Eyeworld

EW NEWS & OPINION 22 April 2016 Insights by J.C. Noreika, MD, MBA pot's tax revenues in Colorado were 66% higher than those of alcohol. In August 2015, Colorado's sales first eclipsed $100 million, a fraction from medicinal sales. That month, one tax on its sale bequeathed al- most $4 million for the construction of schools. As chronic marijuana use contributes to dropping out, the irony is inescapable. Costs are more difficult to calculate. For example, pot's effect on prenatal health is largely unknown. Emergency room utilization involving marijuana when used alone is equal to heroin and marginally less than cocaine. Use may cause long-term detrimen- tal effects to the vascular, neurolog- ic, and immunologic systems. It can affect employability. Fiscal ledgers of many states are in dire straits. It will be hard to rebottle this genie. The inimitable Mr. Spicoli said: "What Jefferson was saying was, Hey! You know, we left this England place 'cause it was bogus; so if we don't get some cool rules ourselves—pronto—we'll just be bogus too! Get it?" Cool or bogus, marijuana's legalization will compel us to get real. EW References 1. Pillard RC. Marijuana. N Engl J Med. 1970;283:294–303. 2. Bell J. On the Haschisch or Cannabis Indica. Boston Med Surg J. 1857;56:209–216. 3. Compton WM, et al. Relationship between nonmedical prescription-opioid use and heroin use. N Engl J Med. 2016;374:154–163. Editors' note: Dr. Noreika has practiced ophthalmology in Medina, Ohio since 1983. He has been a member of ASCRS for 35 years. Contact information Noreika: JCNMD@aol.com mitochondrial respiratory chain en- hancing the risk of vascular events including stroke and heart attack. Neurologically, it may contribute to depression, anxiety, and schizo- phrenia especially in the genetically predisposed; more controversial is marijuana's effect on declining IQ scores. Sociological studies point to marijuana's role in poor grade performance and dropping out of school. A THC blood level of 2.5 ng/ ml leads to a doubling of automo- bile accidents, the incidence likely higher in teens. Modern horticulture produced a 4-fold increase in its po- tency since the 1980s; today's teens are not smoking Wavy Gravy's weed. Is marijuana a gateway drug? Anecdotally, many psychologists treating addiction vehemently oppose its legalization. Marijuana is cheap and available; it plays a prom- inent role in today's drug culture. Where outlawed, street versions may be laced with opioids, stimulants, and hallucinogens to enhance the "kick." In chronic users, adulterants may augment tolerance by synergis- tically altering the brain's dopamine system. W.M. Compton and col- leagues recently wrote that heroin use increased 45.4% among mari- juana users. The steepest increase was among non-Hispanic women 18 to 25 years old. Heroin's mortal- ity increased from 1,842 in 2000 to 10,574 in 2014. In 1968, the Council on Mental Health foresaw that "the ultimate place of marijuana in our culture will reflect social as well as med- ical pressures." Alaska, Colorado, Oregon, Washington, and the Dis- trict of Columbia electorates have approved marijuana's legalization. It has proven an economic bonan- za. Forbes Magazine reported that between July 2014 and June 2015, One need not research the National Institute on Drug Abuse's website or study Sean Penn's spot-on characterization of Jeff Spicoli in Fast Times at Ridgemont High to grasp THC's effects. The synecdochal "pot head" was captured by Dr. John Bell in 1857: "It is, however, a state of great intellectual weakness, in which none of the operations of the mind are performed with energy or effect. The memory, the judgment, the powers of attention and combination, are so much impaired, that the individual is wholly inadequate to the duties of society, and incapable of any continued conversation; his actions and conduct are without steadi- ness and consistency, his thoughts are deficient in concentration and coherence." Other effects have led to phar- macologic trials directed toward mitigating nausea and anorexia of cancer and AIDS chemotherapy, reducing spasticity, meliorating childhood seizure disorders, and attenuating depression. Cannabis is an ancient drug. In 2014, it was the nation's most commonly used illicit pharmaceu- tic. It is particularly popular among adolescents. Surveys reveal teens increasingly discount its risk. Legalization posits 3 key ques- tions: (1) Does marijuana adverse- ly affect the development of the adolescent brain? (2) Does it act as a gateway to other drugs such as cocaine and heroin? (3) How do governments square the franchise's economic bonanza with coincident administrative, legal, and sociomed- ical costs? Marijuana causes withdrawal symptoms suggesting addictive properties. So do alcohol, nicotine, benzodiazepines, and caffeine. Its ef- fect on vulnerable populations such as teenagers is more worrisome. Peer group pressure plays into its appeal. It is estimated 1 in 6 teens have tried it. The brain's endocannabinoid system actively develops until about age 21. This system helps regulate neurohormones such as dopamine crucial to the brain's inherent plea- sure and reward pathways. Research suggests that early exposure to cannabinoids recalibrates the sensi- tivity of these pathways, potentially increasing risk of other drug usage. THC experimentally impairs the Part 2 of this series provides analysis of key issues encompassing the controversy and consequences of marijuana's legalization T rigger warning: The subject matter of this column con- tains material pertaining to marijuana's use. Ophthalmologists are familiar with cannabinoids' intraoc- ular pressure-lowering effect. As vot- ers approve legalization, availability and use will expand. An emotion- ally charged issue, few bright lines demarcate its socioeconomic, moral, political, and generational intersects. In 1970, Richard Colestock Pillard wrote that marijuana is unique in that it is "neither stim- ulant, sedative, tranquilizer, hal- lucinogen nor narcotic although [has] properties of all those drugs." Forests have been felled debating its therapeutic value. Many of marijua- na's effects are subjective and hard to quantify. Reproducible research is limited due to the inevitability of confounding variables. The Internet has magnified the problem as misin- formation from social media's street- wise peer review is rampant. Reports are found in leading journals such as the New England Journal of Medicine, the Journal of the American Medical Association, The Lancet, and specialty journals. Neuroscience has added insight; psychosociological studies are more contentious. A product of the hemp plant, marijuana contains more than 700 distinct chemical entities. Its neu- roactive properties are subscribed primarily to Δ-9-tetrahydrocannab- inol (THC). Human tissue contains cannabinoid receptors that interact with the body's endogenous canna- binoid-like molecules. Receptors are concentrated in areas of the brain modulating cognition, memory, coordination, and the perception of time, the slowing of which may be marijuana's most distinct delusion. Weeding out the facts J.C. Noreika, MD, MBA

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