No to Weed

 

 

 

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A Second Drug Wave is Coming: Marijuana

By James A. Avery, MD, Visiting Assistant Professor of Medicine at the University of Virginia

I love going to the beach and body-surfing the waves. When my kids were young, I always warned them about the second wave. In other words, the first wave knocks you silly and makes you less aware that a second wave is coming.

The first wave was the opioid epidemic. In 2016, more Americans died from drug overdoses (67,000) than during the entirety of the Vietnam War (58,200). (1) The second and more insidious wave is coming – it’s the marijuana wave.

 

On April 11, 2018, one of the largest marijuana corporations, Acreage Holdings, announced they had a new spokesman, John Boehner. The Republican former Speaker of the House said in an interview, “Over the last 10 or 15 years, the American people’s attitudes have changed dramatically (towards the legalization of marijuana); I find myself in that same position.” (2)

 

Boehner is right. Sixty-four percent of Americans, including a majority of both Republicans and Democrats, want to legalize marijuana, according to an October 2018 Gallup survey. (3) That’s the most since the pollster began asking the question in 1969. As of July 2018, thirty states plus the District of Columbia have legalized medical marijuana, while nine of those states (plus D.C.) also allow recreational marijuana. (4)

 

But does public opinion always reflect the truth of a situation? Is marijuana a beneficial medication? Is marijuana safe? Let’s dig deeper.

 

Marijuana: A Botany Lesson

Cannabis sativa is just a plant. Technically, an annual herbaceous flowering plant indigenous to eastern Asia. It has been cultivated throughout recorded history and each part of the plant is harvested differently, depending on the purpose. The flowers (and to a lesser extent the leaves and stems) contain the psychoactive chemical compound, known as THC. As a drug it usually comes in the form of dried flower buds (marijuana), resin (hashish), or various extracts collectively known as hashish oil.

 

Hemp, a variety of the Cannabis sativa plant species that has little THC and therefore no hallucinogenic properties, has proven to be very valuable to mankind. It was one of the first plants to be spun into usable fiber 10,000 years ago and it can be refined into a variety of commercial items including paper, textiles, clothing, biodegradable plastics, paint, insulation, biofuel, food and animal feed.

 

Marijuana: A Chemistry Lesson

The two main cannabinoids, or active ingredients, in marijuana are tetrahydrocannabinol, also called THC, and cannabidiol, or CBD. THC is the “psychoactive” ingredient; it is what produces the euphoria or high that comes from marijuana. CBD is not psychoactive, but it does appear to have a mild anti-anxiety effect. Interestingly, CBD lessens the psychoactive effect and psychotic side effects of THC. (5) There are many other cannabinoids and some of them may prove to be of value but the two key cannabinoids that we know the most about are THC and CBD.

 

Marijuana: A History Lesson

The natural levels of THC and CBD in a typical Cannabis plant were both under 1% until recently. (6) Since CBD lessens the psychedelic effects of THC, some people speculate that marijuana in its original state was probably a relatively mild sedative or calming agent. This is based on records from India around 1000 – 2000 years BCE, when the Cannabis plant was celebrated as one of "five kingdoms of herbs ... which release us from anxiety" in one of the ancient Sanskrit Vedic poems. (7)

 

However, the levels of THC in marijuana rose rapidly as investor money poured into improving the farming technology. Using powerful lights, selective breeding and special soils, the industry created a “new” marijuana. While the CBD stayed the same (under 1%), the average THC content in the new marijuana leaped to over 13% nationwide in 2015. (8) And, in Colorado today, levels of THC are much higher as there are plants pushing past 40%. That’s 10 - 30 times more potent than the marijuana of the 1960s and 1970s. (9)

 

Even in the Netherlands, where marijuana can be purchased in “coffee shops”, concern has grown about the potency. A Dutch government committee report in June 2011 recommended that Cannabis with more than 15% THC be labeled as a hard drug, putting it into the same category as heroin and LSD. (10)

 

Marijuana: Is it a Medicine?

The National Academies of Sciences, Engineering and Medicine recently called on the federal government to support better research, decrying the “lack of definitive evidence on using medical marijuana”. (11) The United States still classifies marijuana as a Schedule 1 Drug putting it into the same class as heroin. Underscoring the federal government’s position, Health and Human Services Secretary Alex Azar recently said there was “no such thing as medical marijuana.” (12) His point was this: there is not enough research or evidence to support the use of marijuana as a beneficial drug.

 

Although some studies have been done, researchers lament that so little is known about how marijuana affects the human body and brain. It has not gone through the clinical trials that all medications go through and there has been virtually no research exploring potential adverse interactions with prescription and non-prescription medications. In other words, at this time, one would be hard pressed to consider marijuana as a legitimate “medicine” since it has not passed through the regular channels required for medicine in the United States.

 

Potential Benefits or Goods

However, there are some solid studies showing that marijuana helps with the treatment of chemotherapy-induced nausea and vomiting and appetite stimulation due to wasting diseases like AIDS. Because of these two indications, two drugs containing synthetic THC, dronabinol (Marinol) and nabilone (Cesamet), have been approved by the U.S. Food and Drug Administration (FDA). These are pharmaceutical-produced, quality controlled and dose-specific medications. Curiously, they have not sold well.

 

In June of 2018, the FDA approved the first marijuana-derived drug, Epidiolex, for two rare forms of epilepsy. Unlike the synthetic medications, which contain THC, Epidiolex does not contain any THC. It is pharmaceutical-grade cannabidiol or CBD derived from the marijuana plant. The FDA considered many clinic studies before approving the medication. This approval should not be an endorsement of all CBD products as most dispensary-grade CBD products are not well-controlled or studied. (13)

 

In addition, there is another other condition that is trending positively in studies: spasticity in multiple sclerosis. For other conditions, like pain, the evidence is weak. In chronic pain, only five out of ten studies showed benefit from marijuana and in neuropathic pain only three out of six studies showed positive results. (14)

 

Finally, there are many other conditions touted for marijuana even though there is absolutely zero evidence. A good example is ALS. Despite multiple states including ALS on their list of approved illnesses for medical marijuana, there has been only one randomized clinical study and the results were unequivocally negative. (15)

 

Until proper studies are done, it would be beneficial for physicians to warn their patients about the marijuana hype. For instance, a study came out a few years ago which showed that CBD (in doses 10,000 times of that found in the plant) reduced the size and growth of some brain tumors. You can guess the headlines: “Weed Cures Brain Cancer.” (16)

 

A 2018 study in the Journal of Clinical Oncology found that 46% of cancer doctors say they’ve recently recommended medical marijuana to their patients although 56% of them admitted they did not have sufficient knowledge to do so. This is irresponsible behavior by physicians who are kowtowing to their even less knowledgeable patients. (17)

 

Recreational Marijuana

While marijuana as a medicine is clearly controversial, recreational marijuana is unequivocally problematic. Today’s culture has made it almost impossible to even talk about limiting its availability to adults. At the same time, advertising campaigns, conducted by powerful corporations and lobbyists, continue to work at reducing the public’s perceived risk.

 

Because of these lobbying efforts, many people view marijuana as a weak hallucinogenic or mild anti-anxiety drug. Some even see it as a safe natural substance that can even promote good health. (18) One hospital in Pueblo, Colorado, reported in July 2018 that nearly half the babies tested over a one-month period had marijuana in their system. Vicky Houston, of Woodland Park, saw nothing wrong with using marijuana while pregnant. “I believe it’s beneficial, I don’t think it’s toxic in any shape or form,” she told a local television newsperson. (19) These claims can be easily refuted scientifically but this false message is dominating the airways.

 

Corporations, like Acreage, following the game plan of the tobacco companies, are actively seeking profits by hiring big names like Boehner with apparently no thought to the long-term effects of what they are promoting and to whom. For instance, there are more marijuana dispensaries in Denver than Starbucks and McDonald’s combined and most are located in low-income neighborhoods. (20)

 

As mentioned earlier, today’s marijuana is a potent highly hallucinogenic drug so recreational use is fraught with danger. Only a few credible studies have been done (and hardly any with THC above 15%) but they provoke concern about the new marijuana. The higher the THC concentration, the higher the likelihood of first episode psychosis and schizophrenia. (21) (22)

 

Heavy marijuana use can damage brain development in youth aged 13 to 18. The 2015 Canadian Centre on Substance Abuse study confirmed the direct link between cannabis use and loss of concentration and memory, jumbled thinking and early onset paranoid psychosis. (23) One of the leaders in the medical field, Dr. Phil Tibbo, initiator of Nova Scotia’s Weed Myths campaign targeting teens, has seen the evidence, first hand, of what heavy use can do as director of Nova Scotia’s Early Psychosis Program. His brain research shows that regular marijuana use leads to an increased risk of developing psychosis and schizophrenia and effectively explodes popular and rather blasé notions that marijuana is “harmless” to teens and “recreational use” is simply “fun” and “healthy.” (24) Multiple researchers have all come to the same conclusion: the younger the brain, the worse the effects in both the short and long-term. (25) (26)

 

Now, let’s look at some of the myths associated with marijuana:

             

Myth #1: “Marijuana is not addictive”

Substance addiction experts would not agree with such a statement: marijuana is definitely addictive. However, it is less addictive than other substances, but current studies (done with lower potency marijuana) estimate that one out every nine adults and one out of every six juveniles who use marijuana will, at some point, meet the DSM criteria for a substance use disorder. (27) (28)

 

Myth #2: “No one has ever overdosed on marijuana”

While it is true that marijuana overdoses do not cause death, it can cause mental impairment and distressing emotional states, such as paranoia, hallucinations and psychosis. Overdoses can also cause arrhythmias, lethargy, clumsiness, dry mouth, dizziness and hypotension. (29)

 

Myth #3: “No one has ever died from marijuana”

Marijuana has and will kill people in the same way tobacco and alcohol has killed people. While people addicted to heroin decline visibly within a few years, people addicted to tobacco and alcohol don’t typically experience the negative effects for about twenty years. In a similar way, frequent users of marijuana will decline gradually – physically and emotionally. Lung diseases like chronic bronchitis and chronic obstructive pulmonary disease (COPD), schizophrenia, anxiety, depression and chronic apathy have all been reported in frequent users. (30)

 

Marijuana will cause fatal accidents. From 2010 to 2014, marijuana-related traffic deaths increased 92 percent in Colorado while all traffic fatalities in the same period rose only 8 percent. (31) In addition, marijuana deaths and injuries hit an all-time time in 2015 in Colorado as marijuana was named as the culprit in fatal fires, psychotic killings, explosions and suicides. (32)

 

Myth #4: “We can protect our young people and limit marijuana to adults”

Surely our experience with cigarettes, alcohol and prescription drugs would tell us otherwise when it comes to teens; overall accessibility and availability leads to an increase in teen usage. And, in the May 2018 issue of Pediatrics, researchers disturbingly found that Cannabis use is on the rise among adults with children in the home. (33)

 

In Conclusion:

This second drug wave has the potential to devastate our country. As a physician, I worry that the next generation is going to grow up in a place where pervasive marijuana use is accepted and possibly encouraged. If that happens, we will be seeing the deleterious effects of marijuana on the brain and body play out in our offices and society will see the harmful effects played out in our streets, schools, churches, neonatal units, hospitals and homes.

References:

1. https://www.cdc.gov/drugoverdose/data/overdose.html

2. https://www.nytimes.com/2018/04/11/us/politics/boehner-cannabis-marijuana.html

3. http://news.gallup.com/poll/221018/record-high-support-legalizing-marijuana.aspx

4. http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx

5. National Academies of Sciences, Engineering, and Medicine. The Health Effects of Cannabis and Cannabinoids: Current State of Evidence and Recommendations for Research. Washington, DC: The National Academies Press; 2017.

6. Cort, B, Weed Inc., Health Communications, Deerfield Beach, Florida, 2017.

7. "Marihuana: The First Twelve Thousand Years" (Springer, 1980).

8. Cort, B, Weed Inc., Health Communications, Deerfield Beach, Florida, 2017.

9. https://www.cnn.com/2013/08/09/health/weed-potency-levels/index.html

10. https://universonline.nl/2011/06/27/garretsen-qualify-strong-cannabis-as-hard-drugs

11. National Academies of Sciences, Engineering, and Medicine. The Health Effects of Cannabis and Cannabinoids: Current State of Evidence and Recommendations for Research. Washington, DC: The National Academies Press; 2017.

12. https://www.daytondailynews.com/news/local/such-thing-medical-marijuana-health-secretary-says-dayton/La8dTJgu6nF3ojSc1z6yPO/

13. https://jamanetwork.com/journals/jama/article-abstract/2661569. In this 2017 study published in JAMA researchers tested 84 products purchased from 31 different online CBD sellers. Roughly seven out of 10 items had different levels of CBD than what was written on the label. Of all of the items they tested, roughly half of the items had more CBD than was indicated; a quarter had less. And 18 of the samples tested positive for THC, despite it not being listed on the label.

14. Koppel BS, Brust JC, et al. “systemic review: Efficacy and safety of medical marijuana in selected neurologic disorders: Report of the Guideline Development Subcommittee of the American Academy of Neurology,” Neurology 82, no.17 (2014): 1556-63.

15. Weber B, Goldman B, et al. Tetrahydrocannabinol for cramps in ALS: a randomized, double-blind crossover trial,” Journal of Neurological Neurosurgery Psychiatry 81 (2010): 1135 – 40.

16. Here is an internet article that tries to appear more scientific than the headline I listed in the article: http://www.collective-evolution.com/2015/04/15/the-us-finally-admits-cannabis-kills-cancer-cells/

17. llana Braun, M.D., Boston; Andrew Epstein, M.D., et al. “Cancer Docs Seek More Study of Medical Marijuana,” Journal of Clinical Oncology, published online May 10, 2018.

18. https://www.psychologytoday.com/us/blog/almost-addicted/201301/marijuana-is-all-natural-so-what-s-the-problem

19. http://denver.cbslocal.com/2016/07/11/marijuana-pregnant-thc-positive-babies-colorado/

20. https://www.coloradopotguide.com/colorado-marijuana-blog/2015/december/26/more-dispensaries-in-colorado-than-mcdonalds-starbucks-combined/

21. https://www.mdedge.com/psychiatry/article/97219/schizophrenia-other-psychotic-disorders/high-thc-cannabis-use-tied-higher

22. American Friends of Tel Aviv University. (2017, April 26). Cannabis use in adolescence linked to schizophrenia: Psychoactive compound in cannabis may trigger the brain disorder, researchers say. ScienceDaily. www.sciencedaily.com/releases/2017/04/170426124305.html

23. R Douglas Fields. (2017, October 9) Link Between Adolescent Pot Smoking and Psychosis Strengthens: Research presented at a Berlin psychiatric conference show teenage cannabis use hastens onset of schizophrenia in vulnerable individuals. Scientific American.  Retrieved January 4, 2018 from https://www.scientificamerican.com/article/link-between-adolescent-pot-smoking-and-psychosis-strengthens/

24. http://www.ccdus.ca/Resource%20Library/CCSA-Effects-of-Cannabis-Use-during-Adolescence-Report-2015-en.pdf

25. Cookey J, Bernier D, Tibbo P.  (2014) White matter changes in early phase psychosis and cannabis use: an update and systematic review of diffusion tensor imaging studies. Schizophrenia Research 2014 Jul; 156(2-3):137-42.

26. https://theconversation.com/marijuana-at-school-loss-of-concentration-risk-of-psychosis-90374

27. Anthony JC, Warner LA, et al, “Comparative Epidemiology of Dependence on Tobacco, Alcohol, Controlled substances, and Inhalants: Basic Findings from the National Comorbidity Survey,” Experimental and Clinical Psychopharmacology 2, no.3 (1994): 244-68

28. Lopez-Quintero C, Perez de los Cobos J, et al, “Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis and cocaine: Results of the National Epidemiologic Survey on alcohol and Related Conditions (NESARC), “Drug and Alcohol Dependence, nos. 1-2, (May 2011): 120-130.

29. https://drugabuse.com/library/marijuana-overdose/

30. Volkow, ND, Baler, WM, et al, “Adverse Health Effects of Marijuana.” New England Journal of Medicine 370 (2014): 2219-27.

31. https://www.denverpost.com/2017/08/25/colorado-marijuana-traffic-fatalities/

32. https://www.scribd.com/document/361299028/The-Legialization-of-Marijuana-in-Colorado-The-Impact-Volume-5-October-2017

33. Renee Goodwin, Keely Cheslack-Postava et al, “Cannabis use up among parents with children in the home”, Pediatrics, published on-line May 14, 2018.

 

 

Three Sidebars:

Marijuana in Genesis

In the beginning, God created Cannabis sativa and it was good. As Christians, we believe the story of Genesis that God created everything – man, cows and marijuana; it was all declared good. (1) But the fall happened and man began using creation for selfish and sinful purposes. For example, fire is good. It keeps us warm at night but many homes, businesses and lives have been lost to arson. Since the Bible tells us that humans were given dominion over all the earth and told to subdue it, our mandate is to use everything our Creator has given us to its fullest potential and greatest good – to God’s glory.

 

 

Recreational Marijuana: A Christian Perspective

It is my impression that most Christians base their opinions on marijuana in large part on their views regarding alcohol. So, let’s discuss the two dominant Christian perspectives on alcohol.

 

Many Christians choose not to drink alcohol at all. They consider the harmful effects of alcohol on individuals and society – liver failure, divorce, physical and sexual violence, car accidents, etc. – and decide to abstain. This is a very understandable position and it is strengthened by Romans 14:30, which calls on us to consider the effects of our actions on weaker brothers, and 1 Corinthians 6:12, which cautions us to not be mastered by anything. Clearly, teetotaling Christians could apply the same principles to recreational marijuana.

 

Other Christians, however, choose to drink. They may like a glass of wine with dinner or a social drink at a party. Most in this camp will stress their awareness of alcohol’s dangers and acknowledge the Biblical prohibitions against drunkenness. This is also an understandable position and is strengthened by Galatians 5:19 -21, 1 Timothy 3:3 and Titus 1:7 which seem to permit alcohol as they only label drunkenness as sin. When Paul tells us “to not be drunk with wine”, he is not arguing against wine – he is arguing against drunkenness. Therefore, Christians who drink might think they can apply the same principle to marijuana: I will smoke a joint daily with dinner but I will avoid getting high. (I am assuming it is legal in their state as Christians do have an obligation to submit to government edits). (1) However, there are some serious problems with this position:

Therefore, in conclusion, I do not believe recreational marijuana has a place in the life of a believer.

 

References:

 

Medical Marijuana: A Christian Perspective

What about medical marijuana? I believe Christians can explore the medical uses of the compounds in marijuana within established medical-legal bounds. As I mentioned in the medical section of this article, our medical knowledge regarding marijuana is thin. Christians affected by diseases that may benefit from marijuana already have access to two marijuana-based prescription medications. As a hospice physician who has seen some of the worst cases of suffering, I can tell you unequivocally that we have more medications today than ever in the history of the world to reduce pain and suffering. Maybe marijuana will eventually fulfill its promise and help mankind as a medicine or maybe its many uses as hemp are its greatest good. The jury is still out and wisdom dictates patience until some substantial studies come out.

 

 

 

 

 

 

 

 

 

 

 

 

 

Marijuana Letter to Editor 061118c

 

Date  June 11, 2018

 

To Editor State Newspaper

 

I am a local physician and a person representing many health care professionals in the American Academy of Medical Ethics (AAME)   throughout the country.  Our foundational premise in writing you is simple: we feel science should be your guide when it comes to the legalization  of medical marijuana.

Because of the science, we are in strong opposition to the legalization of medical marijuana. Instead, we reasonably contend that cannabis-based and cannabinoid medications should be subject to the same FDA scrutiny as any other medication.

The practice of medicine must rest on evidence-based solid data. For this reason, all reputable medical organizations support the Food and Drug Administration’s (FDA) rigorous approval process to determine whether a medication should be made available to the public - not state legislature enactments.

Marijuana: A Chemistry Lesson

The two main cannabinoids, or active ingredients, in marijuana are tetrahydrocannabinol, also called THC, and cannabidiol, or CBD. THC is the “psychoactive” ingredient; it is what produces the euphoria or high that comes from marijuana. Interestingly, CBD lessens the psychoactive effect and psychotic side effects of THC. (1)

 

Marijuana: A History Lesson

The natural levels of THC and CBD in a typical Cannabis plant were both under 1% until recently. (2) Since CBD lessens the psychedelic effects of THC, most experts agree that marijuana in its original state was probably a relatively mild sedative or calming agent.

 

However, the levels of THC in marijuana rose rapidly as investor money poured into improving the farming technology. Using powerful lights, selective breeding and special soils, the industry created a “new” marijuana. While the CBD stayed the same (under 1%), the average THC content in the new marijuana leaped to over 13% nationwide in 2015. (3) And, in Colorado today, levels of THC are much higher as there are plants pushing past 40%. (4) That’s 10 - 30 times more potent than the marijuana of the 1960s and 1970s. This is not the marijuana of your parents.

 

Even in the Netherlands, where marijuana can be purchased in “coffee shops”, concern has grown about the potency. A Dutch government committee report in June 2011 recommended that Cannabis with more than 15% THC be labeled as a hard drug, putting it into the same category as heroin and LSD. (5)

 

That’s the basic science.

 

But, there are powerful lobbyist and corporations ready to make significant profits on marijuana and they oppose reasonable science. (6) They are following the game plan of the tobacco companies and have spent millions reducing the public’s perceived risk. (7) Their effective marketing campaign has made it almost impossible to even talk about limiting marijuana availability to adults. For instance, there are more lobbyists  in Colorado regarding marijuana than for any other legislative topic. Let me give you four myths these powerful lobbyists have promoted:

 

Myth #1: “Marijuana is not addictive”

Not a single respected substance addiction expert would ever agree with such a statement: marijuana is definitely addictive. However, it is less addictive than other substances, but current studies estimate that one out every nine adults and one out of every six juveniles who use marijuana will, at some point, meet the DSM criteria for a substance use disorder. (8) (9)

 

Myth #2: “No one has even overdosed on marijuana”

While it is true that marijuana overdoses do not cause death, it can cause mental impairment and distressing emotional states, such as paranoia, hallucinations and psychosis. Overdoses can also cause arrhythmias, lethargy, clumsiness, dry mouth, dizziness and hypotension. Ask any physician who works in an emergency room.

 

Myth #3: “No one has ever died from marijuana”

Marijuana has and will kill people in the same way tobacco and alcohol has killed people. While people addicted to heroin decline visibly within a few years, people addicted to tobacco and alcohol don’t typically experience the negative effects for about twenty years. In a similar way, frequent users of marijuana will decline gradually – physically and emotionally. Lung diseases like chronic bronchitis and COPD, schizophrenia, anxiety, depression and chronic apathy have all been reported in frequent users. (10)

 

Marijuana will cause fatal accidents. From 2010 to 2014, marijuana-related traffic deaths increased 92 percent in Colorado while all traffic fatalities in the same period rose only 8 percent. (11)

 

Myth #4: “We can protect our young people and limit marijuana to adults”

Surely our experience with cigarettes, alcohol and prescription drugs would tell us otherwise when it comes to teens; overall accessibility and availability leads to an increase in teen usage. And, in the May 2018 issue of Pediatrics, researchers disturbingly found that Cannabis use is on the rise among adults with children in the home. (12)

 

Myth #5 “ This is a good way to solve the opiod addiction prevalent and growing in the US”

That is like fighting fire with gasoline.  It defies common sense to approve THC with its hallucinogenic properties as a treatment for opoid addiction.

 

The South Carolina Medical Association at its recent meeting April 2018 approved a resolution which in part says the following: “ Whereas the SCMA opposes legislation that requires physicians without the benefit of adequate clinical or academic research, to be the sole, legal access point for marijuana and its derivatives in SC. “

 

As a legislator, you have sworn to serve and protect the public good. We ask you to have the courage to oppose the lobbyist and profit-seekers who give no thought to the long-term effects of what they are promoting and to whom.

 

Legalizing marijuana at this time would violate the well-established rules of medication approval and defy common sense. Wisdom dictates patience until substantial studies come out addressing the issues I have raised. Let the FDA do its job! Please respect the historical and reasonable limits regarding legislature involvement in medication approval. Vote “No” on the legalization of medical marijuana.

 

 

Respectfully submitted,

 

Richard S McCain MD

Orthopaedic Surgeon Columbia, SC

 

References:

1. National Academies of Sciences, Engineering, and Medicine. The Health Effects of Cannabis and Cannabinoids: Current State of Evidence and Recommendations for Research. Washington, DC: The National Academies Press; 2017.

2. Cort, B, Weed Inc., Health Communications, Deerfield Beach, Florida, 2017.

3. Cort, B, Weed Inc., Health Communications, Deerfield Beach, Florida, 2017.

4. https://www.cnn.com/2013/08/09/health/weed-potency-levels/index.html

5. https://universonline.nl/2011/06/27/garretsen-qualify-strong-cannabis-as-hard-drugs

6. https://www.denverpost.com/2014/12/19/colorado-pot-lobby-loud-clear-on-regulations-as-government-listens/

7. https://www.denverpost.com/2014/12/19/colorado-pot-lobby-loud-clear-on-regulations-as-government-listens/

8. Anthony JC, Warner LA, et al, “Comparative Epidemiology of Dependence on Tobacco, Alcohol, Controlled substances, and Inhalants: Basic Findings from the National Comorbidity Survey,” Experimental and Clinical Psychopharmacology 2, no.3 (1994): 244-68

9. Lopez-Quintero C, Perez de los Cobos J, et al, “Probability and predictors of transition fro