This presentation will review the current research around medical marijuana and discuss the issues around the recent legalization of recreational use. We will explore common clinical questions regarding marijuana use including testing and concurrent controlled substance use.

1. Psychiatry & Behavioral Medicine
Symposium
Michael Vizachero, MD, MBA, AAHIVS
October 9, 2019
Marijuana: Medicinal
Use and Legalization
Ramifications

2. No conflicts of interest
The views expressed are my own and do not represent the views of
Spectrum Health or others

3. Which is not a name for marijuana?
Devils Lettuce
Nug
Giggle smoke
Lean
Lime pillows

4. Let’s build some “street cred”
Marijuana: Flower, Pot, weed, lime pillows, Mary Jane, giggle smoke,
nug, devil’s lettuce
MJ Concentrates/Hash oil: wax, hash, budder, dabs, shatter
Check out the DEA intelligence report:
Slang Terms and Code Words: A Reference for Law Enforcement
Personnel. DEA-HOU-DIR-022-18, July 2018

5. Objectives
Review the harms and potential medicinal benefits of marijuana and its
chemical components
Discuss the recent legalization of recreational cannabis in Michigan and
its implications for users
Understand the practical clinical consideration for prescribing controlled
substances and concurrent cannabis use

6. Outline
Pharmacology of Marijuana
Historical use and changes
Research considerations
Evidence for medicinal use
Evidence for harms
Addiction/Cannabis Use Disorder
Legalization
Prescriber issues

7. The pharmacology
∆ 9- Tetrahydrocannabinol (THC) is the major psychoactive ingredient in
marijuana
Cannabidiol (CBD) 2nd most prevalent active ingredient
Over 500 active chemicals, > 100 cannabinoids currently identified
■ Compounds differ depending on method of use (smoked, vaporized,
ingested, etc)
■ Differ by strain

8. The pharmacology
Act at cannabinoid receptors in the body(CB1, CB2)
■ The body makes is own signaling molecules endocannabinoids that act
at these receptors (actively being researched)
■ Receptors are located primarily in the CNS (brain), but also
peripherally
■ GI, muscle, liver, fat tissue (CB1), immune cells (CB2)
Involved in the reward pathway

9. A word on CBD (cannabidiol)
“In humans, CBD exhibits no effects indicative of any abuse or
dependence potential”
- World Health Organization
Primarily obtained from hemp (< 0.3% THC)
Grey legal status federally and state to state, though easily obtained
Supplement status, so safety, dosage and purity not verified

10. More words on CBD
Potential medical applications include :
■ Epilepsy (Epidiolex, FDA approved 7/2018)
■ Neuropathic pain
■ Anxiety
■ Insomnia
■ Anti-inflammatory
Potential side effects
■ Drug interactions
■ nausea, fatigue and irritability

11. A little further into the weeds…
Tetrahydrocannabinolic acid (THCA)
■ Precursor to THC (Decarboxylation)
■ Up to 90% plant THC content
■ Rapidly converts to THC when heated, degrades to
CBD
■ Not converted in vivo
■ NOT psychoactive
■ Studies very limited on human effects
■ May active peripheral CB1 receptors
■ controversial
■ Many in vitro studies suggest anti-inflammatory,
immunomodulatory, neuroprotective, and
antineoplastic actions
Moreno-Sanz G. Can You Pass the Acid Test? Critical Review and Novel Therapeutic Perspectives of Δ9-Tetrahydrocannabinolic Acid
A. Cannabis Cannabinoid Res. 2016;1(1):124-130. Published 2016 Jun 1. doi:10.1089/can.2016.0008

12. Marijuana related pharmaceuticals approved in the US
Dronabinol(Marinol/Syndros)- synthetic THC used in AIDS wasting and
chemo-induced N&V
Nabilone (Cesamet)- synthetic cannabinoid used as anti-emetic,
appetite stimulant and to treat neuropathic pain
Nabiximols (Sativex) (THC+CBD)- treats MS spasticity (phase III trials,
currently available outside US)
Cannabidiol (Epidiolex)- childhood epilepsy

13. Historical Use- Not Your Mother’s Hemp
Use likely dates back to Central Asia over 12,000 years ago
Earliest medical use 2700 BC for constipation, malaria, rheumatic pains,
and “female disorders”
Likely brought to Americas by English and Spanish settlers in 1600s

14. Historical Use- Not your Father’s Hemp
Today, cannabis is the most widely used illicit substance in the US
Marijuana concentration active chemical content has changed
dramatically
■ Cultivation/ trait selection
■ Processing
■ Growing methods

15. Processing methods
Marijuana- whole plant
Hashish- physically extracted resin
concentrate
Hash Oil/Dabs
■ Highly concentrated THC extract produced
using butane (up to 80% THC)
■ Differ in moisture content
Synthetic cannabinoids (“spice”)- variable
and unpredictable effects
Inhalation produces rapid onset high vs
ingestion

16. Growing methods
Warehouse cultivation provides
higher yields and more consistent
products.

17. Marijuana potency is rising
Previous THC content 10%, now up to 30%
CBD (likely the major beneficial component) content is now negligible
■ Could change with future consumer demands
All current strains relatively the same in terms of THC:CBD despite
differing colors, etc.
Chemical and fungal contaminants of uncertain significance
State mandated testing of retail marijuana in Colorado, meeting of the American Chemical Society
https://www.acs.org/content/acs/en/pressroom/newsreleases/2015/march/legalizing-marijuana-and-the-new-science-of-weed-video.html

18. Pop quiz
Which of these is not a schedule I drug?
■ GHB
■ Cocaine
■ Marijuana
■ Heroin
■ LSD
■ “…what is a schedule I drug?”

19. Scheduled substances
Controlled Substances Act of 1970 classified cannabis as a Schedule I
substance defined as:
■ having a high potential for abuse
■ having NO currently accepted medical use in treatment in the United
States
■ having a lack of accepted safety for use under medical supervision
National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public
Health Practice; Committee on the Health Effects of Marijuana: An Evidence Review and Research Agenda. The Health Effects of
Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington (DC): National
Academies Press (US); 2017 Jan 12. 15, Challenges and Barriers in Conducting Cannabis Research.

20. Scheduled substances
Other substances classified in Schedule I include:
■ Heroin
■ LSD
■ Mescaline
■ hallucinogenic amphetamine derivatives
■ fentanyl derivatives (synthetic opioid analgesics)
■ gammahydroxybutyrate (GHB)
Schedule II substances—also have a high potential for abuse and may lead
to severe psychological or physical dependence, but have currently
accepted medical use

21. The research dilemma
National Institute on Drug Abuse (NIDA) funds the majority of cannabis
research due to its status as a schedule I drug.
■ Mission: “Advance science on the causes and consequences of drug
use and addiction and to apply that knowledge to improve individual
and public health”
Not interested in the health benefits (only 16% of funding investigated
therapeutic properties in 2015)

22. The research dilemma
All of the cannabis that NIDA provides to investigators is sourced from
the University of Mississippi through the NIDA Drug Supply Program
■ Lower potency and fewer strains than commercially available through
state dispensaries
Route of administration, blinding and difficulty in standardized dosing all
contribute to research challenges

23. The research dilemma
Federal law prevents studying
commercially available product
composition, effects, or
contaminants in humans or animal
models

24. Medicinal marijuana: the process
Obtaining a card
■ Doctors letter and state forms/fees
Minors require 2 doctor certifications
Approved medical uses vary by state
Approved dispensaries and growing limits for personal use

25. Michigan approved uses
Post-Traumatic Stress Disorder
Cancer
Glaucoma
HIV/AIDS
Hepatitis C
Amyotrophic Lateral Sclerosis
Crohn's Disease
Agitation of Alzheimer's disease
Nail Patella
A chronic or debilitating disease or medical
condition or its treatment that results in
wasting syndrome; severe and chronic pain;
severe nausea; seizures, and severe and
persistent muscle spasms.
Arthritis
Autism
Chronic pain
Colitis
Inflammatory bowel Disease
Obsessive compulsive disorder
Parkinson's
Rheumatoid arthritis'
Spinal cord injury
Tourette's syndrome
Ulcerative colitis
So there must be good evidence…right?

26. Medical Marijuana: The
Evidence

27. Chronic pain
There is substantial evidence that cannabis is an effective treatment for
chronic pain in adults.
■ Studied NIDA cannabis or preparations like nabiximols that are not
available in US
■ Commonly available preparations not studied
■ Others cite low quality, short f/u, and failure to address common
causes (eg back pain)
National Academies of Sciences, Engineering, and Medicine 2017. The Health Effects of Cannabis and
Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National
Academies Press.

28. Cancer
There is insufficient evidence to support or refute the conclusion that
cannabinoids are an effective treatment for cancers, including glioma.
■ 16 in vivo (preclinical) studies found an antitumor effect of
cannabinoids, no human trials
■ Smoking may cause some cancers (H&N)
National Academies of Sciences, Engineering, and Medicine 2017. The Health Effects of Cannabis and
Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National
Academies Press.

29. Chemotherapy-induced nausea and vomiting
There is conclusive evidence that oral cannabinoids are effective
antiemetics in the treatment of chemotherapy induced nausea and
vomiting.
■ Nabilone and dronabinol (THC based)
■ No studies on whole plant or CBD
Other causes not studied
National Academies of Sciences, Engineering, and Medicine 2017. The Health Effects of Cannabis and
Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National
Academies Press.

30. Anorexia and weight loss
Limited evidence that cannabis and oral cannabinoids are effective in
increasing appetite and decreasing weight loss associated with
HIV/AIDS.
Insufficient evidence to support or refute the conclusion that
cannabinoids are an effective treatment for cancer-associated anorexia-
cachexia syndrome and anorexia nervosa.
Older small studies have shown increase caloric intake from snacking
National Academies of Sciences, Engineering, and Medicine 2017. The Health Effects of Cannabis and
Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National
Academies Press.

31. Epilepsy
Good evidence that CBD is effective as adjuvant treatment in pediatric-
onset drug resistant epilepsy
■ Epidiolex
There is insufficient evidence to support or refute the conclusion that
cannabinoids are an effective treatment for other epilepsy syndromes
Stockings, et al. Evidence for cannabis and cannabinoids for epilepsy: a systematic review of controlled and
observational evidence. J of Neurology, Neurosurgery, and Psychiatry. Vol 89, Issue 7
National Academies of Sciences, Engineering, and Medicine 2017. The Health Effects of Cannabis and

32. Spasticity
Substantial evidence that oral cannabinoids are an effective treatment for
improving patient-reported multiple sclerosis spasticity symptoms, but
limited evidence for an effect on clinician-measured spasticity
Insufficient evidence to support or refute the conclusion that
cannabinoids are an effective treatment for spasticity in patients with
paralysis due to spinal cord injury.
National Academies of Sciences, Engineering, and Medicine 2017. The Health Effects of Cannabis and
Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National
Academies Press.

33. Insomnia
Moderate evidence of improved short-term sleep outcomes in individuals
with sleep disturbance associated with obstructive sleep apnea
syndrome, fibromyalgia, chronic pain, and multiple sclerosis.
■ Primarily nabiximols
Other studies show marijuana reduces REM sleep and cessation causes
rebound insomnia
National Academies of Sciences, Engineering, and Medicine 2017. The Health Effects of Cannabis and
Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National
Academies Press.

34. Limited/insufficient evidence
Irritable Bowel Syndrome
Tourette's Syndrome
Amyotrophic Lateral Sclerosis (ALS)
Huntington’s Disease
Parkinson’s Disease
Dystonia
Dementia
Glaucoma
Traumatic Brain Injury
Intracranial Hemorrhage
Addiction
Anxiety/Depression
PTSD
Schizophrenia
National Academies of Sciences, Engineering, and Medicine 2017. The Health Effects of Cannabis and
Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National
Academies Press.

35. Now the Bad News…

36. Acute intoxication effects
Euphoria
Hunger
Relaxation
Less common
■ Panic, anxiety, nausea, dizziness
■ Paranoia and panic more common in naïve users and higher doses
(dabs)
No known risk of fatal overdose

37. Negative effects of short-term use
Impaired short-term memory, making it difficult to learn and to retain
information
Impaired motor coordination, interfering with driving skills and increasing
the risk of injuries
Altered judgment, increasing the risk of sexual behaviors that facilitate
the transmission of sexually transmitted diseases
In high doses, paranoia and psychosis
Volkow N. Adverse Health Effects of Marijuana Use. N Engl J Med. 2014 Jun 5; 370(23): 2219–2227.

38. Negative effects of long-term or heavy use
Addiction (in about 9% of users overall, 17% of those who begin use in adolescence, and 25 to 50% of
those who are daily users)*
Altered brain development*
Poor educational outcome, with increased likelihood of dropping out of school (up to 60% more likely) *
Cognitive impairment, with lower IQ among those who were frequent users during adolescence*
Diminished life satisfaction and achievement (determined on the basis of subjective and objective
measures as compared with such ratings in the general population)*
Symptoms of chronic bronchitis
Increased risk of chronic psychosis disorders (including schizophrenia) in persons with a predisposition
to such disorders
*The effect is strongly associated with initial marijuana use early in adolescence.
Volkow N. Adverse Health Effects of Marijuana Use. N Engl J Med. 2014 Jun 5; 370(23): 2219–2227.

39. Second hand exposure
Very little research exists regarding the risk of second hand marijuana
smoke.
Evidence suggests that the chemical composition of second-hand
marijuana smoke is similar to that of second-hand tobacco smoke,
although differences in the concentrations of the components vary.
In vitro studies have shown marijuana smoke produces similar, though
not identical, damage to cell.
Holitzki H, Dowsett LE, Spackman E, Noseworthy T, Clement F. Health effects of exposure to second- and third-hand
marijuana smoke: a systematic review. CMAJ Open. 2017;5(4):E814–E822. doi:10.9778/cmajo.20170112

40. The “stoner”
“Amotivational syndrome” is a postulated syndrome in which cannabis
use fosters apathy through the depletion of motivation-based constructs
such as self-efficacy
■ Some evidence based on short term studies in college students
■ MJ use associated with more sedentary behavior in adolescents
Lac A, Luk JW. Testing the Amotivational Syndrome: Marijuana Use Longitudinally Predicts Lower Self-Efficacy Even
After Controlling for Demographics, Personality, and Alcohol and Cigarette Use. Prev Sci. 2018 Feb;19(2):117-126.
Vancampfort D. Et al. Cannabis use and leisure-time sedentary behaviour among 94,035 adolescents aged 12-15
years from 24 low- and middle-income countries. Addictive Beh. 2019 Aug 20;99:106104

41. Other studied effects
COPD- no obvious association, actually studied as therapy
■ Helpful in mild asthma (widespread use in 19th century)
Lung cancer- in vitro evidence only
Highly concentrates in breast milk
Decreases or increases? sperm production/motility
Increased risk of testicular cancer
Questionable increase in stroke, MI, afib
Epigenetic effects
Ribeiro L, Ind PW. Marijuana and the lung: hysteria or cause for concern?. Breathe (Sheff). 2018;14(3):196-205
Hsiao, Philip et al. Adverse Effects of Cannabis on Male Reproduction. European Urology Focus, Vol 4 , Issue 3 , 324 – 328
M.F.F. de Carvalho, et al. Head and neck cancer among marijuana users: A meta-analysis of matched case–control studies, Archives of
Oral Biology, Volume 60, Issue 12, 2015, Pages 1750-1755

42. Cannabinoid hyperemesis syndrome
Intractable severe nausea and vomiting in long term heavy marijuana
users
Exact mechanism is unknown, mostly case reports
Treatments include
■ Hot showers and baths (diagnostic)
■ Topical capsaicin cream
■ Haloperidol, benzodiazepines, even opioids have reported benefit
■ Antiemetics (rarely effective)
■ Marijuana cessation

43. Is marijuana addictive?
Both DSM and WHO ICD recognize cannabis dependence
Dopamine release decreased in patients with “severe dependence”
similar to effects of other abused substances
Occurs in about 9% of regular users

44. Withdrawal symptoms
Insomnia
Anorexia
Anxiety
Irritability
Depression
Tremor
Predominantly behavioral and affective vs physical (like opioids)

45. The “gateway” drug?
Two proposed theories
■ Sequential gateway model – first use (usually in adolescence) of legal substances
(alcohol, tobacco), leads to cannabis use, and then use of more harmful illegal drugs
such as stimulants, opiates, or hallucinogens.
■ Assumes causal relationship > preventing cannabis prevents later use of other illegal
drugs
■ Common liability model – Pre-existing environmental and genetic factors contribute to
all substance use and substance use disorders, using a specific substance at one time is
not a major factor in determining what substance is used at a later time
Data mostly supports the common liability model
the underlying prevalence of substance use in the population also influences the sequence
of substance use
Vanyukov MM, et al. Common liability to addiction and "gateway hypothesis": theoretical, empirical and evolutionary perspective. Drug Alcohol Depend. 2012 Jun;123 Suppl 1:S3-17.
Epub 2012 Jan 18.
Degenhardt L, et al. Evaluating the drug use "gateway" theory using cross-national data: consistency and associations of the order of initiation of drug use among participants in the
WHO World Mental Health Surveys. Drug Alcohol Depend. 2010 Apr;108(1-2):84-97. Epub 2010 Jan 8.

46. Treatment
The most effective available treatments for cannabis use disorder are
psychosocial approaches
■ Motivational interviewing/enhancement
■ CBT
■ Acceptance commitment theory
■ Relapse Prevention
■ Mutual help groups
No pharmacotherapy approved treatment
Lévesque, A. and B. Le Foll (2018). "When and How to Treat Possible Cannabis Use Disorder." Medical
Clinics of North America 102(4): 667-681

47. Medical therapies
N-acetylcysteine- possibly beneficial in adolescents
Gabapentin- effective in one RCT
Multiple antidepressants, anxiolytics, and anticonvulsants have shown
mixed/negative results

48. Legalization

49. Consequences of legalization
States that legalized…
Increased MJ use
Decrease opioid related deaths (correlation)
■ Individual level data shows the opposite
Increased marijuana related ED visits (intoxications, burns, child
exposures)
?More fatal MVAs related to use (dec overall)
The Effect of Medical Marijuana Laws on Marijuana, Alcohol, and Hard Drug Use. Nat Bureau of Econ Res. Working Paper No. 20085
Monte AA, Zane RD, Heard KJ. The implications of marijuana legalization in Colorado. JAMA. 2015;313(3):241-2.
Wilkinson ST, Yarnell S, Radhakrishnan R, Ball SA, D'Souza DC. Marijuana Legalization: Impact on Physicians and Public Health. Annu Rev Med. 2015;67:453-66.

50. Driving “high”
Study: MI adults with chronic pain seeking medical cannabis certification
Past 6-month driving while under the influence rates were:
■ 56% “within 2 h”
■ 51% “a little high”
■ 21% “very high”
Bonar E, et al. Driving under the influence of cannabis among medical cannabis patients with chronic pain. Drug and Alcohol
Dependence, 2019-02-01, Volume 195, Pages 193-197

51. Consequences of legalization
Adolescence more likely to try but not
chronically use this or other drugs
■ Other studies find no effect
The Effect of Medical Marijuana Laws on Marijuana, Alcohol, and Hard Drug Use. Nat Bureau of Econ Res. Working Paper No. 20085
Choo, et al. The Impact of State Medical Marijuana Legislation on Adolescent Marijuana Use. Journal of Adolescent Health 55 (2014)
160e166

52. Some complexities of legalization
Pest and Insecticides affect water quality, plant and animals
Excess water utilization
Organized Crime activity
Forest damage

53. Follow the money…
Worldwide spending on cannabis reached $9.5 billion in 2017
Projected to increase to $32 billion by 2022, a compound annual growth
rate (CAGR) of 27.5%.
Multiple cannabis related stocks and investing firms
Likely increases pressure for legalization prior to scientific acceptance.
“How to Invest in Marijuana Stocks”. The Motley Fool.
https://www.fool.com/investing/2018/10/12/how-to-invest-in-marijuana-stocks.aspx
Accessed, Feb 4, 2019

54. Legalization in Michigan
Tenth state to legalize recreational use, Nov 2018
Draft rules and regulations due December 2019
■ First dispensary permits for recreational sale likely 2020
297,515 medical marijuana patients in Michigan

55. Implications for Practices
Let’s look at interactions with commonly prescribed
controlled substances

56. Opioids and cannabis
CB1 receptors and mu opioid receptors often co-located in areas of the
brain, especially reward pathway
■ May decrease opioid withdrawal symptoms and rewarding properties
of opiates
■ CBD has been shown to reduce heroin cravings in recently abstinent
individuals
Evidence as adjunctive pain reliever
Wiese B, Wilson-Poe AR. Emerging Evidence for Cannabis' Role in Opioid Use Disorder. Cannabis Cannabinoid
Res. 2018;3(1):179-189. Published 2018 Sep 1.

57. Opioids and cannabis: The good
Medical Marijuana correlated with clinically and statistically significantly
lower opioid-related mortality rates and reductions in the number and
cost of prescription medications used by Medicare and Medicaid patients
People taking medical cannabis consistently report substituting
cannabis for other prescription and illicit drugs
Preliminary historical cohort study showed improvements in pain
reduction, quality of life, social life, activity levels, and concentration, and
few side effects from using cannabis at one year for medical marijuana
Bachhuber, M. et al. Does Medical Cannabis Use Increase or Decrease the Use of Opioid Analgesics and Other Prescription
Drugs? J Addict Med 2018;12: 259–261
Rogers, AH et al. Opioid and Cannabis Co-Use among Adults with Chronic Pain: Relations to Substance Misuse, Mental Health,

58. Opioids and cannabis: The bad
Medical cannabis users are more likely to also use prescription drugs
(medical, nonmedical, or both), and also nonmedical use of opioid
analgesics, stimulants, and tranquilizers
Compared to opioid use alone, opioid and cannabis co-use is associated
with elevated anxiety and depression symptoms, as well as tobacco,
alcohol, cocaine, and sedative use problems, but not pain experience.
Largest, 4 yr prospective study of chronic pain patients on opioids found
greater pain ratings, GAD scores, lower self-efficacy. No evidence of
decreased opioid use
Cambell G, et al. Effects of cannabis use in people with chronic non-cancer pain prescribed opioids. Lancet
Public Health. 2018;3(7):e341-e350

59. Opioids and cannabis: synthesis
While more prospective studies are needed, Marijuana users may be
sicker at baseline which would account for higher illicit drug use yet
reported decreased medication use.
May have adjunctive pain treatment properties as well as beneficial
synergistic effects with opioids

60. Stimulants and cannabis
Reduced metabolism in nucleus accumbens and the disrupted thalamo-
accumbens connectivity (enhanced negative connectivity) in CUD is
consistent with impaired reactivity of the brain reward’s circuit.
methylphenidate normalizes thalamo-accumbens connectivity (shows
direct interaction vs therapy?)
THC and CBD appear to have opposite effects on attention and brain
function
Demiral SB, et al. Methylphenidate's effects on thalamic metabolism and functional connectivity in cannabis
abusers and healthy controls. Neuropsychopharmacology. 2018 Dec 1.

61. Anxiolytics and cannabis
Anxiety top five medical symptoms for which North Americans report
using medical marijuana
Prospective longitudinal studies had conflicting findings regarding the
association between long-term cannabis use and anxiety disorders
THC potentiates the sedative effects of other central nervous system
depressants such as alcohol and benzodiazepines

62. Other drug interactions
THC is metabolized by similar liver pathways as other drugs including
■ Warfarin
■ TCAs
■ Sildenafil
■ Clinical significance is unknown

63. In conclusion
Overall data regarding the risks and benefits of MJ are unclear
■ Benefit in HIV/AIDS cachexia, nausea/vomiting related to chemotherapy,
neuropathic pain, and spasticity in MS
■ Primarily cognitive and addictive side effects
Legalization is a complex relationship between state and federal law
■ Societal acceptance precedes science
■ Medical use should be held to the same standards as other drugs
Interactions with controlled substances
■ May potentiate benzos and opiates
■ May interfere with stimulants
■ MJ users more likely to use other drugs

64. Thank You!
Michael Vizachero, MD, MBA, AAHIVS
Michael.Vizachero@spectrumhealth.org

65. Drug testing
Urine drug testing is the standard of care in routine testing
■ Does not identify acute vs chronic use
■ Fat solubility means long time in tissue/urine
Other tests:
■ Blood: invasive, long wait time, poor sensitivity
■ Sweat: send out
■ Saliva: POC testing does exist , not for chronic use (<3 days), low
sensitivity
■ Hair: chronic (3-6 months), send out

66. Drug testing
Immunoassays (POC testing)
■ Tests for 11-nor-9-carboxy-delta
9-tetrahydrocannabinol (THC-
COOH)

67. Cannabis use disorder
A problematic pattern of cannabis use leading to clinically significant impairment or distress as manifested by at least two of the following occurring in a 12 month period:
1. Cannabis is often taken in larger amounts over a longer period than was intended.
2. There is a persistent desire or insignificant effort to cut down or control cannabis use.
3. A great deal of time is spent in activities necessary to obtain cannabis, use cannabis or recover from its effects.
4. Craving or a strong desire or urge to use cannabis.
5. Recurrent cannabis use resulting in failure to fulfill major role obligations at work, school or home.
6. Continued cannabis use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of cannabis.
7. Important social, occupational or recreational activities are given up or reduced because of cannabis use.
8. Recurrent cannabis use in situations which is physically hazardous.
9. Cannabis use is continued despite knowledge of having persistent or recurrent physical or psychological problems that are unlikely to have been caused or exacerbated by
cannabis.
10. Tolerance, as defined by either:
1) A need for markedly increased amounts of cannabis to achieve intoxication and desired effect, or
2) A markedly diminished effect with continued use of the same amount of cannabis.
11. Withdrawal, as manifested by either:
1) The characteristic withdrawal symptoms for cannabis, or
2) A closer related substance is taken to relieve or avoid withdrawal symptoms.
The “4 C’s” Compulsion, Control, Cravings, Consequences