers.

Major media outlets have largely failed to highlight the relevant scientific issues in each case. What we see instead is that journalists and others who are covering drugs and addiction issues are not making connections with solid scientific sources in the neurochemical research community. All too often, media reports of adverse drug events are sourced solely by police officers, or spokespersons on behalf of for-profit rehab centers, who are no more ready to make science-based pronouncements on these matters than anyone else.

States are now in the process of relaxing strictures on the possession and use of cannabis—and they are doing it well before they have put in place a set of evidence-based policies for the implementation of this new state of affairs. Who is in charge of directing policy decisions in Washington and Colorado? What will be the regulatory structure at the level of county and municipal government? Whose voices will actually be heard? Should the feds leave it to the states, and the states leave it to the counties, who then leave it to the cities? To what degree are the two states taking the medical and health aspects of this sweeping change into account? Can evidence be substituted for opinion in such cases? If so, how?

Even if the Department of Justice decides to shut down all efforts at relaxing marijuana statutes, it will need to rely upon a sound collection of scientific evidence to make its argument. The media play a compelling role in drug discussions, but coverage traditionally has been limited to articles about the legal, political, and sociocultural ramifications of the changes. These are all critical parts of the story, but science journalists need to step forward and direct more coverage toward emerging medical issues and the findings of science. Ordinary citizens will want to have at least a partial grasp of the medical and science-based decisions that state and federal governments will be making about personal health and habits as they legislate and adjudicate these concerns.

The federal government will have to begin working with states rather than against them, if public opinion continues to change on legalization issues. At the same time, the feds will be called upon to provide guidance for the states that is consistent with international drug treaties. Congressional committees will have to grapple with the realities of setting forth the limits and logistics of the market for marijuana in coherent and consistent ways. Incredibly, very little of this is pinned down, firmly understood, or even grasped as imminent problems by either legalizers or their opponents. Many of the issues that took years to wrestle down with cigarettes, such as warning labels on cigarette packages, will present themselves with equal and immediate force in the case of states with legalization plans.

In addition, marijuana policy makers in Colorado and Washington will have to render decisions concerning sales to minors, cannabis in the workplace, DUI marijuana laws, addiction issues, sales outlets, tax issues, and the results of ongoing medical research on marijuana. Some states allow private dispensaries, some have banned them. Some allow private cultivation of cannabis, and some do not. 

As for the newer synthetic drugs—the cannabis-like products known as Spice, and designer stimulant drugs known collectively as “bath salts”— these chemicals exist in a twilight zone of ignorance, with very little sound medical information passing to the public. Few people understand with any degree of certainty just what is inside those shiny foil packages. This glaring disconnect between clinical research and media reports leads to unsupported tales of face-eating zombies and dead teenagers on bath salts, well in advance of the drug testing that might factually answer questions about drug-related behavior. Meanwhile, scientists fear that the continuing effort to ban every substance illegally marketed in this category will close off certain valuable avenues of research, including new drug discovery.

Finally, the ongoing battle to lower the soaring use and abuse of oxycontin, Vicodin, and other opiate drugs has caused problems for legitimate pain patients across the country. Yet this medical aspect of the painkiller panic is rarely remarked upon. Some addiction researchers believe that as prescription painkillers are removed from the market or made more difficult to abuse, those with opiate addictions will migrate to heroin in greater numbers. Scientific research on addiction suggests that this may well be the case. 

What is missing specifically from most drug policy debates is the recognition of the vast metabolic variation among individuals. Different drugs affect different people differently, and for the first time, neuroscientists are building a solid body of information that could help policy makers better forecast the results of their actions. Lethality, side effects, tolerance, and susceptibility to addiction all vary widely due to metabolic differences among people.

But some shared reactions, and basic withdrawal parameters, do exist. Congress, the FDA, NIDA, as well as state health agencies and other regulatory bodies, need information about drugs and drug use that scientists have been busily compiling. The public needs this information, too. We need to search for ways media can more effectively inject science-based drug information into current policy debates. 

Science journalists are perfectly situated to serve as potential communicators between warring parties. What can the media do to markedly enhance intelligent, science-based coverage of drug issues?

Photo: Telstar Logistics

Strong Pot: What Do Schizophrenics Think?

Small study asks patients for their opinions.

The theory, fiercely debated in the research community, that strong cannabis can actually cause schizophrenia—or is associated with relapse in schizophrenics who smoke it—is the subject of a small study from Switzerland on outpatient schizophrenics, some of whom were pot smokers.

 A study of this kind, with only 10 subjects, verges on the anecdotal. Nonetheless, it is worth a look, just to see if any verification of the theory lurks therein.

In their paper for the open access Harm Reduction Journal—“Do patients think cannabis causes schizophrenia? A qualitative study on the causal beliefs of cannabis using patients with schizophrenia”—psychiatric workers with the Research Group on Substance Use Disorders interviewed patients who attended an outpatient clinic at the Psychiatric University Hospital in Zurich. The researchers did it because, as the paper states, “patients’ beliefs on the role of cannabis in the pathogenesis of schizophrenia have—to our knowledge—not been studied so far…”

“None of the patients described a causal link between the use of cannabis and their schizophrenia,” the researchers determined. However, several of the schizophrenics did have their own version of a disease model to account for their illness. Five of the patients attributed their schizophrenia to “upbringing under difficult circumstances,” and three placed the blame on “substances other than cannabis (e.g. hallucinogens).” The remaining two patients gave “other reasons.”

Interestingly, four of the patients “considered cannabis a therapeutic aid and reported that positive effects (reduction of anxiety and tension) prevailed over its possible disadvantages (exacerbation of positive symptoms).” The authors conclude that excluding schizophrenic patients from treatment settings because of marijuana use “may cause additional harm to this already heavily burdened patient group.”

Graphics Credit: http://www.salem-news.com

Michigan, Massachusetts Pass Marijuana Proposals

Voters bolster medical marijuana movement—or do they?

On November 4, both Michigan and Massachusetts passed harm reduction measures aimed at eliminating stiff penalties for possession of small amounts of marijuana. Opponents vowed to keep fighting.

In Michigan, on a vote of 63% to 37%, voters passed Proposal 1, allowing for the physician-supervised possession and use of cannabis. However, the initiative did not go as far as allowing for licensed medical dispensaries, as California has done. Nonetheless, this was not a happy outcome for the President’s Office of National Drug Control Policy and its director, John P. Walters, who campaigned strenuously against the measure, calling it an “abomination” and said it was likely to lead to marijuana shops in every neighborhood. For its part, the Michigan Coalition for Compassionate Care said that passage of the proposal would mean that “seriously ill Michiganders who use medical marijuana with their doctors’ recommendation will no longer face the threat of arrest and jail.”

Similar scare tactics failed to deter the electorate of Massachusetts, where 65% of voters came down in favor of Question 2, which calls for rolling back penalties for possession of small amounts of marijuana to traffic-fine levels—a strategy which was adopted successfully, if briefly, by Oregon, Alaska, and other states some 35 years ago.

As in Michigan, a full-on campaign against the measure painted a picture of dire consequences for Massachusetts, such as a surge of workplace safety issues and traffic accidents. According to the Marijuana Policy Project, the state’s District Attorneys predicted an epidemic of teen marijuana use. State authorities have the ability to amend the new statute under state law.

Michigan and Massachusetts now become the 13th and 14th states to offer some protection for the medical use of marijuana. Both propositions were heavily endorsed by major newspapers in both states. The city of Fayetteville, Arkansas, as well as Hawaii County in Hawaii, passed ballot measures designed to make marijuana enforcement a low priority for local law officers.

Meanwhile, in California a proposition designed to divert greater numbers of drug offenders from jail to treatment, while decriminalizing the possession of up to an ounce of marijuana by anybody, went down to defeat. Supporters of Proposition 5 had argued that the change was necessary because of serious overcrowding in California’s state jail systems. (See Addicts, Alcoholics Overwhelm Prison System).

Here's a brief roundup of drug-related propositions on last week's ballots:
Marijuana Policy Project

Graphic Credit: Michigan Coalition for Compassionate Care

medical marijuana

Minister Says Marijuana is a Sacrament

That’s Reverend Stoner to you, brother

Nice try, Craig X. Rubin. But the California courts aren’t buying it. Ministers, mail-order or otherwise, are unlikely to merit federal protection for the use of pot as a church sacrament.

Ordained, as were so many of us, as a minister of the Universal Life Church, and thereby licensed to perform legal weddings and, in days gone by, to attempt conscientious objector status in military matters, Rubin was charged with possession with attempt to sell. The leader of the 420 Temple faces up to seven years in prison for dealing.

The 41 year-old Rubin has no legal experience but is representing himself in the case. Not much is known about his court strategy, but a two-pronged defense appeared to be emerging: Rubin will argue that marijuana is the “tree of life” mentioned in the Bible (if not in the movie, “The Fountain,”) and that an officer held a shotgun to his head during the arrest. He is not contesting the allegation of possessing pot, which he said the churches uses as a sacrament during services. He is currently free on $20,000 bail.

Rubin spent last weekend preparing for jury selection by consulting with Native American elders in as sweat lodge at the bottom of the Grand Canyon. This may not be as crazy as it sounds, as tribes in the West have accumulated considerable legal expertise in these matters due to the use of peyote in Native American Church rituals.

“He is as good as I’ve seen any defendant representing himself,” said Michael Levinsohn of the National Organization for the Reform of Marijuana Laws (NORML).

In the event, Superior Court Judge Mary H. Strobel neatly side-stepped the federal issues at hand, ruling that the Reverent Rubin could not use federal statutes as a defense against state drug charges.

Sources:

--Glazer, Andrew. “Minister cites religious protection in marijuana defense.” Associated Press Newswire, 07/24/2007

--“Minister: Marijuana is a sacrament.” Focus on Faith, MSNBC.com. July 26, 2007. http://www.msnbc.msn.com