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 Pot President

Hendrik Hertzberg on the hypocrisy of the hip.

In a blog post at the New Yorker last week, Hendrik Hertzberg spotlighted a recent joke made by the President of the United States at the White House Correspondents dinner. In reference to the rapidly changing media landscape, Obama said: “You can’t keep up with it. I mean, I remember when BuzzFeed was just something I did in college around two A.M. (Laughter.) It’s true! (Laughter.)”

The days of expressing a cringing contrition for your “youthful experimentation,” or claiming that you didn’t inhale, or clearly over.

But of course, the president’s joke wasn’t really that funny. Hertzberg cites statistics from Ethan Nadelmann of the Drug Policy Alliance, suggesting that “from fifty to a hundred thousand Americans are behind bars for pot, and only pot, on any given night.” The Office of National Drug Control Policy (ONDCP) disputes those figures, but the point is not so much whose numbers are closer to the truth, but rather the simple fact that while the president made his joke, too many people are locked up in federal and state prisons for an offense that a growing number of states are backing away from enforcing.

As Hertzberg put it, the subtext of the president’s pot joke was that it “allowed the tuxedoed, evening-gowned, middle-aged audience at the Washington Hilton to feel, for a precious moment, hip. The subtext was that smoking pot, whether a lot or a little, is just a normal part of growing up…. Nor has it done much to blight the lives of the other people in the Hilton ballroom, most of whom, like the rest of the media, political, and Hollywood elites, have smoked pot, too.”

Obama, they say, was a champ stoner in school. He was, writes David Maraniss in his biography of Obama, skilled at “interceptions”—sneaking an extra hit off the joint when it hadn’t gotten all the way around yet.  Obama, writes Hertzberg, really ought to feel “a smidgen of shame that the government he heads treats people who do exactly what he used to do, and now casually jokes about, as criminals.”

We haven’t heard much lately about the Boomer hypocrisy inherent in such roomfuls of high achievers who used to get high. (Some of them still do.) Jobs and reputations and bank loans are not endangered by these sly references and knowing winks. What hurts jobs and reputations is a stretch in federal prison—the unwilling route taken by many less fortunate Americans.

Hertzberg is wrong when he says that “marijuana-associated suffering enters the picture only when prohibition does.” Like most pro-legalization commentators, he does not mention addiction liability, or lasting cognitive effects on younger smokers.  But it is true that a disproportionate amount of suffering is caused by marijuana prohibition laws. The farthest corners of the debate are staked out, but decriminalization—the missing middle ground—still offers society a more balanced starting point than full-tilt legalization. Merriam-Webster says that to decriminalize is “to repeal a strict ban on, while keeping under some form of regulation.” State policy makers, although they don’t use the term very often, are pursuing what amounts to decriminalization. Nobody other than world-peace-through-weed zealots is arguing for a repeat of the track record with cigarettes (a drug in the process of being re-criminalized). And the regulation of alcohol does not offer a compelling model for marijuana’s future as a semi-legal drug. Happily, marijuana is not nearly as dangerous as alcohol or nicotine, so that helps.

It might surprise some readers to know that a majority of the Dutch aren’t interested in legalizing marijuana. They are concerned about keeping it out of the hands of minors. They’re not very happy with the trend towards higher and higher levels of THC. This is expressed in the fact that marijuana is, and likely will remain, illegal in The Netherlands. The narrow coffee shop exception is misleading in this regard. It was not designed to make marijuana more acceptable, but to deal creatively with the problem of street sales. You almost never see a drug deal going down on the streets of Amsterdam. That’s because a) It’s stupid, you can just waltz into a coffee shop if you’re over 21. b) Dealers have a hard time beating coffee shop prices. c) Dutch police come down heavily on street dealers.  Why? See a) above. The Dutch are no freer to wander their canal-lined streets with a joint in hand than Americans are free to wander Capitol Mall Boulevard with an open bottle of Jack.

Now that’s decriminalization. And an unfair comparison, of course, since the Dutch nation is so much smaller and more homogenous than the U.S. But lately, the talk has been about states, not the country at large. And at the state level, some of the Dutch lessons may apply.

What should our president do about all of this? Hertzberg has three proposals:

—Tell the Justice Department to “end the absurd classification of marijuana as a supremely dangerous Schedule I drug, like heroin.” Alcohol, let us recall, does not have a drug classification because it is not a scheduled substance at all. This American ambivalence is reflected by the names of the country’s premier drug research groups, the National Institute on Drug Abuse (NIDA), and the Monty Pythonesque National Institute on Alcohol Abuse and Alcoholism (NIAAA).

—Promise to “avoid making life unnecessarily difficult” for the states that have made provisions for medical marijuana or legalization.

—Change the name of the Drug Czar’s Office of National Drug Control Policy to something like the “Office of National Harm Reduction Drug Policy.”

Adopting any or all of these changes would be a useful step toward a decriminalized future for marijuana. Here’s the essential point: We have to make a space for marijuana use in American culture. I mean above the ground, and unassociated with jail time. While still murky from a medical point of view, there is just no doubting that millions of Americans prefer pot to alcohol as a recreational drug. Given alcohol’s role in the American death toll, and the lack of any such grim trail of the dead in marijuana’s case, there’s no shame in that decision, from my point of view.

Graphics Credit: http://www.anonymousartofrevolution.com/

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

Is Marijuana Addictive?

The argument continues.

For more, see Marijuana Withdrawal.
See also Marijuana Withdrawal Revisited

Marijuana may not be a life-threatening drug, but is it an addictive one?

There is little evidence in animal models for tolerance and withdrawal, the classic determinants of addiction. For at least four decades, million of Americans have used marijuana without clear evidence of a withdrawal syndrome. Most recreational marijuana users find that too much pot in one day makes them lethargic and uncomfortable. Self-proclaimed marijuana addicts, on the other hand, report that pot energizes them, calms them down when they are nervous, or otherwise allows them to function normally. They feel lethargic and uncomfortable without it. Heavy marijuana users claim that tolerance does build. And when they withdraw from use, they report strong cravings.

Marijuana is the odd drug out. To the early researchers, it did not look like it should be addictive. Nevertheless, for some people, it is. Recently, a group of Italian researchers succeeded in demonstrating that THC releases dopamine along the reward pathway, like all other drugs of abuse. Some of the mystery of cannabis had been resolved by the end of the 1990s, after researchers had demonstrated that marijuana definitely increased dopamine activity in the ventral tegmental area. Some of the effects of pot are produced the old-fashioned way after all--through alterations along the limbic reward pathway.

By the year 2000, more than 100,000 Americans a year were seeking treatment for marijuana dependency, by some estimates.

A report prepared for Australia’s National Task Force on Cannabis put the matter straightforwardly:

There is good experimental evidence that chronic heavy cannabis users can develop tolerance to its subjective and cardiovascular effects, and there is suggestive evidence that some users may experience a withdrawal syndrome on the abrupt cessation of cannabis use. There is clinical and epidemiological evidence that some heavy cannabis users experience problems in controlling their cannabis use, and continue to use the drug despite experiencing adverse personal consequences of use. There is limited evidence in favour of a cannabis dependence syndrome analogous to the alcohol dependence syndrome. If the estimates of the community prevalence of drug dependence provided by the Epidemiologic Catchment Area Study are correct, then cannabis dependence is the most common form of dependence on illicit drugs.

While everyone was busy arguing over whether marijuana produced a classic withdrawal profile, a minority of users, commonly estimated at 10 per cent, found themselves unable to control their use of pot. Addiction to marijuana had been submerged in the welter of polyaddictions common to active addicts. The withdrawal rigors of, say, alcohol or heroin would drown out the subtler, more psychological manifestations of marijuana withdrawal.

What has emerged is a profile of marijuana withdrawal, where none existed before. The syndrome is marked by irritability, restlessness, generalized anxiety, hostility, depression, difficulty sleeping, excessive sweating, loose stools, loss of appetite, and a general “blah” feeling. Many patients complain of feeling like they have a low-grade flu, and they describe a psychological state of existential uncertainty—“inner unrest,” as one researcher calls it.

The most common marijuana withdrawal symptom is low-grade anxiety. Anxiety of this sort has a firm biochemical substrate, produced by withdrawal, craving, and detoxification from almost all drugs of abuse. It is not the kind of anxiety that can be deflected by forcibly thinking “happy thoughts,” or staying busy all the time. A peptide known as corticotrophin-releasing factor (CRF) is linked to this kind of anxiety.

Neurologists at the Scripps Research Institute in La Jolla, California, noting that anxiety is the universal keynote symptom of drug and alcohol withdrawal, started looking at the release of CRF in the amygdala. After documenting elevated CRF levels in rat brains during alcohol, heroin, and cocaine withdrawal, the researchers injected synthetic THC into 50 rats once a day for two weeks. (For better or worse, this is how many of the animal models simulate heavy, long-term pot use in humans). Then they gave the rats a THC agonist that bound to the THC receptors without activating them. The result: The rats exhibited withdrawal symptoms such as compulsive grooming and teeth chattering—the kinds of stress behaviors rats engage in when they are kicking the habit. In the end, when the scientists measured CRF levels in the amygdalas of the animals, they found three times as much CRF, compared to animal control groups.

While subtler and more drawn out, the process of kicking marijuana can now be demonstrated as a neurochemical fact. It appears that marijuana increases dopamine and serotonin levels through the intermediary activation of opiate and GABA receptors. Drugs like naloxone, which block heroin, might have a role to play in marijuana detoxification.

In the end, what surprised many observers was simply that the idea of treatment for marijuana dependence seemed to appeal to such a large number of people. The Addiction Research Foundation in Toronto has reported that even brief interventions, in the form of support group sessions, can be useful for addicted pot smokers.

--Excerpted from The Chemical Carousel: What Science Tells Us About Beating Addiction © Dirk Hanson 2008, 2009.

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