1. June 5, 2013L.A. County Task Force1 Marijuana: Access, use and harm reduction. Amanda Reiman, PhD MSW Policy Manager, CA areiman@drugpolicy.org

2. June 5, 2013L.A. County Task Force2 Today’s Talk Part I: Becoming a legal patient in CA. Part II: A review of the medical evidence Part III: Marijuana as a substitute for other drugs

3. June 5, 2013L.A. County Task Force3 Part I Becoming a patient in CA

4. June 5, 2013L.A. County Task Force4 Who Can Be a Patient in CA? Text of the law: “any condition for which marijuana provides relief” Why is it so open? How does this compare to other states? Most common reasons for use in CA –Chronic pain, insomnia, anxiety –Physical AND mental health conditions

5. June 5, 2013L.A. County Task Force5 The Process Obtain a recommendation from a licensed physician –Difference between recommendation and prescription Do I need a card? –Patient ID Center in Oakland –SF Dept. of Public Health Should I get a grower’s certificate? Finding a dispensary –Weedmaps.com –Stickyguides.com –IPhone apps

6. June 5, 2013L.A. County Task Force6 The “Pot Docs” Why are all these clinics opening up? Are these REAL doctors? How do I know which to choose? –Medi-Cann –Dr. Lucido What will happen once I go there? Do they take insurance?

7. June 5, 2013L.A. County Task Force7 Benefits and Risks of Being a Patient Benefits: –Legal protection –Access to safe medicine –Access to a variety of medicine –Additional services at dispensaries –Purchase risk vs. illicit market Risks: –Federal law does not recognize medical marijuana –Public housing, employment, child issues –CHP can be hit or miss

8. June 5, 2013L.A. County Task Force8 FAQ’s Can my doctor report me for asking him/her to write a recommendation? Do I have to have a recommendation from the city where I will be obtaining marijuana? How does the “caregiver” program work? How much marijuana can I grow for myself? Can I bring medicine to other states? Can I purchase medicine in other medical marijuana states? Can an employer ask me if I am a medical marijuana patient?

9. June 5, 2013L.A. County Task Force9 Suggestions for staying safe Put your medicine away as soon as you get back in the car Do not medicate in public Do not come to work, child’s school, etc. heavily medicated if possible Do not talk about your patient status too openly with co- workers, other parent’s etc. If you live in Federal or shared housing, try vaporizers or edibles.

10. June 5, 2013L.A. County Task Force10 Do’s and Don’t’s DO: Keep a journal of the products and strains you use so you know what works best for you. DO: Use marijuana for the first time with someone who has used it before if possible. DO: Ask questions at the dispensary. Never feel embarrassed! DON’T: Drive or operate heavy machinery until you know how marijuana affects you. DON’T: Consume your medicine in a place where you are vulnerable (car, park, etc.) DO: Enjoy it! DON’T feel guilty for feeling good!!!!

11. June 5, 2013L.A. County Task Force11 Part II Modern marijuana therapeutics

12. June 5, 2013L.A. County Task Force12 Modern marijuana therapeutics... Used to be thought of for symptom management, but curative? Low toxicity makes it appealing 19 states plus DC allow medical marijuana use Endocannabinoid system may hold the key

13. June 5, 2013L.A. County Task Force13 A review of the recent evidence: Alzheimer’s Disease 2 recent studies (2005; 2007) found that the administration of a synthetic cannabinoid: – prevented cognitive impairment –decreased neurotoxicity –reduced the brain swelling associated with AD –led to better performance on a maze memory test Neuro-protective qualities of marijuana

14. June 5, 2013L.A. County Task Force14 Recent evidence: Chronic Pain Most common reason for medical marijuana use. Clinical trials (2007; 2008) have shown that smoked marijuana reduced the neuropathic pain of AIDS patients more than 30% compared to placebo. Key aspects: –Multifunctional: Calming AND addresses nerve pain. –Multiple cannabinoids work better than single ones (Entourage effect). –marijuana + opiates works better than opiates alone.

15. June 5, 2013L.A. County Task Force15 Recent evidence: Gliomas (brain tumors) Numerous studies report that cannabinoids play a role in cancer cell death. Furthermore, natural THC has been found to be more effective than synthetic THC. There is also support for cannabinoid based therapies for a slew of other cancers, including breast, prostate and skin cancer. Unlike chemotherapy, cannabinoids can differentiate between healthy and unhealthy cells.

16. June 5, 2013L.A. County Task Force16 Recent Evidence: Other conditions –Lou Gehrig’s disease –MS –Arthritis and osteoperosis –Diabetes mellitus –Fibromyalgia –GI disorders (IBS, Krohns..) –Hepatitis C –HIV –Hypertension –Incontinence –Tourette’s syndrome –MRSA –Sleep Apnea –ADD/ADHD/Autism

17. June 5, 2013L.A. County Task Force17 marijuana and mental health Like all drugs, the safety of marijuana is affected by set and setting. There is support for the link between marijuana use and symptoms of depression, psychotic problems, and schizophrenia. These occurrences are largely among adolescents and those pre-disposed to mental illness Treating PTSD, anxiety and depression Different cannabinoids have different effects –THC vs. CBD

18. June 5, 2013L.A. County Task Force18 For more information... Armentano, P. (2010). Emerging Clinical Applications for Cannabis and Cannabinoids: A review of the recent scientific literature, 2000-2010. Available online at www.norml.org www.norml.org

19. June 5, 2013L.A. County Task Force19 Part III marijuana and SUD, and as a substitute for alcohol, illicit and prescription drugs

20. June 5, 2013L.A. County Task Force20 How it relates to SUD treatment Do people in SUD need to abstain from marijuana? –Schwartz, 2010 “This exploratory study suggests that medical marijuana is consistent with participation in other forms of drug treatment and may not adversely affect positive treatment outcomes. In this small sample, marijuana use did not seem to compromise substance abuse treatment amongst the medical marijuana using group, who (based on these preliminary data) fared equal to or better than non-medical marijuana users in several important outcome categories (e.g., treatment completion, criminal justice involvement, medical concerns). What is the role of the SUD counselor regarding marijuana use? Response from traditional 12 step programs Role of marijuana in harm reduction

21. June 5, 2013L.A. County Task Force21 Types of substitution Psychoactive –Instead of wine after work To address and reduce cravings for other substances –Treating addiction To improve outcomes while reducing side effects –Prescription drugs

22. June 5, 2013L.A. County Task Force22 Definition of terms Substitution –Conscious/unconscious choice to use one drug instead of another –First substitution study: Mikuriya (1970) Relates to harm reduction… –safety –level of addiction potential –effectiveness in relieving symptoms –access –level of acceptance

23. June 5, 2013L.A. County Task Force23 Medical marijuana patients and substitution Regular use, stable supply, access to not granted under a standardized prescription system, yet still legitimized by a doctor’s recommendation (self- medication) Mikuriya et al. (2007) survey of 11 medical marijuana doctors in California –All doctors had seen patients who were using marijuana as a substitute for alcohol One said that over half of her patients reported preferring marijuana to alcohol Another reported that 90% of his patients reduced their alcohol use after beginning the use of medical marijuana

24. June 5, 2013L.A. County Task Force24 Medical marijuana patients and substitution Reiman (2007) study of 130 medical marijuana patients –19% reported previous alcohol treatment –50% reported using marijuana as a substitute for alcohol –47% reported using marijuana as a substitute for illicit drugs –74% reported using marijuana as a substitute for prescription drugs

25. June 5, 2013L.A. County Task Force25 Medical marijuana patients and substitution Harris et al. (2000) study of 100 medical marijuana patients (mostly HIV patients) –59% reported alcohol abuse and 16% reported alcohol dependence in their lifetime –Based on urinalysis, 50% tested positive for a drug other than marijuana –83% had experienced a psychiatric disorder in their lifetime and 44% were currently dealing with a psychiatric disorder: self medication? Psychological symptoms of illness?

26. June 5, 2013L.A. County Task Force26 Berkeley Patient’s Group Study N=350 anonymous patient surveys collected at Berkeley Patient’s Group in Berkeley, CA Male (68%) single (54%), White (66%), mean age 39, health insurance (including Medical) (74%), work full time (41%), have completed at least some college (81%), make less than $40,000 a year (55%) 71% report having a chronic medical condition, 52% use marijuana for a pain related condition, 75% use marijuana for a mental health issue, 64% need ongoing treatment in addition to marijuana 85% report marijuana has less unwanted side effects than their other treatment, 88% report that marijuana makes their symptoms much better.

27. June 5, 2013L.A. County Task Force27 Berkeley Patient’s Group Study 40% have used marijuana as a substitute for alcohol, 26% as a substitute for illicit drugs and 66% as a substitute for prescription drugs The most common reasons given for substituting were: less adverse side effects (65%), better symptom management (57%), and less withdrawal potential (34%) with marijuana

28. June 5, 2013L.A. County Task Force28 Thank you! areiman@drugpolicy.org areiman@drugpolicy.org for more information