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Q&A: Director of the National Institute on Drug Abuse

By: Christine tatum Special to The Gazette
August 9, 2015 Updated: August 9, 2015 at 4:21 am
photo - Dr. Nora Volkow
Dr. Nora Volkow 

Dr. Nora Volkow represents a lot of inconvenient truths about marijuana that just don't square with industry claims and popular opinion that the drug is medicine, "safer than alcohol" - or even on its way to being adequately regulated by states that have sanctioned its use.

The director of the National Institute on Drug Abuse in Bethesda, Md., Volkow is one of the world's top experts on the use and abuse of cannabis and research of the drug's impacts on individual and public health.

Volkow's command of the science was on display when she appeared in Denver alongside Gov. John Hickenlooper and Ricardo Lagos, former president of Chile, at the Biennial of the Americas, a festival that brought together leaders from North, Central and South America to address shared interests. Volkow recently spoke with The Gazette:

Question: What do you most want Americans to understand about how marijuana legalization affects public health?

Answer: It is important to remember that it is the legal drugs, in other words, nicotine and alcohol, that are, by far, the main drivers of drug-induced morbidity and mortality in our country. That is not because they are more dangerous, but because their legal status makes them much more accessible to people, increasing the overall number of individuals exposed to them and facilitating their regular use. That, in turn, leads to a much greater number of people affected negatively by them. Even when compared to the most dangerous illegal drugs, such as methamphetamine and heroin, there are many more people dying from the use of legal drugs. We should keep this simple fact in mind when discussing legalizing a third drug: the unintended consequences could be equally far reaching and hard to reverse once they are discovered.

Q: Which marijuana-related health problems do you think are most underreported or most inaccurately reported - and, therefore, most misunderstood by the general public?

A: One of the effects most challenging to explain to the public relates to the effects of chronic marijuana use on cognition, particularly when use begins early, during adolescence or even childhood. When use starts early, the known effects of marijuana on brain physiology and experience-driven brain adaptations interact with developmental processes that make the young brain particularly sensitive to these toxic effects, which can result in long-term changes to the brain.

Another issue that is grossly misunderstood or underappreciated is that, like other drugs of abuse, marijuana can be addictive.

Q: Is cannabis medicine? If so, what for, and in what form?

A: Cannabis in smoked form is unlikely to be an ideal medicine due to its effects on the lungs and the difficulty of achieving reproducible dosing.

We can say with certainty is that cannabis contains active ingredients with potential therapeutic properties. In fact, the FDA has already approved medicines based on THC for the treatment of wasting syndrome and to control nausea in chemotherapy patients. And there is preliminary evidence suggesting THC may have therapeutic efficacy in the treatment of pain. There is also a great deal of interest in developing medications based on another constituent of the cannabis plant called cannabidiol (CBD). CBD, which does not give users the classic 'high,' has shown some promise in controlling seizures in children with severe forms of epilepsy (including Dravet and Lennox-Gastaut syndromes), and preliminary trials of a CBD-based drug are underway by GW Pharmaceuticals. There are likely many more applications for these other cannabinoids that are supported by a scientific rationale and some intriguing preliminary results that warrant more research.

Q: How do you respond to the assertion that marijuana is safer than alcohol, other drugs?

A: Most drug abuse researchers are reluctant to draw simple comparisons between the harms of different classes of drugs - and for good reasons. Substances can affect the body and brain in different ways, and there is so much variability in how different individuals respond to them that comparisons between drugs - or statements about 'what drug is worst for you' - are of little use in predicting outcomes for a given individual. A drug that proves relatively benign for one person's life and health may have a disastrous effect on another person for reasons ranging from differences in age and genetic vulnerability to countless variables in life experience. If you are addicted to a drug, that is the one that is worst for you.

In the case of alcohol-versus-marijuana comparisons, the difficulty is compounded by an imbalance in the available data. Because alcohol is legal, its use is much more widespread and often continues throughout the lifespan. As a result, its adverse health effects and its impact on personal and public safety - for example, fetal alcohol syndrome or driving risk - are well understood. Scientists cannot yet speak with the same degree of confidence about some of the health and safety effects of marijuana. For instance, its contribution to pulmonary and cerebrovascular function, or the exact degree to which it harms a developing fetus or impairs driving. What data we do have on marijuana's effects are occasionally difficult to interpret because marijuana users frequently use alcohol as well - whereas the reverse is less likely to be true, making it difficult to separate the effects of the two substances.

Q: What kind of research do you want to see more of? Which recent and/or ongoing research do you want the public to know about?

A: There is a significant need for more research following up on promising preclinical and early clinical research findings related to the potential therapeutic value of some of the components of marijuana, including THC and CBD. NIDA specifically is working to understand the potential therapeutic value of these compounds for the treatment of substance use disorders as well as pain. Other NIH institutes are studying the value of these compounds for other disorders relevant to their missions.

Additionally, from NIDA's perspective, it is important to continue research related to the changing landscape of marijuana use, including strains of higher THC potency; new routes of administration - for example, vaping and consuming edibles; new drug combinations; and a culture of rapidly changing norms and perceptions. For example, what are the consequences of long-term use of 'medical marijuana' among vulnerable populations, such as patients with AIDS, cancer, cardiovascular disease, multiple sclerosis or other neurodegenerative diseases or elderly persons? And the impact of in-state marijuana policies and related market forces - for example, youth-targeted advertising, pricing wars, and the emergence of FDA-approved cannabis-based medicines - on use and related public health and safety outcomes?

One of the most important questions we need to answer is whether and to what extent the association between early marijuana use and long-term, adverse effects on aspects of life - such as IQ, academic achievement, well-being and mental health - reflects a causal relationship. This is why NIDA is coordinating a 10-year study that will follow the trajectory of 10,000 children. We call this the Adolescent Brain Cognitive Development (ABCD) study, which is about to be launched jointly by several NIH Institutes. By gathering neuro-imaging data as well as a broad range of data regarding substance use, mental health and other outcomes - including IQ and cognition - the study will clarify the impact of marijuana use on development, reveal the effects of multiple substance exposures and disentangle the effects of marijuana and other drugs from various confounding factors - particularly prior exposure to substances.

Q: What ideas do you have about ways to speed medical research of cannabis and cannabis use disorder treatment and the dissemination of those findings to practice?

A: As mentioned before, THC and other chemicals in the marijuana plant have a wide range of potential medicinal properties, and thus the possible therapeutic uses of marijuana are a subject of increasingly intense interest. The challenge is to learn how to encourage research but keep research subjects safe. We want to optimally harness the potential medical benefits of marijuana's chemical constituents without exposing healthy or sick people to the various intrinsic risks of smoking or otherwise ingesting marijuana in its crude form, particularly when product quality, composition, purity and dosing are inconsistently standardized - as may be the case with 'medical marijuana.'

We think the U.S. Department of Health and Human Services' recent removal of one level of review (by the Public Health Service committee) that has been necessary for approval for non-NIH-funded studies should help. In addition, we think that consideration should be given to reducing other barriers to research, including the administrative and regulatory burden associated with doing research on Schedule I drugs, the restriction of marijuana produced for research purposes to a single source, and issues related to the disparity between federal and state laws.

The medical cannabis research portfolio is potentially very vast, so it must be said that most of this portfolio falls outside of NIDA's defined mission. However, NIDA does have a natural interest in exploring at least two major applications for cannabis-based medications: the treatment of substance use disorders, including cannabis use disorders, and the development of alternative - meaning non-opioid-based - approaches for pain management.

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