1. MARIJUANA LEGALIZATION
Weed Better Be Ready!
Rapid and dramatic, revolution
Ilene Hofrenning MSN, FNP-BC
Health Center Director
Framingham State University

2. No presenter has an actual or. potential conflict of interest in
No presenter has an actual or potential conflict of interest in relation to this activity or presentation.

3. Objectives Pros and cons of marijuana legalization
Effects of legalization on use of marijuana, especially in adolescents and young adults
Brief discussion of endocannabinoid system in the brain and how marijuana effects it
Adverse effects of marijuana especially for those who start early and use frequently
Marijuana addiction
How do we address these issues in the Health Center?

4. Why do people use marijuana?

5. Marijuana contains many chemicals including cannabinoids
THC – tetrahydrocannabinol
Psychoactive component
Active in the brain
Induces the “high”
CBD – cannabidiol
Nonpsychoactive
Active in the periphery
Acts on immune system, anti-inflammatory

6. Marijuana Today

7. Marijuana Legalization
Medical
1996 CA is first state to legalize medical marijuana
Recreational
2012 CO and WA pass ballot initiatives to legalize recreational marijuana
2014  OR and AK legalize marijuana
2016  CA, ME, MA, NE also legalize marijuana
2018 VT is first state to legislate legalization
Bar graph

8. 24 million people in the US used marijuana in the last month (8%) 19
24 million people in the US used marijuana in the last month (8%) % among college students
200 million people in the world use marijuana

10. Marijuana Legalization PRO CON
Industry can be regulated – potency, labeling, safety of product
Majority of users are not harmed
No lethal overdose
Does not cause violence
New industry – will increase jobs and tax $
Black Market will decrease
Use will increase, especially among adolescents and young adults
With increased use, there will an increase in negative consequences of use – effect on brain devel, addiction, ER visits, traffic accidents – all which will cost $
More research is needed re risks and benefits before it’s on the market
Black market will increase

11. Marijuana Legalization is coming to your state (if it's not there already!)
This is a multi-billion dollar industry including sales, tax revenues, jobs – hard for states to resist
Growing acceptance of marijuana legalization
% approve legalization
% approve legalization

12. Medical marijuana has normalized use
“We will use medical marijuana as a red herring to give marijuana a good name.”
Keith Stroup
head of NORML, 1979
NORML graphic and statement

14. Impact of Legalization in Colorado
2000 Medical Marijuana
2009 Commercialization of MMJ
2012 Recreational marijuana
Jan Retail sales

15. Number of Marijuana Dispensaries, Starbucks and McDonalds

16. Percentage of monthly users ages12-17 CO compared to US average

17. States with Medical
and Recreational Marijuana Have Highest Rates of Use Among year olds

20. Impact of Legalization in CO
Traffic fatalities when driver tested positive for marijuana up 225%
ER visits rates related to marijuana per 1000 visits up 35%
Pounds of illegal marijuana seized up 700%
2016 tax revenue $180 million (0.8% of budget)
Price of marijuana per lb fell 25%
Rocky Mountain HIDTA 2017

21. Marijuana Legalization Is Coming
Our population – adolescents and young adults- are vulnerable to the negative effects of marijuana.
As college health professionals, what are the issues we need to be aware of and concerned about?

22. What are the effects of marijuana we should be concerned about?
Cognitive Effects
Anxiety and depression
Increased risk of psychotic disorders (schizophrenia)
Potential for Addiction/Cannabis Use Disorder

23. Cognitive Effects
“There’s growing literature, and it’s all pointing in the same direction:
Starting young and using frequently disrupts brain development.”
Susan Weiss, Director of Research
NIDA

24. Endocannabinoids and THC
Anandamide was discovered in
1992 and named after the
Sanskrit word “ananda” meaning “bliss, joy, delight.”
Add about Is
raili discovering amandanide

25. Endocannabinoids and THC
Anandmide is a natural endocannabinoid. THC is 4 times as likely to attach to cannabinoid receptors so the brain slows down production of the endocannabinoids.

27. Brain development and neural connections pruning continues until age 26

28. Short Term Cognitive Effects
Problems with learning and memory
Executive functioning (attention, planning, abstract reasoning, decision making)
Altered time and spatial perception
Poor coordination and balance
Effects academic performance
Effects judgment
Effects driving skills

29. Driving Under the Influence
THC Effects
Decreases muscle coordination
Increases reaction time
Decreases ability to judge distance
Decreases peripheral vision

30. Long Term Effects on Brain
Decrease in IQ – study in NZ of a cohort of followed for 25 years found that early, regular long term use resulted in an 8 point drop in IQ.
? Graph here, add to previous slide
Meier, Prac. Natl. Sci.,2012

31. Anxiety and Depression
Marijuana decreases anxiety in the short term but as its effect wears off, there often is rebound anxiety which is often at a greater level, so more marijuana is used to decrease the anxiety.
Panic attacks – often related to high concentrations of THC.
Heavy marijuana use associated with depression.
Hill, 2015

32. Marijuana Use and Risk of Schizophrenia

33. Is Marijuana Addictive?
Definition of addiction: Repeated use of a substance despite negative consequences. Marijuana withdrawal syndrome: Anxiety Insomnia Irritability
VolkowND, N Engl J Med, 370,

34. Is Marijuana Addictive?
1/11 (9%)
of adults who try marijuana will develop an addiction
1/6 (17%)
of adolescents who try marijuana will develop an addiction %
of daily users
will develop
an addiction
2.7 million Americans meet DSM-5 criteria for marijuana addiction
VolkowND, N Engl J Med, 370,

35. Long Term Effects
Multiple long term studies suggest that early-onset cannabis use especially when combined with alcohol use, is predictive of lower educational attainment, diminished life satisfaction, increased likelihood of addiction, and other health problems. Marijuana is a Performance Degrading Drug
Brooks et al., 2008; Hill, 2015, Meier et al., 2012; Sabet, 2013
Cite
Jonathan P. Caulkins
Carnegie Mellon University
National Affairs 2016

36. Assessment of Students Regarding Marijuana Use
Ask about use, especially if they are being seen for respiratory symptoms, sleep problems, anxiety, depression, vomiting, abdominal pain, if they indicate academic, family or social problems
Determine extent of use
Identify if symptoms may be related to use
Ask why they use – important to get their perspective!
If appropriate, discuss marijuana addiction

37. Assessment of Students in Health Center, cont’d
Employ harm reduction strategy
Discuss importance of avoiding DUI, either as driver or passenger, especially avoiding combining alcohol and marijuana
Interactions with prescribed medications unknown
Medical marijuana card?
Document this discussion in the medical record

38. Acute Marijuana Intoxication
Incidences increases with easier access to marijuana, stronger THC potency, edibles
Tachycardia, elevated BP (sometimes orthostatic BP)
Anxiety, panic, paranoia, agitation, psychosis
Treatment – reassurance, fluids prn, rest in a quiet room, sometimes benzodiazipines needed
Can last a few hours if smoked or vaped, longer if ingested

39. Marijuana Hyperemesis Syndrome
Seen in heavy chronic users, incidence has increased in legalized states
Frequent daily vomiting relieved by hot showers
Can lead to “scromiting” - screaming and vomiting
Screaming due to psychosis and/or abd pain
Treatment – rest, fluid replacement
Occasionally benzodiazapines or haloperidol needed
Capsaicin has been studied for abd pain

40. Legality of Marijuana in the US 2018
Who’s next? AZ AR CT DE FL IL MD MI MN MT NH NJ NY OH RI
States with legal marijuana CO WA AK OR CA ME MA NV VT

41. In Summary
There is a good chance that marijuana legalization is coming to your state
Legalization increases use especially in adolescents and young adults
Marijuana has short tem and long term effects on the brain especially for those who start young and use frequently
Marijuana is addictive, greater risk for those that start as adolescents
Important to assess use and give accurate information nonjudgmentally to students
Stay up to date with what’s happening in your state

42. THANK YOU!
Ilene Hofrenning MSN, FNP-BC Framingham State University

43. Other Physiological Effects
Adrenergic symptoms
Tachycardia
Hypertension (also orthostatic hypotension)
Tachypnea
Dry mouth
Conjunctival injection
Coronary artery constriction
Increased appetite
? Move to assessment

44. National Survey on Drug Use and Health
Population based survey asking questions about past month drug and alcohol use and diagnostic criteria for abuse and dependence conducted annually
70,000 respondents annually
20 million marijuana users; 137 million alcohol users
21% of current marijuana users met diagnostic criteria for abuse/dependence
13% of alcohol users met criteria
20% of marijuana users use 80% of marijuana consumed
CaulkinsJ, Nat Affairs 2016

45. Psychosis
Several studies have shown that using marijuana increases the risk of developing psychosis by a factor of 2 to 6.
Another study concluded that using marijuana could hasten the development of psychotic symptoms by 3 years – significant because the earlier the onset of psychosis, the worse the long term outcome.
Robin Murray of London’s Institute of Psychiatry estimated that 25,000 schizophrenic diagnoses could have been avoided if no cannabis use.
25K fewer cases in UK

46. 1840s to 1930s widely prescribed in US and Europe for a variety of ailments
Listed in US Pharmacopeia as treatment for:
Neuralgia
Gout
Rheumatism
Tetanus
Cholera
Convulsions
Chorea
Hysteria
Depression
DTs
Insanity
Uterine hemorrhage

47. History of Marijuana Prohibition
1913 – 1970’s state and federal laws prohibiting marijuana
Reefer Madness
? Clip or Reefer madness

48. History of Prohibition cont’d
1970 Controlled Substance Act classifying marijuana as Schedule I (no medicinal value and potential for harm)
1980’s President Ronald Reagan’s War on Drugs

49. Words for MJ