Marijuana ADDICTION MEDICINE EDUCATIONAL SERIES WORKBOOK Marijuana

Marijuana ADDICTION MEDICINE EDUCATIONAL SERIES WORKBOOK

Marijuana STEVEN KIPNIS, MD, FACP, FASAM MEDICAL DIRECTOR OASAS ROBERT KILLAR, CASAC DIRECTOR COUNSELOR ASSISTANCE PROGRAM OASAS KAITLYN PICKFORD, MA FELLOW – CENTER FOR WOMEN IN GOVERNMENT AND CIVIL SOCIETY GOVERNMENT AFFAIRS OFFICE OASAS

FLOWERING PLANTS • There are 250, 000 – 350, 000 species of flowering plants o We have tested most of them • • • Medicinal value Poisons Psychoactive Religious ceremonies Magic Initiation into puberty Escape reality Fashionable Social pleasure

FLOWERING PLANTS • Psychoactive substances are found in various parts of the plant o o o Resin Fleshy fruit Stems Leaves Seeds Roots

FLOWERING PLANTS • Psychoactive substances can be introduced into the body by o o o Eating Drinking (teas) Smoking Inhalation Ointments Enemas

FLOWERING PLANTS • Psychoactive substances are usually members of the chemical class o Alkaloids • Contain nitrogen • Many are toxic • Some are teratogenic (can interfere with normal embryonic development) o Indole rings • 8 carbon atoms and 1 nitrogen • Same structure is seen in serotonin o This group may interfere with serotonin in the brain

CANNABIS FAMILY • Cannabaceae contains two genera o o Cannabis Humulus (hop plant) • Resin used as a preservative and as a natural flavor in beer

CANNABIS • Known as cannabis, hashish, hemp and marijuana o Source of: • • o o Strong fiber for rope and paper Nutritious fruit Industrial oil Medicine Cannabis Sativa is a fiber plant Cannabis Indica is a resin plant

CANNABIS • Male and female plants o o Female plants are better resin producers If female plant is not allowed to be fertilized, it flowers but does not produce seeds – sinsemilla (spanish for “without seeds”) • Greatest resin producers

CANNABIS • Resin contains o Hallucinogenic compounds called cannabinoids • Delta-1 Tetrahydrocannabinol, also known as o o Delta-1 -THC • Major active compound in the cannabis plant

CANNABIS • How is it used? o Leaves and flowering tips are dried • Smoked • Consumed as tea • Mixed into food o Resin from flowering heads • Smoked • Mixed with tobacco • Alcohol extract (cannabis oil) is mixed with tobacco and smoked

CANNABIS HISTORY • 4, 000 BC - used as a medicine o Rheumatism – loss of yin (female energy) • 2, 700 BC - Chinese emperor said “liberator of sin - good for female weakness, gout, rheumatism, malaria, beri, constipation and absent-mindedness”

CANNABIS HISTORY • 1, 400 BC - in India used to treat anxiety o o Bhang (drink from leaves) Ganja (dried resin) • 1, 200 BC - found in a Chinese burial site, also used for bow strings and paper (mixed with mulberry bark)

CANNABIS HISTORY • First century AD o o o Chinese use it to treat constipation, malaria and absentmindedness Greeks use it to treat earaches and as a pleasurable dessert made from the seeds Indian physicians used it for treatment of fever, insomnia, appetite stimulation, headaches and sexually transmitted diseases

CANNABIS HISTORY • 200 A. D. Chinese use it as anesthesia for operations • 13 th century, Marco Polo learned of a band of thugs in Iran whose leader controlled his followers using hashish. These murderers were called hashishins which was modified to assassins later on.

CANNABIS HISTORY • Folk medicine in Europe • Germany - to treat seizures, aid in childbirth • Poland - for toothache (seeds put on hot stones and vapors inhaled) • Czechoslovakia - to treat fever • Russia - to treat jaundice • Serbia - as an aphrodisiac

CANNABIS HISTORY • Pilgrims grew it for fiber: ropes and clothing • 1843 U. S. Medical text, treatment for o o o Gout Tetanus Hysteria Depression Insanity Dysentery

CANNABIS HISTORY Sumo wrestler with hemp belt which is part of the ritual to cleanse the ring prior to a match

CANNABIS HISTORY • 1850 listed in US pharmacopoeia o Abolished use in 1937 Marijuana Tax Act • 1951 Bogg’s Act o Increased penalties for marijuana use because it was thought to lead to heroin addiction • 1956 Narcotics Act o Imposed mandatory prison sentences for cannabis possession • 1965 THC first isolated

CANNABIS HISTORY • 2003 - 75 million people in the US have tried marijuana at least once (34% of population) • DAWN* data of emergency room visits show marijuana is number 1, alcohol number 2 and cocaine number 3 • New hydroponically grown marijuana with increased THC levels • Age of onset of use declining from 16 year old to 13. 6 year olds o Brain is still not completely developed *The Drug Abuse Warning Network (DAWN) is a public health surveillance system that monitors drug-related hospital emergency department visits and drug-related deaths to track the impact of drug use, misuse and abuse in the U. S.

ER VISITS VS. POTENCY CAUSE AND EFFECT?

CANNABINOIDS 60 cannabinoids have been isolated from the hemp plant and there are naturally occurring cannabinoids in most species called endocannabinoids, in a similar fashion as endorphins (opiates) have been found.

CANNABINOIDS • There are two main receptors for cannabinoids in humans o CB 1(in brain) if stimulated produces • Euphoria • Impaired short term memory and sense of time o CB 2 (in spleen, peripheral sites) if stimulated produces • Immunosuppressant activity • Not psychoactive

CANNABINOIDS • Receptors have also been found in the o o o Cerebellum – body movement and coordination Cortex – higher cognitive functions Nucleus accumbens – reward Basal ganglia – movement control Hypothalamus – body temperature, salt and water balance, reproductive functions Amygdala – emotional responses, fear

CANNABINOIDS • Receptors have been found in the hippocampus - an area that controls food intake • Works through leptin system – a peptide that controls satiety • A defect in the leptin or endocannabinoid system may lead to obesity

SPECT SCAN HEATHLY SURFACE VIEWS TOP DOWN VIEW UNDERSIDE VIEW

SPECT SCAN THC Abuse A SPECT scan showing the underside of the brain with area that is showing no activity

CANNABINOIDS Cannabis use in the adolescent is highly correlated with subsequent alcohol use.

PREPARATION OF CANNABIS • Marijuana o o Not a single drug but a complex mixture of over 400 chemicals Dried flowering tops and leaves of the plant • THC concentration 0. 5% - 5% in the past, now up to 20 – 25% Dried cannabis buds

PREPARATION OF CANNABIS • Hashish – dried cannabis resin and flowers o THC concentration, 2 - 8% or higher Pieces of Hash

PREPARATION OF CANNABIS • Hash oil – extraction of THC from hashish with an organic solvent o THC concentration 15 - 50%

CANNABIS • Routes of marijuana administration o Joints • Average is 500 mg of marijuana inside of rolling papers • 20% - 50% of the THC makes it into the bloodstream o Blunts (marijuana in hollowed out cigar) • 6 times the amount of marijuana • 20% of the THC makes it into the bloodstream

CANNABIS • Routes of marijuana administration o Pipes • Stone, ceramic or glass • 50% of the THC makes it into the bloodstream o Water pipes • Bongs – most efficient • 90% of the THC makes it into the bloodstream

PREPARATION OF CANNABIS • “Fry” / “fry sticks” / “wets” / “wac” o Marijuana soaked in embalming fluid or formaldehyde • In NYC, it has been reported that marijuana has been cooked in butter and spread on toast

CANNABIS KINETICS • THC o o Noncrystalline Waxy liquid at room temperature (-) Trans-isomer is 6 to 100 times more potent than (+) transisomer Psychoactive effect when bound to CB 1 receptor

CANNABIS KINETICS • THC mechanism of action o o Peripheral and central effect Low dose • Mixture of depression and stimulation o High dose • CNS depression

CANNABIS KINETICS • Typical joint o o 0. 5 - 1 gram cannabis THC concentration 5 - 150 mg 20 to 70% of THC is delivered in the smoke • 2 - 3 mg THC can produce a brief high Lipid soluble so deposited into fat tissue

CANNABIS KINETICS • 80 probable biologically inactive metabolites of THC • 11 -hydroxy - THC is the primary active metabolite • THC is eliminated in the feces and 33% in the urine

CANNABIS KINETICS • Oral use o o o Psychoactive effects slowed to about one hour Absorption is erratic High is less intense, but lasts longer than if smoked • IV use o Water insoluble so cannot be injected

CANNABIS KINETICS • SMOKING three cannabis joints will cause you to inhale the same amount of toxic chemicals as a whole packet of cigarettes. o o The French Consumer Institute tested regular Marlboro cigarettes alongside 280 specially rolled joints of cannabis leaves and resin in an artificial smoking machine. The tests examined the content of the smoke for tar and carbon monoxide, as well as for the toxic chemicals nicotine, benzene and toluene. Cannabis smoke contains seven times more tar and carbon monoxide. Someone smoking a joint of cannabis resin rolled with tobacco will inhale twice the amount of benzene and three times as much toluene as if they were smoking a regular cigarette, the study said.

CANNABINOIDS Desired effects of the user o o o o Sense of well being Relaxation Euphoria Modified level of consciousness Altered perceptions Intensified sensory experiences Altered time sense Sexual disinhibition

PHARMACOLOGIC ACTIONS • Psychomotor effects • Behavioral effects • Cognitive effects

PHARMACOLOGIC ACTIONS • Psychomotor effects o o o Object distance distortion Object outlines distorted Inability to make rapid judgment Slowed reaction time Impaired tracking behavior Slowed time perception All are dose-related

PHARMACOLOGIC ACTIONS Cannabis and Motor Function: f. MRI Changes Following 28 Days of Discontinuation • The authors hypothesized that supplementary motor cortex (SMA) and anterior cingulate cortex (ACC) activation in chronic cannabis users, studied 4 to 36 hours after their last episode of use, would disappear by Day 28 of abstinence during finger-tapping tests. • The results suggest that residual diminished brain activation is still observed 28 days after discontinuing cannabis use in motor cortical circuits. Source: Experimental and Clinical Psychopharmacology Volume 16, Issue, Feb. 2008, Pages 2232.

PHARMACOLOGIC ACTIONS • Behavioral effects o “Amotivational Syndrome” • Little scientific evidence for the existence of this • Tolerance to marijuana was supposed to be a manifestation of desensitization of brain cells, and in addition to contributing to the supposed dependence liability this desensitization of brain cells was supposed to create an amotivational syndrome characterized by apathy and inactivity. • The hypothesis was that this desensitization would impede normal brain operations and render individuals somewhat sluggish and unmotivated. The hypothesis has been challenged on both behavioral and pharmacological grounds.

PHARMACOLOGIC ACTIONS • Increased focus on taste • Increased appetite (street slang - ”munchies”) • Dry mouth

PHARMACOLOGIC ACTIONS • Cognitive effects may be due to a reduction in blood flow to the brain - seen even 30 days after last use in heavy smokers. (A study in February 2005 found increase blood flow – indicative of narrowed arteries; much like those seen in hypertension. ) o Impaired short-term memory • Especially verbal IQ o o Impaired attention Impaired integration of complex information • Chronic marijuana user – “College was the best 6 years of my life. ”

PHARMACOLOGIC ACTIONS • Psychomotor effects • Behavioral effects • Cognitive effects Evidence of brain damage is equivocal in the chronic user

PHARMACOLOGIC ACTIONS • British Medical Journal 2006 o 2. 9% prevalence of cannabis in the driving population • 2. 5% of fatal crashes o 2. 7% prevalence of alcohol in a similar population • 28. 6% of fatal crashes

TEEN USE • University of Maryland’s center for substance abuse research published in Sept 2004 o Warning signs of teen use ( 34, 000 6 th, 8 th, 10 th and 12 th graders) • • Use of cigarettes and alcohol before age 15 Arrests for alcohol and other drugs 20 or more unexcused absences from school Attitude that smoking cigarettes and marijuana is safe

Effects of Exposure During Pregnancy • Research has shown that some babies born to women who abused marijuana during their pregnancies display altered responses to visual stimuli, increased tremulousness, and a high-pitched cry, which may indicate neurological problems in development. • During the preschool years, marijuana-exposed children have been observed to perform tasks involving sustained attention and memory more poorly than nonexposed children do. In the school years, these children are more likely to exhibit deficits in problemsolving skills, memory, and the ability to remain attentive. Fried PA, Makin JE. Neonatal behavioral correlates of prenatal exposure to marihuana, cigarettes and alcohol in a low risk population. Neurotoxicology and Teratology 9(1): 1– 7, 1987. Lester BM, Dreher M. Effects of marijuana use during pregnancy on newborn crying. Child Development 60(23/24): 764– 771, 1989. Fried PA. The Ottawa prenatal prospective study (OPPS): Methodological issues and findings. It’s easy to throw the baby out with the bath water. Life Sciences 56(23– 24): 2159– 2168, 1995. Fried PA, Smith AM. A literature review of the consequences of prenatal marihuana exposure: An emerging theme of a deficiency in aspects of executive function. Neurotoxicology and Teratology 23(1): 1– 11, 2001.

ADDICTION LIABILITY • 9% of those who ever used become dependent • Dependence associated with gradual increase in use • No scientific evidence that it is a “gateway” drug o Study by Royal Children’s Hospital Center in August 2004 showed that teenagers who smoked cannabis daily for at least a month are 4 times more likely to become addicted to nicotine by the time they reach their 20’s. • Reverse directionality: cannabis → tobacco → alcohol → drugs and not tobacco → alcohol → cannabis → drugs

ADDICTION LIABILITY • Withdrawal difficult to demonstrate o 10 hour onset and 5 day duration • • • o Anxiety Mental clouding Insomnia Anorexia Irritability Tremor Depression Headache Craving Very similar to nicotine withdrawal, except there is weight loss in marijuana and weight gain in nicotine withdrawal

ADDICTION LIABILITY • Withdrawal may be due to the release of corticotropin releasing factor (CRF) in the amygdala o Similar release in opiate, alcohol and cocaine withdrawal • 71% of marijuana users relapse to marijuana use within 6 months after achieving initial 2 weeks of abstinence

Cannabis Use and Later Life Outcomes • Research to examine the associations between the extent of cannabis use during adolescence and young adulthood and later education, economic, employment, relationship satisfaction and life satisfaction outcomes. o o A longitudinal study of a New Zealand birth cohort studied to age 25 years. Measures of: cannabis use at ages 14 -25; university degree attainment to age 25; income at age 25; welfare dependence during the period 21 -25 years; unemployment 21 -25 years; relationship quality; life satisfaction. Also, measures of childhood socio-economic disadvantage, family adversity, childhood and early adolescent behavioral adjustment and cognitive ability and adolescent and young adult mental health and substance use.

Cannabis Use and Later Life Outcomes • There were statistically significant bivariate associations between increasing levels of cannabis use at ages 14 -21 and: lower levels of degree attainment by age 25 (P < 0. 0001); lower income at age 25 (P < 0. 01); higher levels of welfare dependence (P < 0. 0001); higher unemployment (P < 0. 0001); lower levels of relationship satisfaction (P < 0. 001); and lower levels of life satisfaction (P < 0. 0001). These associations were adjusted for a range of potentially confounding factors including: family socio-economic background; family functioning; exposure to child abuse; childhood and adolescent adjustment; early adolescent academic achievement; and comorbid mental disorders and substance use. After adjustment, the associations between increasing cannabis use and all outcome measures remained statistically significant (P < 0. 05).

Cannabis Use and Later Life Outcomes • The results of the present study suggest that increasing cannabis use in late adolescence and early adulthood is associated with a range of adverse outcomes in later life. High levels of cannabis use are related to poorer educational outcomes, lower income, greater welfare dependence and unemployment and lower relationship and life satisfaction. The findings add to a growing body of knowledge regarding the adverse consequences of heavy cannabis use. Source: Fergusson, David M. ; Boden, Joseph M. ; Addiction Volume 103, Number 6, June 2008 , pp. 969 -976(8).

TOXICITY AND ADVERSE EFFECTS • Mental health issues have been seen to co-occur in users. o o o o o Transient panic and anxiety Depersonalization Bizarre behavior Delusions Hallucinations Acute mania Acute paranoia Depression (possibly) Psychosis (possibly) Aggression

TOXICITY AND ADVERSE EFFECTS • MENTAL HEALTH ISSUES o Depression? • Mixed evidence from a variety of research studies • Degenhardt et al in a longitudinal study concluded that regular cannabis use and depression co-occur more often than would be expected by chance. o Psychosis? • Inconclusive research • Arseneault et al concluded that heavy cannabis use (regular and long-term) contributes as one of many factors, forming a “causal constellation” of factors including psychological vulnerability and genetics.

TOXICITY AND ADVERSE EFFECTS • MENTAL HEALTH ISSUES o Psychosis? • 2005 research in Biological Psychiatry described a common gene (comt) that makes cannabis five times more likely to trigger schizophrenia. o o Comt plays a part in the production of dopamine 25% of the population have this gene • 15% of this group are likely to develop psychotic conditions if exposed to cannabis early in life • The self medication hypothesis has been discounted o Aggression • Using is associated with decrease aggression unless taken in periods of high stress

TOXICITY AND ADVERSE EFFECTS • IMMUNE SYSTEM o CB 2 receptors on immune system cells = immune modulation • Decrease macrophage function • Decrease killer cell function • Increase in HIV - 1 host infections o Randomized, placebo controlled study in Annals 2003 – no increase in HIV RNA or protease inhibitor levels in 21 day trial of oral and smoked cannabinoids

TOXICITY AND ADVERSE EFFECTS • CARDIOVASCULAR SYSTEM o Increase heart rate • Marijuana alone 29 -36 beat/min increase • Marijuana & cocaine 49 beat/min increase o o Decrease blood pressure Increase myocardial infarction risk • PULMONARY o o Tracheitis (inflammation of the trachea) 3 cannabis cigarettes = 20 tobacco cigarettes with significantly more carcinogens

TOXICITY AND ADVERSE EFFECTS • REPRODUCTIVE / ENDOCRINE SYSTEM o o Alters pituitary hormones Decreases prolactin (a pituitary hormone that stimulates lactation after childbirth) o o o Decreases growth hormone Decreases luteinizing hormone Galacctorhea (the production of breast milk in men - or in women who are not breastfeeding) Decrease testosterone in males Decrease sperm production Decrease sperm motility

TOXICITY AND ADVERSE EFFECTS • MISCELLANEOUS o Questionable effect on fetus –probably due to polypharmacy (use of multiple medications) o o o Decrease effectiveness of SSRI anti-depressants Increase drowsiness if used with tricyclic antidepressants Heavy sedation if used with benzodiazepines Alcohol toxicity causes vomiting due to an increase in acetaldehyde. Marijuana anti-emetic effect can suppress the chemo-trigger point and lead to severe alcohol toxicity Multiple cavities in youth? • Dry mouth and eating sweets? o Lethal doses of marijuana are not known

MEDICAL USES • Difficult to determine doses if smoked • Significant adverse effects associated with any smoked medication, especially if to be used in a hospital setting

MEDICAL USES • Relieve nausea o Most trials used dronabinol and not smoked marijuana; however, in trials that compared the two, dronabinol was more effective.

MEDICAL USES • The U. S. Food and Drug Administration (FDA) has given the green light to Valeant Pharmaceuticals International to bring the synthetic cannabinoid drug nabilone (Cesamet) back to market after 17 years. Nabilone is also sold in Canada. • The drug, similar to the THC medication, Marinol, was originally marketed by Eli Lilly and Co. but withdrawn from the market in 1989. It is now approved by the FDA for treatment of vomiting and nausea caused by chemotherapy and is listed as a Schedule II controlled substance.

MEDICAL USES • Increase appetite o o o Dronabinol does appear to work No controlled studies in smoked marijuana Smoked and oral form increased weight (fat not lean body mass) • Annals 2003; 139: 258 -266 • Decrease muscle spasm o o Suggested for multiple sclerosis Anecdotal information • Decrease intraocular (eye) pressure o Better preparations available for the control of intraocular pressure as seen in glaucoma

MEDICAL USES • Decrease chronic pain o o Anecdotal NIDA study at University of Arizona (Dr. Malan) • Compound am 1241 o Acts on CB 2 receptors • Pain relief without the central nervous system side effects such as sleepiness and anxiety • Study done on neuropathic pain

MEDICAL USES • Anticonvulsant o o o First used in the 1940’s for the treatment of seizures Better therapeutic agents today University of Saskatchewan (8/2004) showed one dose of THC in rats could decrease grand mal seizures, but multiple doses lead to an increase in convulsions.

MEDICAL USES • 2004 - Israeli soldiers suffering from combat stress were treated with cannabis to relieve their symptoms o PTSD trials are ongoing • August 2004 issue of Cancer Research article by Guzman o THC may inhibit genes that make protein, vascular endothelial growth factor (VEGF) • This protein stimulates the growth of blood vessels in tumors

MEDICAL USES • Sativex o o Whole plant medicinal cannabis extract Produced by Bayer and GW pharmaceuticals and approved for use in Canada for multiple sclerosis and neuropathic pain (2005) Contains THC and nabidiolex, not delta - THC Phase 3 trials in multiple sclerosis patients showed that sublingual spray was safe and effective for symptom relief

MEDICAL USES • Journal of Psychopharmocology 6/05 o Marijuana may have a benefit in treating bipolar disorder • Cannabidiol (a cannabinoid found in cannabis) has a calming effect • THC prevented severe highs and lows

MEDICAL USES • The main active ingredient in marijuana is more effective at blocking an enzyme that causes the brain damage common to Alzheimer's disease than approved drugs already on the market, according to researchers from the Scripps Research Institute. o o low doses of THC inhibits an enzyme that breaks down acetylcholine, needed for learning and memory. The drug also appears to prevent the formation of fibrils, which damage healthy brain tissue. Reference: Eubanks, L. M. , et al. (2006) A Molecular Link between the Active Component of Marijuana and Alzheimer's Disease Pathology. Molecular Pharmaceutics

MEDICAL USES • Bowel study backs cannabis drugs – Gastroenterology 2005 o o o People with inflammatory bowel disease had an abundant number of a type of cannabinoid receptors in their body. They believe this is part of the body's attempt to dampen down the inflammation and that giving a drug that binds to these receptors could boost this. When people have Crohn's disease or ulcerative colitis - collectively known as inflammatory bowel disease or IBD - their immune system goes into overdrive, producing inflammation in different areas of the digestive tract. • Both the patients and the healthy people had similar numbers of CB 1 receptors in their gut. However, the IBD patients had far greater numbers of CB 2 receptors. o o o The normal job of CB 1 and CB 2 receptors is to switch immune responses on or off. CB 1 receptors also help to promote wound healing in the lining of the gut. Potential therapy - very selective cannabis-derived treatments may be useful as future therapeutic strategies in the treatment of Crohn's and ulcerative colitis. More trials are needed

MEDICAL USES • Overall problems of use o Mode of administration • o o o o No smoking in hospitals No standard dose of smoked marijuana Smoke is hazardous in and of itself Smoking may impair immune system response Difficulty concentrating on complex tasks Slowed reaction times Tolerance develops quickly Effect is 4 - 6 hrs

MEDICAL USES • Overall problems of use o o o o Chronic bronchitis can develop Pharyngitis (inflammation of the pharynx) can develop Large airway obstruction can be seen Acute panic reactions can develop Acute paranoia can develop Heart rate increases 20 - 100% for 2 - 3 hrs Decreased blood pressure seen with use

MARIJUANA AND THE LAW • MEDICAL MARIJUANA FOR PATIENTS WITH A DEBILITATING CONDITION • OTHER RELATED LAWS • US SUPREME COURT CASES • FEDERAL GOVERNMENT • NEW YORK

MARIJUANA AND THE LAW • Favorable medical marijuana laws were enacted in 35 states since 1978 however laws are ineffective due to federal governments overarching prohibition o 5 states have since let their laws expire or they have been repealed

MARIJUANA AND THE LAW • Federal trafficking penalties for 1 st offense o o 1000 kg or > = not less than 10 yrs 100 to 999 kg = not less than 5 yrs or > 40 yrs 50 to 100 kg or 10 kg hash = not > 20 yrs <50 kg = not > 5 yrs

MARIJUANA AND THE LAW 12 STATES HAVE LEGISLATION JUSTIFYING MARIJUANA USE FOR MEDICINAL PURPOSES

TIMELINE OF MEDICAL MARIJUANA LEGISLATION California Proposition 215 November 1996 Washington State Ballot Initiative 692 November 1998 Oregon Measure 67 December 1998 Hawaii Senate Bill 862 December 2000 Maine Citizen Initiative Question 2 December 1999 Alaska Ballot Measure 8 March 1999 Colorado General Election Amendment 20 June 2001 Nevada Referendum Question 9 – October 2001 Vermont Senate Bill 76 July 2004 New Mexico Senate Bill 523 July 2007 Rhode Island Senate Bill 70 January 2006 Montana Initiative 148 November 2004

CALIFORNIA Compassionate Use Act • 1 st state to pass such legislation • Limits possession to 8 ounces of usable marijuana and 6 mature plants or 12 immature plants • Voluntary registry system – as of January 08, 36 counties participated in the registry system and 18, 847 cards were issued

WASHINGTON State Ballot Initiative 692 • Washington State Medical Quality Assurance Board determines the list of qualifying debilitating conditions • No official registry for patients • State license and signed notice of a physician must be produced upon the request of an officer of law

OREGON THE OREGON MEDICAL MARIJUANA ACT • Must possess an identification card to circumvent criminal penalties • Possession limited to 6 mature plans and up to 24 ounces of usable marijuana • Must have been diagnosed with debilitating condition at least 12 months prior to arrest to use medical necessity defense • Program overseen by The Advisory Committee on Medical Marijuana in the Department of Human Services

ALASKA MEDICAL MARIJUANA INITIATIVE • Possession limited to 1 ounce of usable marijuana and 6 plants • Mandatory state registry for all patients • Identification cards must be renewed annually

MAINE CITIZEN INITIATIVE QUESTION 2 • No patient registry established by law • Possession limited to 2 ½ ounces of usable marijuana

HAWAII SENATE BILL 862 • “The benefits of medical use of marijuana would likely outweigh the health risks…” • Patient must have a valid identification card to possess marijuana • Possession is limited to 1 ounce of usable marijuana and 7 plants, 3 of which can be mature

COLORADO GENERAL ELECTION AMENDMENT 20 • Medical Marijuana Registry was implemented by the Colorado Department of Public Health and Environment • If patients do not register with the state, they may argue an affirmative defense of medical necessity if convicted of possession.

NEVADA REFERENDUM QUESTION 9 • Voluntary state registry identification card program • Possession limited to 1 ounce of usable marijuana and 7 plants, 3 of which can be mature.

VERMONT SENATE BILL 76 • Mandatory state registry program - $50. 00 fee • Possession limited to 2 ounces of usable marijuana and 9 plants, 2 of which can be mature • The Medical Marijuana Review Board reviews all denial appeals • Physicians from neighboring states are permitted to recommend medical marijuana to Vermont residents

MONTANA INITIATIVE 148 • Mandatory registry identification system • Limits possession to 1 ounce of usable marijuana and 6 plants

RHODE ISLAND THE EDWARD O. HAWKINS AND THOMAS C. SLATER MEDICAL MARIJUANA ACT • Possession limited to 2 ½ ounces of usable marijuana and 12 plants • Senate Bill S. 791 aa/House Bill H. 6005 aa repealed the 1 year sunset clause, making the Medical Marijuana Act permanent.

NEW MEXICO THE LYNN AND ERIN COMPASSIONATE USE MEDICAL MARIJUANA ACT • The legislation creates the Medical Marijuana Board • Made up of 7 appointed members • Purpose is to evaluate applications and make recommendations regarding the identification card system as well as the qualifications for medical marijuana use

ARIZONA and MARYLAND ARIZONA AND MARYLAND HAVE CREATED LAWS THAT DO NOT OUTRIGHT PERMIT THE USE OF MEDICAL MARIJUANA

ARIZONA BALLOT PROPOSITION 200 • This legislation legalizes the use of medical marijuana when a physician prescribes the drug, which requires the Federal Drug Administration’s (FDA) approval. • The FDA has not approved the drug, and therefore, it cannot be prescribed by Arizona physicians.

MARYLAND HOUSE BILL 702 • Allows “specified” individuals in specified prosecutions to introduce, and requiring the court to consider as a mitigating factor, specified evidence related to medical necessity…” • This very vague law permits the defense of criminal necessity if arrested for marijuana possession • If defendant can prove medical necessity, the maximum fine cannot exceed $100. 00

THE FEDEAL GOVERNMENT DOES NOT RECOGNIZE THE MEDICINAL USE OF MARIJUANA

THE CONTROLLED SUBSTANCES ACT • Establishes 5 classifications or schedules of drugs • Department of Justice and the Department of Health and Human Services jointly determine a drug’s classification • Cannabis is placed in Schedule 1 meaning it has a high potential for abuse and no acceptable medical use

MEDICAL MARIJUANA CASES THAT REACHED THE HIGHEST COURT

UNITED STATES V. OAKLAND CANNABIS BUYERS’ COOPERATIVE (OCBC) AND JEFFERY JONES • OCBC organized to supply marijuana in California subsequent to the passage of Proposition 215 • The court concluded that because the Controlled Substance Act did not recognize the medical necessity of marijuana under any circumstances, it could not be used as a defense in court

GONZALES V. RAICH • Supreme Court ruled the federal government can arrest and charge individuals on cannabis related crimes, regardless of the defendant's state law in regard to cannabis • Rationale – Federal law (Controlled Substance Act) preempted state law • Also took into account the Commerce Clause of the US Constitution as marijuana would affect interstate commerce

MEDICAL MARIJUANA CASES THAT REACHED THE HIGHEST COURT A. 4867 B - THE NYS MEDICAL MARIJUANA BILL IS IN REVIEW IN THE NEW YORK STATE ASSEMBLY. IT DOES NOT HAVE A “SAME AS” BILL IN THE NEW YORK STATE SENATE AT THIS TIME

JUSTIFICATION • Emphasizes the need for alternative medical relief for New Yorkers suffering from a debilitating condition • Reaffirms New York’s strong stance against the use of marijuana for reasons other than medical necessity • Claims that state government does have the authority to permit such use

PATIENT CERTIFICATION PROCESS • Debilitating condition must be documented in health care record • Patient must be under the care of a licensed practitioner • Other treatments have proven ineffective

POSSESSION • Patient must possess a valid registry identification card to evade criminal interference • Possession limited to 2 ½ ounces of usable marijuana and 12 plants • Must purchase marijuana from a registered organization

REGISTERED ORGANIZATIONS • • • Pharmacy Licensed facility Not-for-profit organization Local health department Registered producers (requiring agricultural expertise)

CHANCES OF SUCCESS • Assembly Bill 4867 -B, sponsored by Assemblyman Gottfried, passed the New York State Assembly in 2007 but died in the New York State Senate • Without a “same as” senate sponsor, the bill has no chance of success

FEDERAL VS. STATE • As stated in A. 4867 -B, this policy would not go into effect until such time that there was a change in federal law that permits the medical use of marijuana or New York is granted permission by the federal government to implement its policy • Both options are unforeseeable • The legislation could not go into effect

WHAT DOES THE FUTURE HOLD FOR MEDICAL MARIJUANA? • The federal government has not allowed states to make medical marijuana decisions without interference. • HOWEVER, the Supreme Court did not reverse current state laws nor did it prohibit future states from enacting similar legislation. • This very well could open the door for other states to pass medical marijuana legislation, including New York state.

LAW OUTSIDE THE USA • Canada o July 2003 the Canadian government started to deliver to physicians marijuana seeds in order to treat 582 approved patients – so that the patients can start to grow the plants themselves • A bag of 30 seeds will cost $20 o o o US border patrol will increase activity? Counter to the Canadian government’s policy of urging people to stop smoking Fall 2004, pharmacies in British Columbia started to sell marijuana for medicinal purposes without a prescription • A pilot project of the national health service • Strong criticism of the proposal has come from patients o $110 an ounce and it is “lousy pot”, “tastes like lumber”

LAW OUTSIDE THE USA • Netherlands o Government made medical marijuana legal in September 2003

AND THEN THERE IS… • Chronic Candy is a marijuana-flavored lollipop and gumdrop line. The developers claim, "every lick is like taking a hit. " Chronic Candy is a hemp-based confection. There have been no illegal substances found in the candy. A breakdown of the ingredients reveals a lot of sugar in the forms of glucose, dextrose, sugar, inverted sugar, and starches, along with different dyes for color and a "natural hemp flavor", presumably, hemp oil flavoring. There is no drug in the candy. The candy is imported from Switzerland contains no THC, the psychoactive ingredient in marijuana. They are distributed through a very small (two person) business out of California.