Hello, my name is Libby Stout, I'm an addiction psychiatrist, and I'm happy here to be presenting some information on the negative impacts of high-potency THC, especially on the developing brain and mental health. My disclosures, basically I don't have any, I do like to point out that I am on the speakers bureau for the National Marijuana Initiative out of Ida, and this is a website for them. I'm also on the board of Isaac, and this is the website for them, and I encourage people to look at those websites, there's a wealth of information that you can get through those websites. What I want to cover basically is how did we get here, and why do we need to talk about it, what are the consequences we're seeing from high-potency THC, and what can we do about it? I like to start with the fact that we didn't really even know why people liked cannabis until the 1960s. Basically people had studied all the other addictive drugs, we knew how they worked, we knew why people liked them, but people hadn't really been studying cannabis. There was this group in Israel who were taking apart the different cannabinoids and injecting them into rhesus monkeys, and they discovered that when they injected THC, the monkeys became very calm and sedate. And then they discovered that there was a receptor in the brain that THC fit into perfectly, and that's how it got called a cannabis receptor. I'm really sorry that ever happened because that has made people believe that we have a receptor in our brain that says we're supposed to smoke cannabis, but that's not really true because the same group with others around the world in the 1990s discovered why we have these receptors, and they discovered that we have this system in our brain now called the endocannabinoid system. And we create our own chemicals for these receptors, and one of them has been named anandamide. Anandamide is a Sanskrit word for supreme joy or bliss, and it looks very similar to THC. So THC can sit in that receptor and block the ability of our own natural chemical to actually work. So there's been much research now on the endocannabinoid system, and it's really a very exciting part of this whole mission and goal. So this is our homeostatic system. It regulates the balance between excitatory and inhibitory neuronal activity to achieve homeostasis. And it also plays a really important role during adolescent development, and that's something I'll get into a little bit more. This is a really excellent webinar that I encourage people to look at if you're interested. Yasmin Hurd is a researcher who has been studying the early effects of cannabis exposure on the developing brain and behavior. She has some really very fascinating research all across the lifespan of how cannabis affects the developing brain. And when I listened to this webinar, what I got out of it is really no one should be using cannabis unless you're 25 years of age or older, where your brain is fully developed, and you never plan to have children, because it's also been found to affect the gametes or the egg and the sperm, which then can affect the developing brain of the offspring. But we've had a really significant change in marijuana. So basically, in Colorado, when we legalized medical in 2000, the highest potency of THC was around 4 to 5%, and there were no concentrates. However, now we have concentrates that are very high, can exceed up to 90% THC, and they're smoked in a rig or using butane torch. In Colorado, and this is also true around the country, we've seen this massive increase in potency in the cannabis products. Marijuana has been around for centuries, and always up until the 1960s, 70s, it was usually less than 2 to 3% THC average. Then it got up to this 5% around the time we legalized medical. And since then, it has just dramatically increased. So now the average potency in the plant is usually around 20%, but there are plants that go up to 30, even 40% THC, and we have concentrates that go up to 90 plus percent THC. And there is absolutely no research on these concentrates for anything medical. However, they are heavily advertised and marketed as medicine. And yet we have many studies showing that there are significant problems with high THC. If you look at the National Academies of Science publication they did back in 2017, and said that there was research supporting the use of cannabis for some medical conditions, most of that data was based on this first study, which is a very large systematic review and meta-analysis of all the studies that had been done to that point. And in that, you can see that the research on smoked cannabis was all done with less than 10% THC. Most of the research was done with isolated cannabinoids. And so there was really small amounts of THC that were being used in these studies. So we actually have no legitimate science that validates medicinal cannabis greater than 10%. There in fact was this study where they were looking at, well, does it really do anything for pain, actually? So they got healthy volunteers to be willing to have capsaicin injected into their forearm. That's the stuff out of hot peppers. And apparently when you do that, it's very painful. And they found that if they smoke a cigarette with 2% THC, there was no benefit for pain. However, 4% actually provided some significant pain decrease. 8%, on the other hand, caused increased pain or hyperalgesia, which is something that we see with opiates. That's why opiates are not the solution for chronic pain. This is a researcher who is an anesthesiologist who researches chronic pain and also cannabis for chronic pain. And even he says that the THC range supported by scientific evidence for medicinal purposes is lower than 10%. When you start getting higher than 10%, you get into the really risky areas of all the other possible consequences. And he advises people to look at this with some very serious concerns. His group also went around the country and looked at what was available in different states that had legalized in their dispensaries. This is the results out of Colorado. And basically, pretty much everything that's available is greater than 15% THC. It is very hard to find the old-time marijuana that people had actually benefited from. And therefore, the cannabis industry has been allowed to aggressively market and advertise these products as medicine, and they're sold as medicine. This allows people, especially kids and their parents, to believe that this is safe, that there's nothing wrong with this. However, we have had a lot of problems with kids using these products, dabbing wax or shabby vaping high-potency hash oil. And there's been a significant increase in people using this. Also, we have the edibles that are usually packaged in highly attractive packages that make kids think that they're good, that they look like candy. And people have had significant consequences from this. So this is just something I put together to explain the difference between what is FDA approved THC, because we actually have drugs like Dronabinol or Marinol, which is pure THC. But it is recommended maximum dose, 20 milligrams a day. Most of the studies that the National Academies of Science based their findings on were done with this drug called nabixamol or Sadabix, which is not available in the United States, but is available in most other countries. It's an oral mucosal spray that you spray into your mouth, and it contains a balance of THC and CBD. And in those studies, the maximum dose was about 130 milligrams of THC per day. If, on the other hand, you look at what's available in our medical market, you can get a gram bag of Shatter, which may be 80 percent THC. That means there's 800 milligrams of THC in that bag. And even if you take account for the bioavailability from smoking being much less, there's still about 200 milligrams. And in Colorado now, 18 to 20 year olds can purchase two bags of these a day with a medical card, and adults can purchase eight grams. So this is a whopping amount of THC. This is not medicine. And this is a video that we put together trying to explain the kind of insanity of all of this. So I want to go through the different effects on the different lifespans of people, starting with pregnancy. In Colorado, there has been a twofold increase in cannabis involving pregnancy hospitalizations. And this is starting to be true around the country. Why this is important is because there is good data showing that prenatal cannabis use increases the likelihood of many of these consequences, like preterm birth, low birth weight, small for gestational age. There's even some associated potential major congenital abnormalities. And so these are reasons why it's important for a time of birth. But there's also concern about the developing brain of the offspring. So this is a study, a prospective study, looking at multiple children comparing women who used cannabis during their pregnancy to women who did not. And the children were assessed for their IQ at the age of six. The examiners were blinded to whether they'd been exposed to cannabis or not. And the outcome was basically that in utero exposure actually had a significant negative effect on school age IQ. And then this is a study out of Canada showing that there is an increase in autism spectrum disorder diagnoses when kids are exposed to cannabis in utero. And that is concerning. Now we have this long prospective study, the ABCD study, going on in this country. And this is a cross-sectional analysis at one point in time where they were looking at over 11,000 children. And so this is following children over their lifetime and then looking at whether they were exposed to cannabis prenatally or after. And this is just showing that during middle childhood, kids that were exposed to prenatal cannabis had greater psychopathology. And so there is this idea that prenatal cannabis exposure may increase the risk for psychopathology. So this is kids that are having even psychotic symptoms during middle childhood. A more recent publication from this ongoing study showed that this is progressing into early adolescence. So there is this increased vulnerability to psychopathology in children exposed to cannabis in utero. And there's a long list of diagnoses in this article. The most significant ones include conduct disorder and aggressive behavior or role breaking in the children or the early adolescence. In spite of this, we have research like this. This is out of Colorado. And this is a phone script. So this is a researcher who was calling 400 dispensaries in Colorado saying that she was eight weeks pregnant experiencing some morning sickness. And did they have any products they could recommend? And nearly 70% of the dispensaries recommended cannabis products to treat nausea in the first trimester. This is in spite of all of the research out there showing that it is not helpful for the offspring. Very few of them recommended that they talk to their health care provider without prompting. And there are quotes in the article. The one that bothers me the most is, technically with you being pregnant, I do not think you are supposed to be consuming that. But if I were to suggest something, I would suggest something high in THC. So this is basically buddheaders practicing medicine without a license. And then this is, you know, happening across the country. This is a publication out of California looking at their really significant increases in pregnant women using cannabis. And the study actually found that they were much more likely to use cannabis if they were living closer to a dispensary than if they were living far away from a dispensary. And then they had a qualitative study asking women specifically questions what they thought about this fact that they were now able to do it. And they basically said that legalization led to easier cannabis access, so either by going to the dispensary or having it delivered, and greater acceptance. So there was reduced stigma. And so women would actually say that they felt so much better about this because now they could talk to their doctor about it and tell them that they were using cannabis because of the decreased stigma. And that's concerning to me because that means they're not really open to learning about how, even though it may help with their nausea, how it may affect their offspring's brain development. And then this is a study just showing that many of the women that are using this for pregnancy, and this is across the United States, are developing cannabis use disorder, meaning they're really becoming addicted to it. And the people with cannabis use disorder have a higher prevalence of depression, anxiety, and nausea, interestingly enough, in those with cannabis use disorder compared with out, regardless of what other substances they might have been using. Then we move on to the children. So this is looking at, this is early data out of Colorado, just showing that over the period that we had increased access to cannabis and opened the doors for legal cannabis in 2014, there were increases in children being reported to poison control centers and showing up in the emergency room having ingested edibles. And so this, at that time, was much higher than the rest of the United States. And this is also happening in Canada. And they had an interesting way that they started their legalization process. They had two periods. So one, period one, was when they legalized a great deal of marijuana, but not edibles. And then period two is when they legalized edibles. And they found that, as a result, there was an 800% increase in cannabis poisonings in children in Ontario. And this is in spite of the fact that they have much stricter regulations than we do. And so they have a maximum of 10 milligrams of THC in the entire package. We have a maximum of 100 milligrams in the entire package. And they had much better child-resistant packaging and marketing restrictions. Interestingly, though, if you look at the different provinces in Canada, Ontario, Alberta, and British Columbia legalized edibles. And Quebec did not legalize edibles. And so they actually did not see the same increase in cannabis poisonings in children 0 to 9 years of age. And then National Poison Control's data in the United States is showing a significant increase in reports of poisonings with children. So in 2017, there were 207 reported cases. In 2021, there were over 3,000 reported cases. So that's an increase of 1,375%. And many of them end up being admitted. Often they're abdundant. They cannot be awakened. It's very scary for parents when this happens. And then again, we have no idea what that's going to do eventually to their developing brain. We also have data that teenage cannabis use has increased dramatically over the last 20 years. And this is a study just showing that there's been like a 245% increase since 2000. And this is at the same period that we've documented that teen alcohol use has steadily declined, which is a good thing. This is looking at high-potency products in adolescents and showing that compared with low-potency cannabis, high-potency cannabis is associated with a greater risk of psychotic symptoms, depression, anxiety, and cannabis dependence. And the people in the industry always say that there's nothing wrong with high-potency because people can titrate their use of it. However, adolescents don't know how to do that. And they usually end up consuming much higher concentrations of THC. This is out of the UK showing a similar thing that high-potency cannabis really can affect significantly adolescents' mental health. So this was showing that use of high-potency cannabis was associated with a significant increase in the frequency of cannabis use, likelihood of cannabis problems, and likelihood of anxiety disorder. Why this is important during adolescence is this is a very important time of brain development. And this is something that we now know that the endocannabinoid system plays a very big role in. And so when you're born with a certain number of neurons, during childhood you have a massive increase in neurons because there's a lot of things happening. People are learning a lot, they're doing a lot of things. But then during puberty, the brain is tasked with deciding which of these neurons are we going to keep, which are we going to strengthen and myelinate, and which of them are we going to prune because they're causing interference. And it's interesting to note that there's two receptors in the brain that play a role in this. One is the nicotinic cholinergic receptors, and they're not called nicotinic because we're supposed to smoke tobacco. They're called nicotinic because nicotine works on those receptors. And the other ones are the cannabinoid CB1 receptors. So this is our own natural endocannabinoid system that is supposed to be deciding this. And so the way this works is, for example, with anandamides. The brain decides when they're needed. They're produced locally because we have the enzymes to produce them. They're used immediately, and then they're destroyed because we have the enzymes to destroy them. If you put a fat-soluble THC in this developing brain, it sits in that receptor, and it doesn't go away. And so it really can affect this fine-tuning process. And one of the problems is that THC actually has a stronger binding capacity to the receptor than our own natural anandamide. So these anandamide levels are typically elevated in the prefrontal cortex during late adolescence. They are reduced by escalating high doses of THC. So flooding the system with THC can disrupt this delicate process and may induce lasting effects on impulse control as well as cognitive and executive functioning. And this is why we see research like this. So this is a really excellent study looking at over 3,000 teens in Montreal, and they're comparing teens who use cannabis to teens who don't, and then also looking at the frequency of their use. And they're looking at different cognitive functions, so the number of errors on working memory tasks, the solid line, the blue lines are the kids that don't ever use cannabis, and the red lines are current use and past year use. And so basically they have more problems with working memory. And then this is performance on delayed recall memory tasks. So the people not using cannabis have better recall than those who are using regularly. And then this one is perceptual reasoning tasks. The ones not using cannabis have a better outcome. And then this was the number of errors on inhibitory control tasks, so looking at the executive functioning. And the people not using cannabis had a lot less errors than the people using regularly. And so this study actually said that cannabis may be worse for teens' brains than alcohol. This is a large prospective study in New Zealand following over a thousand people. They followed them for 20 years, picking them up at 13 before they engaged in cannabis use, and then again at 38 testing their IQ. And they found that the people who never used cannabis had a pretty stable IQ over that period of time. However, those who were using persistently had a drop in eight points average. And you may think, well, what does that mean? Well, if you're Mensa, it probably doesn't mean much. But if you have the normal average IQ, which is 100, that's the bell curve of IQ, and you drop by eight points, you're in a severely affected range. This group has continued to follow these people. So this is a more recent publication where they are following them now to age 45 and continuing to do IQ tests. And they found that the long-term cannabis users had an average drop in IQ of 5.5 points. The people who never used cannabis didn't have a drop. And then they compare this to the tobacco users, long-term alcohol users, which actually had significantly less of a drop. And then people who were just recreationally using had a drop. And those who actually quit had a drop, meaning it didn't really recover. So I think this is a very important thing to think about on how it can really affect memory and attention. Then we get into addiction. When you increase the potency of a drug, you increase the addiction potential. We know that about all drugs. We definitely have seen that with the opiates. Codeine is not nearly as addicting as oxycontin. And now we have fentanyl, carfentanil. But we've also seen this now with marijuana. Because in the old time, marijuana, when the THC was 2% or less, it wasn't really considered to be addicting. In fact, it was classed in the hallucinogen category, where hallucinogens do not have a withdrawal syndrome. Therefore, they're not considered addicting. However, we now see a marked withdrawal syndrome with high-potency THC. The Dutch figured this out. This group found that when the potency of their plant averaged 20%, which is what we have now, there was a lag time. But there was this increased need for treatment for cannabis use disorder. And this group came out recommending that anything greater than 15% should be considered a hard drug like cocaine. And they recommended capping the potency of THC at 15%. This is data out of this country. And the first graph on the left is from wave 2004 to 2005. And back then, that's when the cannabis highest potency was about 5%. And this is showing that the most addictive drug we have is nicotine. People have agreed with that for a long time. Alcohol is the drug used the most, but it doesn't have near the addiction potential like nicotine. And most studies say that 15% to 23% of people who use alcohol can become alcohol dependent. Other drugs have different addictive potentials. And this one was cannabis was less than 10%. And people were saying, well, it's not a big deal. However, in this wave, 2012, 2013, when we started having the high-potency concentrates, it has increased to 30%. So now 30% potential have cannabis use disorder. And when people are beginning to use before the age of 18, they're four to seven times more likely to develop cannabis use disorder. And it is happening very rapidly. This is a study, again, in adolescents, just looking at, well, if kids start using, what is the likelihood that they're going to continue to use and have problems? And they found that the progression to higher levels of cannabis use was strongest when they were using cannabis concentrates than for any other product. And so this is just, again, looking at the high THC products. So then we definitely have this marijuana withdrawal syndrome. And it's pretty pronounced, especially when people are using high THC. It makes it very difficult for people to quit because these are very uncomfortable symptoms. So it includes increased anger, irritability, anxiety, depression, and basically people can't sleep. They don't have an appetite and they have severe cravings for marijuana. And this can last for some time because this is a fat-soluble substance that sits in your body for a while. And so basically people are really in a near constant state of withdrawal. And this is what I was seeing in an inpatient treatment program. This is a study showing that people that use medical cannabis are experiencing withdrawal. And that makes sense completely because if you're using a drug as a medicine, you usually take it every day and sometimes multiple times a day. And that's what people are doing with medical cannabis. And so basically this is a study showing that pretty much everybody has withdrawal and some have actually severe withdrawal. And the most severe cannabis withdrawal was associated with smoking cannabis, a longer history of use, greater frequency of use, and then they were also experiencing more cannabis-related problems. And so a lot of people don't like to think about the fact that people that are using medical cannabis may have cannabis use disorder, but they actually do. This is another study comparing two groups of people who were approved for a medical cannabis card. And one group were told they could go ahead and use it immediately, and the other group was told they had to wait 12 weeks before they could start using. And then they looked at the frequency of how often they were using, and the people who got the card and could use it immediately were very quickly up to using it multiple days a week. And then they looked at whether they developed cannabis use disorder symptoms, and they found that the people that had immediate card acquisition had significant increase in cannabis use disorder, meaning that 17% of these people developed cannabis use disorder in just 12 weeks. And what they found was that the highest risk was if they were using the medical marijuana for depression and anxiety. This is showing that there has been a significant increase in cannabis use disorder in veterans. And so this is over a period of time where we've seen increased potency in the products and increased high THC. And this is showing that across all groups there's been an increase, but the highest increase has been in people less than 35 years of age. And it was also found that Black patients consistently had higher prevalence of cannabis use disorder than any other racial ethnic group. Then we get into the idea of psychosis. This is kind of the landmark study. This is the first study that really showed that the increased potency increased the risk for psychosis. And so this was looking at people with their first episode psychosis, and this is people 18 to 65, so all ranges of ages. And they found that the people that were using what they call skunk, because this was out of the UK, which is 15% or more, they had a three times increased risk of psychosis. If they were using daily, they had a five times increased risk of psychosis. However, if they were using the stuff that was less than 5%, like we had before we legalized medical marijuana, there was no associated risk for psychosis. And I think that's why we haven't seen this problem until more recently. This study was replicated in multiple sites around the country, well around Europe, and one site in Brazil, and they found the exact same thing except that they found it for 10% or more. And so people using 10% or higher had a three times increased risk of psychosis, using it daily, a five times increased risk. And so people, the researchers in Amsterdam, for example, said that they felt that if they didn't have this high potency stuff, they could have prevented 50% of these psychotic episodes. This is a very large population-based study out of Denmark, where they have socialized medicine so they can follow everybody. And so this is data on over 7 million individuals. And they were looking at the fact that, well, if high potency THC increases the risk for cannabis use disorder and schizophrenia, we should be seeing it. And so that's exactly what they found out. So over a period of time, since there has been a significant increase in the potency in marijuana, there has been a fourfold increase in cannabis use disorder and schizophrenia. All drugs of abuse have the potential to cause psychosis. We know that about methamphetamine. We know that about alcohol, cocaine. This is a study looking at, well, once you have a drug-induced psychosis, what is the likelihood that you can convert to either bipolar disorder or schizophrenia? And they found that the drug that had the highest conversion rate was cannabis. So cannabis-induced psychosis, almost 50% go on to develop either bipolar disorder or schizophrenia. This is another study out of Denmark, looking at people who use cannabis and whether they have psychotic symptoms. And so people in the industry will tell you that this is normal, it's a hallucinogenic so you can have hallucinations, you can have some psychotic symptoms, but they're mild and you can walk through them and we can teach you how to manage them. So this was a study looking at people that had cannabis-associated psychotic symptoms, but they ended up in the emergency room. So they were not able to handle what it was doing for them. And they found that these symptoms can occur in about one out of 200 people who use cannabis. And the highest risk factor for developing these cannabis-associated psychotic symptoms was young age, mental health vulnerabilities, particularly psychosis liability, and the use of high-potency resin. And so in Denmark at that time, they were having some of the highest potencies of cannabis in Europe. Then we get to the correlation between suicide and cannabis. There has been more and more data coming out about this. This is a very large systematic review and meta-analysis of over 11 studies, over 23,000 adolescents, showing that there is a significant increase in odd ratios for depression, suicidal ideation, and suicide attempts in adolescents who use cannabis versus those who don't use cannabis. In Colorado, THC is the number one drug found in teens who die by suicide in their toxicology. The United Health Foundation found that the Colorado teen suicide rate had increased 58% over this period of time, and it was the highest increase in the country. This is CDPHE data showing that after we opened the doors for legalized cannabis in 2014, there has been a significant increase in the number of teens dying by suicide, and where marijuana is the number one drug found in toxicology when it was reported. We actually found that there was a decrease in reporting, and so that has now been mandated in Colorado that the toxicology has to be reported. This is national data, so this is survey data from the United States, showing that past-year marijuana use is a significant risk factor for suicidal ideation and behavior among adolescents. This study actually found no gender differences and no differences by race or ethnicity, and so basically pretty much all adolescents have an increased risk for suicide when using cannabis. This isn't just adolescents. This is a study of over 3,000 veterans looking at those who had cannabis use disorder versus those who had no lifetime cannabis use disorder, and they found that those with cannabis use disorder had significantly increased risk of suicidal ideation and lifetime suicide attempts. This is actually a good study in the fact that it controlled for pretty much everything that can contribute to suicide, and this was still found to be very significant. Marijuana is not the answer for post-traumatic stress disorder, and in spite of the fact that most of the states have it as an indication for medical marijuana, there has not been a single study done proving that marijuana helps post-traumatic stress disorder. In fact, most of the studies show the exact opposite. The first one that was really published back in 2015 was this observational study of over 2,000 veterans who had been treated in the VA PTSD treatment program. These are inpatient treatment programs around the country. They're usually 30 days long, and then they followed them for four months after that inpatient treatment, and they found that those who had never used marijuana had significantly lower symptom severity four months later, so the treatment was helpful. The stoppers, or people who had used marijuana but then quit, had the lowest level of PTSD symptoms four months after treatment, but those who started using marijuana after that treatment program had the highest level of violent behavior and PTSD symptoms four months later, so the reason why marijuana is not the answer, yes, it does help in the fact that it provides temporary relief, so it numbs the person. It can disconnect them from the traumatic emotions, but in order to keep those symptoms at bay, they have to use every day, sometimes multiple times a day, which then sets them up for the cognitive impairment, potential for psychosis, worsening psychosis, because PTSD can cause psychosis, so then they have the addiction potential, this becomes a vicious cycle, and there's even evidence now that marijuana can cause false memories, and I've actually seen that working with people in treatment where I believe it's more of a severe delusion, it's a fixed illusion that they get, where they believe that something has happened to them, but there's no evidence that it ever happened to them. And it is really hard to treat that doing trauma work. This was a highly anticipated study that was supposed to prove that marijuana helped with PTSD. It was actually a well-designed study, and it looked at several different levels. So it actually had high THC, high CBD, balanced THC, CBD. But overall, what they found was the study failed to find any significant group difference between smoked cannabis preparations with high CBD, high THC, THC balanced, or placebo. So there was no real benefit found. But they also did find that for the people that were generalized to the mild to moderate range, those who received high THC in stage one reported significant increase in withdrawal following the one-week cessation from stage one treatment. So they were experiencing withdrawal. This is an interesting study out of Canada where they had an app on a phone where people could self diagnose post-traumatic stress disorder, put in their symptoms, and then they could put in the cannabis product they were using, and then put in how it helped their symptoms. And this organization could track over 3,000 cannabis products that were sold in Canada. And the results were exactly what I said, that the acute cannabis intoxication did provide temporary relief from intrusions, flashbacks, irritability, and anxiety. However, the baseline PTSD symptom ratings did not change over time. And they detected evidence that people who are using higher doses to manage anxiety over time, which is indicative of the development of tolerance. So they were most likely having withdrawal as well. And if you do any kind of PTSD treatment, like you do trauma treatment, the goal is to get their symptoms rating down to zero. And this definitely did not do that. And so what their recommendation is, while it may be helpful in the short term, it is not an effective long-term remedy for the disorder. And then this is a study, more recent, showing that frequent cannabis use actually can worsen PTSD symptoms in veterans. So comparing the veterans who did not use cannabis or used it infrequently with those who used it frequently, they were much more likely to screen positive for co-occurring major depressive disorder, generalized anxiety disorder, and suicidal ideation. And they also had a small to moderate decrements in cognitive function. And then to the full spectrum of the age, we're seeing a significant increase in older adults using cannabis products. This is a study out of California, just showing that there was a 1,804% increase, but adults 75 to 84 had the largest relative percent increase, over 2,200% increase. And then older Black adults had the highest emergency department visit rate in 2019, and the largest absolute increase. So this is something that we're seeing very problematically because of the drug-drug interactions that cannabis has with multiple medications. And so this is something that people need to be aware of. And people have to ask about cannabis use. You have to be inquiring about cannabis use and the different products they're using and getting that information. Then we get into the area of violence. So this is actually a fairly old study. This is back in the 90s, when probably the THC was less than 5%. But this is looking at psychiatric patients. So these are people, over 1,100 people, that were discharged after being stabilized in a hospital. And then they were followed for a period of time. And then they were followed for a period and evaluated for their use of drugs, including marijuana, alcohol, and cocaine, as well as episodes of violence. And what this study found that there was the persistence of cannabis use was associated with an increased risk of subsequent violence, significantly more so than with alcohol or even cocaine. This is a more recent study doing the same thing. So looking at people who had been stabilized psychiatrically. So these are psychiatric patients who had had early psychosis. And they actually found that cannabis use disorder was the strongest risk factor of violent behavior. And so 61% of the people with cannabis use disorder had violent behavior compared to 23% with no cannabis use disorder. And of course, the age of onset played a role. So people that were using earlier, like starting before 15, increased violence versus people starting at 17. And they thought that this cannabis use was really linked to impulsivity and lack of insight. So basically effects of cannabis on the executive functioning part of the brain. This is the large Katie study that was done basically to look at medications and see the effect of different medications or people with schizophrenia. But they also did follow violence. And so in this study of over 1400 people, almost a thousand were followed longitudinally. And they found that persistent cannabis use predicted subsequent violence. Violence did not predict cannabis use. So they basically were not quote self-medicating. They weren't taking cannabis because they felt they might be violent. It was more that this was a unidirectional and it persisted when controlling for stimulants and alcohol use. So they feel that cannabis is an important risk factor for violence in the schizophrenia population. And its consumption should be considered separately from that of other drugs when assessing and managing risk and clinical and legal settings. Many people have the false perception that people with schizophrenia are inherently violent and they are not. It's just, this is showing that when you add cannabis to the mix, you can cause problems with violence. This is looking at veterans and showing that those who have a current cannabis use disorder, which is the gray bar, have a much higher risk of difficulty managing anger, aggressive impulses or urges and problems controlling violence in the past 30 days compared to people who have no lifetime history of cannabis use disorder and who have a lifetime history but are no longer using cannabis. So this is basically showing that active cannabis use can definitely increase problems with anger and violence. Then this is a very large meta-analysis of multiple studies of youth and where they look at the factor of cannabis and anger or violence. And this is showing that there is a moderate association between cannabis use and physical violence, which remains significant regardless of study design. So basically bottom line is cannabis use in this population is a risk factor for violence. Then we also have data with domestic violence situations. So this is looking at those involved with intimate partner violence. And it controlled basically for pretty much many things that contribute to this, like alcohol use, antisocial personality symptoms, relationship satisfaction. And they found that marijuana really was positively and significantly associated with both psychological, physical, and sexual perpetration. The problem with this study was basically it only asked about how often did you use cannabis? We have no idea what types of cannabis they were using or the potency of the THC. This is another study where they actually did urine drug screens, which I think are really important for people to think about. So this is because they actually had six participants who had positive urine drug screens and declined having THC in the past 90 days. While it does hang around, the longest I've seen it hang around is like 45 days. I don't think it hangs around 90 days. And so those people were either not being honest or they just didn't remember. But bottom line, the study did find there was a greater quantity and frequency of cannabis use was significantly associated with greater physical perpetration and victimization. And this is even after controlling for age, gender, race, quantity, and frequency of alcohol and stimulant use. Dr. Miller and his group have done several publications like this, where they're looking at high profile cases in the media, looking at, these are people that have committed serious crimes, usually crimes of violence against other people, and the fact that they were using marijuana and then the symptoms that they had that he believes could be associated with their marijuana use, like psychotic, and so basically I'm sure you recognize many of the names in this group, but apparently these are all heavy marijuana users. And so this is really showing that marijuana can cause violent behavior and higher potency is much more likely to result in violent behavior. This is data out of Texas, looking at child fatality cases in neglect and abuse situations, finding that the number one drug present in the perpetrators was marijuana. And then this is out of Arizona, looking at, I think it's Arizona, out of Arizona, looking at, and not all states collect this data. I know we don't seem to collect it in Colorado, but I encourage people to be looking at this data because this is showing child fatalities in neglect and abuse situations. And this is looking both at the toxicology in the child and in the perpetrator and finding that opiates and marijuana were the most common substance found in the children who died and methamphetamine and marijuana were the most common substances found in the perpetrators. Then we have the problem with cannabis hyperemesis syndrome, which is something that many people don't understand and don't even recognize, but it's slowly gaining more traction. People are starting to recognize this as a serious problem. Cannabis, this is this idiosyncratic reaction to cannabis. Cannabis is supposed to help with nausea and vomiting, theoretically. But what they're finding is the people that are using high potency products, using more regularly, meaning they're more addicted to it, are developing the exact opposite where they have severe abdominal pain, nausea, and vomiting that they cannot control. And they're showing up in emergency rooms. And this is a study out of Colorado just showing there's been this 29% increase from 2013 to 2018. And then this is a study showing that basically these people all have cannabis use disorder. So this doesn't happen in people that are using occasionally. This happens in people that are using regularly, frequently, and especially using high potency products. And the only solution is for the person to quit using marijuana. However, it is very hard to convince people that marijuana is causing their symptoms. And then I find that after much work trying to convince somebody that this is what's causing their problems, and they finally agree they have to quit, they can't quit because they have severe cannabis use disorder. And so this has become quite a problem. It's costing a lot of money. People are getting full workups trying to figure out what's wrong with them. And it really is cannabis. And finally, marijuana has not solved our opiate epidemic overdose rates at all. If you look at data from Colorado, so this is the Colorado Department of Public Health and Environment data showing the drug overdose rates over this period of time. And so back in 2000, when we legalized medical marijuana, this was the overdose rates for these drugs. And we basically commercialized marijuana in 2009 because that's when the Obama administration came out with the Ogden Memorandum that said they wouldn't prosecute people in states that had a medical marijuana law as long as they were following the law. And so what they found was that in 2009, there were 5,000 people on our medical marijuana registry. By 2011, there were 119,000 people on the registry. So people were flocking to get their medical marijuana cards. And in 2010, the concentrates hit the market. Then in 2012, we legalized recreational. In 2014, the doors opened to the dispensaries and that's when these death rates took off. So we've had a massive increase in opiate overdose deaths, especially fentanyl. And much of the research is showing that there is a very high correlation between marijuana use and opiate use disorder. And this study basically showed that the first use of marijuana before the age 18 is a very high risk factor for developing opiate use disorder. The industry likes to quote this first article. That was something that came out in 2014. It was a study looking at the states that had enacted medical cannabis laws compared to those that didn't. And so this is between 1999 and 2010. And of course we didn't have the concentrates available then and they found that there was this reduction in deaths. So a 20 or 25% reduction in deaths per 100,000. And so they came out in many newspapers with this quote that said, proof that expanding cannabis laws would reverse the opiate epidemic. However, the industry never talks about this subsequent study that was published in 2019. These people went through the exact same process of the first study. They looked at the same groups and the same states, although they expanded the analysis to 2017. By this time we had concentrates or high potency THC and they included all the other states that now had enacted a medical cannabis law. And they found the exact opposite. So the states with medical cannabis laws actually had a 23% increase in opiate overdose deaths. And then this is to me a very important study because it's looking at people that are on like an MATM, medicated assisted therapy. So these are people with opiate use disorder who are on either buprenorphine or methadone. And then they look at their use of cannabis and they found that cannabis use, regardless of the frequency of use was associated with a 40% increase in the odds of endorsing suicidal ideation. So we have seen many people die from fentanyl overdoses. We never know if those were accidental or intentional. And I think that it's important to think about the fact that if they were using cannabis, they may have been intentional. So basically what can we do about this? We have to just educate. We have to educate people. People need to know the possibilities. We definitely need increase in treatment availability. We need public service announcements about the risks. I think it's always amazing to watch the television and see all these ads for pharmaceutical drugs where they talk about how great they are. And then they tell you all the bad things that can happen to you. We need stuff like that. We definitely need stricter regulations and people need to be collecting data. You can't just ask about alcohol, tobacco and drugs. Most people do not see cannabis as a drug. So you have to have a separate category where you're asking about cannabis. And you definitely need to document the product, the route, the frequency, the potency, the age of onset. And I also encourage people to do urine drug screens. I am very dismayed with the fact that some organizations have opted to take marijuana out of their drug screens. And then I said, don't opt for the Colorado panel. When I was being detailed by drug screening organizations where we're looking for a new company to do drug screens for us, there was a company out of Florida that told me that they had three panels for me. One was all the drugs of abuse. Next one was all the drugs of abuse plus all the psychiatric meds that could be tested. And the third was all the drugs of abuse plus all the psychiatric meds that could be tested minus marijuana. And I said, what is that? And she said, oh, we call that the Colorado panel because we've heard from physicians, primary care physicians in Colorado that they don't wanna know that their patients are using marijuana because they don't know what to do about it. Is that not sad? So one thing that we did do in Colorado enacting stricter regulations, it was a start. We have a long way to go. This was a bill that was passed in 2021 where we were able to get warnings put on the concentrates when people were purchasing them about psychotic symptoms, mental health symptoms, cannabis hyperemesis syndrome and cannabis use disorder. I fought very hard to get suicide on there and the industry fought that tooth and nail which is very sad. We also got limits on concentrates because prior to this, anybody, even an 18 year old with a medical card could purchase 40 grams a day of product like high potency products. Now it's two grams per day for 18 to 20 year olds and eight grams a day for adults. So I'm happy to take any questions at this point. I hope that was helpful. And that's all. People are welcome.

high-potency THC

developing brain

mental health

cannabis

negative effects

adolescent development

cannabis-related poisonings

edibles

opioid epidemic

data collection