1. Medical Marijuana: An Epidemiological Perspective on Consumption and Consequences Linda Simoni-Wastila, BSPharm, PhD University of Maryland School of Pharmacy April 13, 2012

2. Medical Marijuana: Where We’re Going, Where We Have Been Marijuana and medicine Marijuana’s benefits and risks – Health – Social Consumption and consequences of medical marijuana diffusion

3. Marijuana: What It Is An annual, flowering herb Uses: – Stalk  hemp fiber – Seeds  health food; “hemp milk” – Flower buds  marijuana – Resin  hashish – Various extracts  hashish oil Cannabis plants produce unique family of terpeno- phenolic compounds (cannabinoids) – Delta-9-tetrahydrocannabinol (THC) – Cannabidiol (CBD) – Many other phenols and flavenoids

4. Medical Marijuana: Not the new kid on the block 1600s: cultivated in Jamestown for hemp – 1850, 8000 cannabis plantations 1850-1942: included in the United States Pharmacopeia 1913: California law prohibits recreational use 1936: all 47 states prohibit recreational use – 1957: Marijuana Tax Act  discontinuation of marijuana for medicinal use – 1970: marijuana classified CI drug 1996: California passes Compassionate Use Act 2012: 17 states + DC have medical marijuana legislation

5. Marijuana: Medical Uses Used primarily for chronic (cancer and non-cancer) pain; nausea/vomiting; cachexia Other recognized uses: – HIV/AIDS (wasting/appetite loss) – Glaucoma – Seizure disorders – Crohn’s disease – Arthritis – Multiple sclerosis (muscle spasms) – Muscular dystrophy – Agitation (eg, in Alzheimer’s disease/dementia) – PTSD – Hepatitis C

6. Medical Marijuana: The Options “Au naturale” or synthetic? – Marinol®: synthetic delta-9-THC 2.5mg, 5mg, 10mg capsules in sesame oil – Cesamet®: synthetic THC 1 mg capsule – Sativex ®: standardized extracts of THC and CBD Oromucosal spray In Phase III trials in US; approved in many EU countries, New Zealand, and Canada for MS spasticity and neurological issues

7. Medical Marijuana: The Options “Natural” cannabis vs Marinol® – Therapeutic compounds – Strength/Route of administration – Psychoactive profile – Access – Cost

8. Health Risks of Marijuana Short-term effects: – Distorted perception – Memory/learning problems – Loss of coordination – Impaired cognition/problem-solving – Increased heart rate  4-fold increase in heart attacks – Reduced blood pressure Long-term use: – Anxiety, distrust, paranoia – At high-doses  hallucinations; delusions; impaired memory; disorientation – Effects on lungs: cough; acute infections; obstructive disease; cancer? Pregnancy risks: neurological impairment

9. Societal Risks of Medical Marijuana Prevalence of all marijuana use may increase – Encourage recreational use (especially in teens) or do users come out of the closet? Perceived risk of marijuana may decline Increase abuse and dependence – “Gateway” drug  Increase use of “hard” drugs – Criminal activity  – Trauma and injury  impaired function in driving – Treatment  Increased treatment costs

10. Percent of US Citizens 12 and Older Reporting Past-Month Marijuana Use Source: 2010 NSDUH http://www.samhsa.gov/data/NSDUH/2k10NSDUH/2k10Results.htm

11. Percent of US Citizens Aged 12-17 Who Perceive Great Risk from Using Marijuana 1-2 Times/Week Source: 2010 NSDUH http://www.samhsa.gov/data/NSDUH/2k10NSDUH/2k10Results.htm

12. Prevalence and Perceptions of Risk of Marijuana—State Level Analysis of 13 states with MMLs – NSDUH 2002-2008 – Adolescents aged 12-17 2007-2008: – Prevalence of past-month marijuana use in states with MMLs versus states without MMLs 8.3% MML vs 6.4% Non-MML – Perception of marijuana risk in states with MMLs versus states without MMLs 29.5% MML vs 36.2% Non-MML Wall et al, Annals of Epidemiology, Sept 2011

13. Marijuana and Traffic Fatalities Analysis conducted by Andersen and Rees (11/2011) using multiple data sources, including Fatality Analysis Reporting System (FARS), the Behavioral Risk Factor Surveillance System, and alcohol sales by state Found overall traffic fatalities in states with MMLs fell by 9% after MML passage. Negative relationship between MML and traffic fatalities explained by: – Fatalities involving alcohol reduced by 12% Consistent with hypothesis that marijuana and alcohol are substitutes. Alcohol consumption 9especially beer) declined in MML states – Fatalities NOT involving alcohol reduced by 6.4% Individuals use marijuana in privacy of home Source: Anderson and Rees Nov 2011 http://ftp.iza.org/dp6112.pdf

14. Conclusions Will MMLs be successful in achieving their intended consequence: improving health care of individuals requiring cannabinoids? What unintended consequences may occur with increased adoption of MMLs? Paucity of empiric evidence, and this requires attention as states move to legislate the use of marijuana for medical purposes