Marijuana

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Marijuana
West Virginia University School of Medicine
Department of Behavioral Medicine and Psychiatry
Ehab Abdallah M.D.

• Medical Friend or Foe

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Classifying Marijuana

• Marijuana produces some excitatory effects but it
  is not generally regarded as a stimulant.
• Marijuana produces sedative effects, but a person
  faces no risk of slipping into a coma or dying.
• Marijuana produces mild analgesic effects, but it
  is not related pharmacologically to opiates like
  drugs.
• Marijuana produces hallucinations at high doses,
  but its structure does not resemble LSD or any
  other drug formally categorized as hallucinogen.

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• So marijuana is clearly a hybrid drug in a
  league of its own.

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Basic Terminology

• Marijuana is frequently a synonym for cannabis
  but technically the two terms are separate.
• Cannabis is the botanical term for the hemp plant
  cannabis sativa.

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Brief History

• Cannabis sativa have been commercially valuable
  for thousands of years in the manufacture of
  rope, shoes, sailcloth, and containers of all
  kinds.
• Pots made of hemp fiber discovered at
  archeological sites in China date the origins of
  cannabis as far back as the Stone Age.
• Cannabis sativa is arguably the oldest cultivated
  plant not used for food.

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• Spaniards brought cannabis to the New World in
  1545.

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• English settlers brought it to Jamestown,
  Virginia in 1611 as a major commercial crop along
  with tobacco.
• In the eighteenth-century George Washington grew
  cannabis on his farm. Entries in his diary
  indicated that he maintained a keen interest in
  cultivating better strains of cannabis, but there
  is no reason to believe he was interested in
  anything more than a better quality of rope.

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Marijuana The Plant

• Marijuana is obtained from serrated leaves from
  the cannabis plant.
• The key psychoactive factor is contained in a
  sticky substance, or resin, that accumulates on
  these leaves.
• Depending on the growing conditions, cannabis
  will produce either a greater amount of resin or
  greater amount of fibers.

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Marijuana The Plant

• In hot, dry climates such as North Africa the
  fiber content is weak but so much resin is
  produced that the plant looks as if it is covered
  with dew.
• In cooler more humid climates such as North
  America less resin is produced but the fiber is
  stronger and more durable.

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Definitions

• Cannabinoids Any of the several dozen active
  substances in marijuana and other cannabis
  products.
• Delta-9-tetrahydrocannainol (THC) The active
  psychoactive ingredient in marijuana and hashish.
• Marijuana The most commonly available
  psychoactive drug originated from the cannabis
  plant. The THC concentration ranges from
  approximately 1 to 4 percent.

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Definitions

• Sinsemilla A form of marijuana obtained from the
  un-pollinated or seedless portion of the cannabis
  plant, it has a higher THC concentration than
  regular marijuana, as high as 6 percent.
• Hashish A drug containing the resin of cannabis
  flowers, the THC concentration ranges from
  approximately 8 to 14 percent.

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Definitions

• Hashish Oil A drug produced by boiling hashish,
  leaving the potent psychoactive residue, the THC
  concentration ranges from approximately 15 to 60
  percent.
• Hashish oil crystals Solid form of hashish oil.
• Bhang A liquid form of marijuana, popular in
  India.

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The History of Marijuana and Hashish

• The first direct reference to a cannabis product
  as a psychoactive agent dates from 2737 B.C. in
  the writings of the Chinese emperor Shen Nung.
  The focus was on its powers as a medication for
  rheumatism, gout, malaria, and strangely enough
  absent- mindedness.
• In India the use was clearly recreational as the
  most popular form is liquid made from cannabis
  leaves called Bhang.

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History

• The Muslim world also grew to appreciate the
  psychoactive potential of cannabis, encouraged by
  the fact that ,in contrast to its stern
  prohibition of alcohol consumption, The Koran did
  not specifically ban its use.
• In Iran, because of the hot dry climate and high
  resin content of the cannabis, hashish was born
  and its popularity spread quickly during the
  twelfth century from the east to North Africa in
  the West.

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Hashish in the Nineteenth Century

• Before the nineteenth century hashish was not
  known in Europe, Pope Innocent VIII in 1484
  condemned witchcraft and the use of hemp in the
  Black Mass .
• By 1800 marijuana was widely used for two
  reasons 1) French soldiers who had served in
  Napoleons campaigns in Egypt brought hashish
  back with them to their homes in France. 2) The
  wave of romanticism that swept over Europe,
  including an increased interest in exotic stories
  of the East, such as Arabian Nights and The Tales
  of Marco Polo which contained references to
  hashish.

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Hashish in the Nineteenth Century

• In Paris during 1840s a small group of prominent
  French artists, writers and intellectuals formed
  the Club des Hachichins (Club of Hashish-Eaters),
  members included Victor Hugo.
• They gather to take of literature, art and love
  while consuming large quantities of hashish. The
  mixture consisted of a concentrated hemp paste,
  mixed with butter, sweeteners, and flavoring such
  as vanilla and cinnamon.

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Marijuana and Hashish in the Twentieth Century

• By 1890, cotton had replaced hemp as a major cash
  crop in southern states although cannabis plant
  continued to grow wild along road sides and in
  the fields.
• It was not until the 1920s that marijuana began
  to be a noticeable phenomenon.
• Some authors had related the appearance of
  marijuana as a recreational drug to social
  changes brought on by prohibition when it was
  difficult to obtain good quality liquor at
  affordable prices.
• At first its recreational use was restricted to
  Jazz musicians and people in show business.

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Marijuana and Hashish in the Twentieth Century

• Famous mainstream clarinetist and band leader
  Benny Goodman had his popular hit Sweet
  Marihuana Brown.
• Marijuana by that time was tolerated by
  authorities because it was not illegal.
• Marijuana was not considered as a social threat.
• In late the 1920s and the early 1930s there was
  a large migration of Mexicans to the United
  States, they entered the country through towns
  along the Mexican border and along the Gulf
  Coast.

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Marijuana and Hashish in the Twentieth Century

• In Mexican communities marijuana was, in the
  words of one historian a casual adjunct to life
  a relaxant, a remedy for headaches, a mild
  euphoric cheaply obtained for two cigarettes for
  the dollar.
• Rumors about the violent behavioral consequences
  of marijuana smoking among Mexicans began to
  spread. The idea was unchallenged by objective
  data.
• Considering the hysteria against marijuana
  smoking and cannabis use in general Congress
  passed the Marijuana tax act of 1937.

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Marijuana and Hashish in the Twentieth Century

• The marijuana regulation was accomplished
  indirectly as the act did not ban marijuana it
  merely required everyone connected with
  marijuana, from growers to buyers to pay a tax.
• It was a simple procedure that, in effect, made
  it virtually impossible to comply with the law.
• In absence of compliance, a person was in
  violation of the act and therefore subject to
  arrest.
• During the 1940s and 1950s the theory that
  marijuana was connected to violence slowly faded
  away, only to be replaced by a new notion, the
  gateway theory.
• According to the gateway theory marijuana is
  dangerous because its abuse will lead to the
  abuse of heroin, cocaine, or other illicit drugs.

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Marijuana and Hashish in the Twentieth Century

• Penalties for involvement with marijuana
  increased, in certain states the penalties were
  harsh. Judges had the option of sentencing a
  marijuana seller or user to life imprisonment.
  In Georgia, a second offence of selling marijuana
  to a minor could be punishable by death.
• In 1969, the U.S. Supreme Court ruled the 1937
  Marijuana Tax Act to be unconstitutional. The
  argument was made that requiring a person to pay
  tax in order to possess an illegal substance is a
  form of self-incrimination, which would be a
  specific violation of the fifth amendment to the
  constitution.

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• Reefer A common name for a marijuana cigarette.
• Joint a marijuana cigarette.

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Psychiatric Symptoms in Marijuana Users

• Effects of moderate intoxication (Zinberg et al)
  attitude and expectations or mental set and
  environmental combine with pharmacological
  effects to produce subjective experience of
  intoxication.
• Euphoria well-being and peacefulness are
  universally described in experimental studies in
  drug naïve and drug experienced volunteers.
• During cannabis intoxication an awareness of
  alteration in thought processes is frequently
  reported. Subjects may describe their thoughts
  as being fragmented (Ames, 1958) or more
  efficient than usual (Chopra Smith, 1974).

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• Some cannabis users claim that after taking the
  drug they can recall distant memories to which
  they would not ordinarily have access to. (Tart,
  1970).
• However experimental studies on the effect of THC
  on memory did not show any measurable effects on
  long term memory retrieval.
• Suspiciousness and paranoia are common
  experiences.
• Subjects also reported that time seems to pass
  more slowly.
• Marijuana smokers reported increase awareness of
  their surroundings as well as sharpened sense of
  sight and sounds.

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Adverse Reactions

• Anxiety provoking with mild intoxication.
• Panic attacks acute anxiety reactions to
  Marijuana may include restlessness,
  depersonalization, sense of loss of control, fear
  of panic and paranoia.

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Cannabis induced psychotic reaction Acute toxic
confusion

• Toxic psychosis can follow ingestion of cannabis.
• Acute toxic psychosis is more common to occur
  with higher doses of Delta-9-THC.
• Typically symptoms are apprehension
  suspiciousness, confusion, memory impairment,
  depersonalization, de- realization, and
  hallucination.

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Psychiatric Symptoms in Cannabis Users Table
1Case reports of psychosis associated with
cannabis use
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Psychiatric Symptoms in Cannabis Users Table
2Clinical studies of psychosis associated with
cannabis use
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Acute psychotic reaction in clear consciousness

• An acute psychotic reaction may follow cannabis
  use, clinical picture is characterized by rapid
  onset and mixture of affective and schizophrenic
  like symptoms.

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Mood Disturbances

• Self-limiting, dysphoric reactions are well
  recognized consequences of cannabis use.
• Serious mood disturbances can occur with
  prolonged marijuana use, however this has not
  been supported by controlled studies.
• The increased risk of suicide found in one large
  study needs further consideration.
• Clinical reports have suggested that cannabis use
  may precipitate relapse in patients with
  pre-existing depressive disorder.

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Relationship to Schizophrenia

• Some authors found causative role for the drug
  use in the aetiology of chronic functional
  psychosis on the basis that drug using
  schizophrenic patients had better pre-morbid
  personalities and earlier age of onset than the
  non-users.
• Andreasson et al 1987 reported the result of
  prospective study of 45,570 Swedish patients over
  15 year follow-up period the relative risk for
  developing schizophrenia was 2.4 for cannabis
  users compared to non-users and 6.0 for heavy
  users.

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• Marijuana appears to enhance or magnify positive
  symptoms of schizophrenia in established cases.
• Some patients use marijuana to counteract the
  side effects of neuroleptics, or to counteract
  the sense of loss or emptiness a schizophrenic
  may feel when his/her delusions or hallucinations
  are suppressed by medication.
• Peralta Cuesta 1992 published a Spanish study
  of 95 schizophrenic patients, 23 were marijuana
  users, and found no difference in positive
  symptoms, but a significantly higher rate of
  negative symptoms among non-users.

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The Residual Cognitive Effects of Heavy Marijuana
Use in College Students Harrison G. Pope Jr. MD
et al JAMA 1996

• Design Single-blind comparison of regular users
  vs infrequent users of marijuana.
• Participants Two samples of college
  undergraduates 65 heavy users, and 64 light
  users.
• Intervention Neuropsychological tests were
  administered to all subjects , all subjects were
  abstinent from marijuana and other drugs for a
  minimum of 19 hours before testing.

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• Results Heavy users displayed significantly
  greater impairment than light users on
  attentional/executive functions .
• Conclusions Heavy marijuana use is associated
  with residual neuropsychological effects even
  after a day of supervised abstinence from the
  drug.

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Cognitive Functioning of Long-term Heavy Cannabis
Users Seeking Treatment Solowij, PhD et al JAMA
2002

• Objective To examine the effects of duration of
  cannabis use on specific areas of cognitive
  functioning .
• Design, Setting, and Participants
  Multisite retrospective cross-sectional
  neuropsychological study conducted in the US
  between 1997 and 2000 among 102 near-daily
  cannabis users (51 long-term users and 51
  shorter-term users) compared with 33 nonuser
  controls.

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• Results Long-term cannabis users performed
  significantly less well than shorter-term users
  and controls on tests of memory and attention.
  Long-term users showed impaired
  learning , retention , and retrieval compared
  with controls.
  
  
• Conclusions These results confirm that
  long-term heavy cannabis users show impairments
  in memory and attention that endure beyond the
  period of intoxication and worsen with increasing
  years of regular cannabis use.

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Amotivational Syndrome

• 1986 William McGlothin, a psychologist, and Louis
  West, a psychiatrist, proposed that chronic
  marijuana smoking among young people was
  responsible for amotivational syndrome.
• Regular marijuana use may contribute to the
  development of more passive, inward turning
  personality characteristics, for numerous middle
  class students, the subtly progressive change
  from conforming, achievement-oriented behavior to
  a state of relaxed and careless drifting has
  followed their use of significant amount of
  Marijuana.
• Such individuals exhibit greater introversion,
  become totally involved with the present at the
  expense of their future goals and demonstrate a
  strong tendency toward regressive, childlike
  magical thinking.

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Cardiovascular Effect circulation 2001

• Smoking marijuana increase heart rate, supine
  hypertension and postural hypotension.
• Mittleman MD. reported triggering myocardial
  infarction with marijuana.
• Interviewed 3,882 patients with acute M.I an
  average of 4 days after infarction onset.
• Of the 3,882 patients 124 (3.2) reported smoking
  marijuana in the prior year, 37 within 24 hours
  and 9 within 1 hour of M.I. symptoms.

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• Compared with non-users marijuana users were more
  likely to be
• Men
• Current cigarette smokers
• Obese
• Marijuana smokers were less likely to
• Have history of angina
• Hypertension
• Risk of M.I. was elevated 4.8 times over baseline
  in the 60 minutes after marijuana use, the
  elevated risk rapidly decreases thereafter.
• Conclusions smoking marijuana is a rare trigger
  of acute M.I.

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Myocardial Infarction Following the Combined
Recreational Use of Viagra and Marijuana
clinical cardiology 2002

• Viagra is widely prescribed treatment for male
  erectile dysfunction.
• Viagra is metabolized by the cytochrome P450 3A4
  hepatic microsemal isoenzyme.
• Marijuana is an inhibitor of the cytochrome P450
  3A4 isoenzyme.

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• Case report about myocardial infarction following
  combined use of viagra and marijuana.
• Male age 41 years old
• Non-smoker
• No history of D.M. or HTN
• No family history of premature coronary artery
  disease
• No past history of impotence
• Admit smoking marijuana the previous evening and
  taking recreationally one tablet of viagra 12
  hours before onset of chest pain.
• Myocardial infarction was confirmed by EKG and
  cardiac enzymes.

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Effects on sexual functioning and reproduction

• Men
• Reduces level of testosterone
• Reduces sperm count
• Increases percentage of abnormally formed sperm.
• Women
• Reduction in level of lutenizing hormone (LH), a
  hormone necessary for fertilized egg to be
  implemented in the uterus.

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Medical Uses for Marijuana

• Glaucoma
• Smoking marijuana reduces I.O.P. in normal human
  subjects.
• THC eye drops reduce glaucoma symptoms.
• Asthma
• Initial bronchodiltion, followed by
  bronchoconstriction.
• Nausea
• Cancer treatment.
• AIDS patient.

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The End