Cannabis implications for public safety Illinois

1. Current Issues in Police &
Public Safety Psychology:
2019
8-7-2019
State Legalization of Marijuana:
Implications for screening
police & public safety personnel
Ashwani K. Garg, MD
Family Medicine
Lifestyle & Integrative Medicine

2. Disclosures
2
I am in no way representing the views of my employer.
All views are my own.
I have no actual or potential conflict of interest
in relation to this program/presentation.
I will be discussing “off-label” uses of medical cannabis.
Cannabis is a schedule I substances as classified by the DEA
which means illegal/no medicinal use.
Cannabis is regulated individually state-by-state, and
while it is allowed by Illinois’ government, the
federal government has chosen not to sue the state or
to prosecute its sale and use.

3. T
H
C
Agenda
3
1. Pharmacology of Cannabis
2. History/Regulation
3. Illinois Experience
4. Workplace issues
risks/benefits and testing
5. Case Study/discussion
C
B
D

4. “Poison is in everything, and no thing is without poison.
The dosage makes it either a poison or a remedy.”
-’Paracelsus’ (1493-1541), German-Swiss physician and alchemist
PHARMAKON (GREEK) = REMEDY OR
POISON
PHARMAKOS = RITUAL HUMAN SACRIFICE

5. Pharmacology of cannabis
• 421 components, 60 pharmacologically active cannabinoids
• THC and CBD are most well understood
• Highly lipophilic
• Dependence, tolerance, addiction
• CB1: brain - antiemetic, analgesia, neuromodulatory
altered mood, memory, judgement, altered perception
• CB2: immune, hematopoietic, spleen, anti-inflammatory; peripheral
• Presynaptic: modulate neurotransmitter release

7. CB1 and CB2 are in a balance, THC/CBD
balance each other

8. Terpenes are additional compounds
found in cannabis
• Terpenes are aromatic oils that enhance
cannabis with aromas and flavors; found in
many other plants
• These terpenes make each strain of
cannabis truly unique and interact with
CBD and THC to give specific health
effects
• Terpenes are notably absent in synthetic
cannabinoid products

9. Example of terpenes
(leafly.com)

10. Addiction potential of common
substances – it’s all relative

11. WE HAVE OUR OWN
ENDOCANNABINOID SYSTEM!
• Anandamide “bliss molecule” found in various tissues of body
• Dark chocolate found to contain anandamide AND compounds that slow
breakdown
• Lifestyle Medicine is known to help all aspects of ECS
• Feet – exercise increases anandamide and sensitivity of receptors
• Fingers – avoidance of alcohol/tobacco/drugs
• Forks (plant-based foods, green tea reduce breakdown of cannabinoids by inhibiting FAAH)
• Sleep (7 hours / night helps brain homeostasis, memory, mood)
• Stress (mindfulness is a way to manage stress)
• Love (physical/emotional affection, massage, kindness, yoga increase oxytocin)
(based on Dr. David Katz, Yale, “We Can Be Disease Proof” in Huff Po)

12. Where to learn more?
DOH.DC.GOV

13. HISTORY OF MARIJUANA
• Cannabis use goes back 1000’s of years – India, China, Greece
• Sir William Osler 1915 advocated for its use in migraine in textbook
• Listed in the US dispensatory 1845
• Recreational use introduced by Mexican immigrants (1910)
• “Reefer Madness” – minorities and lower income communities
• AMA opposed Marihuana Tax Act 1937 (which added $1 tax and discouraged
its use)
• 1941 – taken off USP and national formulary
• 1944 – NY academy of Medicine report – use of marijuana does not induce
violence, insanity, sex crimes, addiction, drug use
• 1969 – Marihuana Tax Act declared unconstitutional against 5th amendment
• 1970 – Schedule I, no further research, illicit drug in same category as Heroin.
• 1988 – Drug-Free Workplace Act: ALL federal grantees drug free, some
contractors

14. 14
Credit: ACLU Jun 2013:
The War on Marijuana
in Black and White
Fox:
Family Guy
Seth MacFarlane, David Zuckerman

16. MEDICINAL CANNABIS
VS
STREET CANNABIS
• There is a big difference between street cannabis and medicinal cannabis
• “Street cannabis” has high levels of THC – within the last 20 years it has
increased from 34mg / joint to 84mg / joint. For comparative reasons,
medicinal use starts with 5-10 mg/day.
• Often street cannabis is intermingled with other illicit substances such as
fentanyl
• “Gateway drug”? Or Gateway DEALER?
• Chicago gangs: 100,000 gang members in 59 gangs (ABC News)

17. State laws on cannabis and CBD
MAP COURTESY | LAWRENCE PASTERNACK, Ph.D., OSU
17

18. 18

19. Most common certified conditions
1. Cancer
2. HIV/AIDS
3. Amyotrophic lateral sclerosis
4. Multiple sclerosis
Illinois Department of Public Health Annual Progress Report to the General
Assembly: Compassionate Use of Medical Cannabis Pilot Program Act, July
1,2014-June 30, 2015.

21. Medical cannabis use is associated
with decreased pharmaceutical use
boehnke, kevin ET AL

22. PHYSICIAN DILEMMA
• We have no training in the pharmacology of CB1/CB2, THC/CBD
• We are expected to help patients with this – many questions regarding
dosage, forms, types
• Legal state-by-state, but federally illegal. Jeff Sessions has threatened to shut
the whole program down. Banking and insurance restrictions
• No FDA regulation or control such as tobacco and other medications
• State of IL – 41 medical conditions listed
• Physician need only certify medical condition, NOT recommend/endorse use
of cannabis.
• Ideally, patient’s own PCP should fill the form because they have a BONA
FIDE relationship

23. Illinois experience in medical cannabis
Illinois banned recreational cannabis in 1931
1978 Cannabis Control Act: possession of even small amount would result in a
misdemeanor jail sentence up to 30 days
MCPP = medical cannabis pilot program (2013) – 65,000 applications approved
OAPP = opioid alternatives pilot program (2019) – as of now, roughly 6000 certified
Total retail sales since 11-2015: $323,125,506
*** African Americans in IL are 7-8 times more likely than whites to be arrested
than whites despite similar use ***

26. • Cannabis is the most frequently used illegal substance in the world
• Roughly 50% lifetime use in the USA
• Cannabis Use Disorder with heavy chronic use
• Amotivational syndrome: loss of drive and ability to work
• Depersonalization: feeling detached from mental processes and body
• Risk factor for psychosis (1/4 of schizophrenic patients had CUD or cannabis
use d/o)
• Depression/suicidal ideation, anxiety, bipolar depression
• Cognitive deficits, impaired neuropsychologic functioning
• Medical effects including respiratory, cancer, heart, and more
Long-term Effects of Cannabis Use
Understanding that the research is in abusers, not medicinal users.
26
Karila L et. al (France)
Acute and Long-Term Effects of Cannabis Use: A Review
Current Pharmaceutical Design, 2014, 20, 4112-4118

27. • In 2013, an excavator operator turned himself in to face manslaughter in an accident
that caused a building collapse in Philadelphia and killed 6 people
• Sean Benschop, 42, of Philadelphia, had marijuana found in his system
• He ALSO admitted to taking codeine and other Rx drugs, had a soft cast up to his
elbow, and had a previous record of 10 arrests for drug charges, theft, firearms,
and assault.
• 20 people were caught in the fallen debris; 14 were seriously injured with the
accident
Cannabis in the Workplace
Anecdote
27
https://abcnews.go.com/US/excavator-operator-surrenders-
philadelphia-building-collapse/story?id=19356293

28. • The intended and unintended physiologic effects of marijuana on neurocognitive
performance range from several hours to beyond 28 days of subsequent abstinence.
• Blood levels, while useful for MRO reporting, are not indicative of impairment (usually
legally 5 ng/ml)
• Neuropsychologic testing can be useful, and it is no guarantee the worker will improve
by the next day
• MRO’s are inconsistent in enforcement; it may be reasonable to do a medical
investigation when a test is positive and to assess for impairment and suitability for work
• In Illinois, recreational cannabis will be legalized in 2020. MRO’s will have to decide how
to assess positive screens and impairment. Positive screens can remain positive for 1-5
days after use, and with heavy use, up to 1 month afterwards.
Medicinal Cannabis in the Workplace
28
Medical Marijuana in the Workplace: Challenges and Management Options for Occupational Physicians
Goldsmith, RS et al:
JOEM Volume 57, Number 5, May 2015 pp. 518-525

29. • Urine (5-30 days after use)
• Blood (5-30 days after use)
• Breathalyzer – Hound Labs (near 0 2-3 hours after)
Marijuana Testing
29

30. • Middle aged man with inflammatory bowel disease, severe chronic diarrhea, abdominal
pain, joint pain
• Previously using Norco, Percocet, and at one point, Fentanyl and Oxycontin
• Now well controlled on medicinal cannabis together with pharmaceuticals
• Approached his employer’s HR which is Fortune 500 company
• Asked the question:
• Which would you rather have, an employee on a prescribed opioid all day, every
day?
• Or occasional use of cannabis at home, and not impaired at work?
Anecdote from a patient
Case example
30

31. “Legal” substances in the workplace
31
We have a federal law against
cannabis use, however consider
all the pharmaceuticals that can
alter the mind that workers use
every day – consider the effects
on the brain and work
performance
Consider alcohol which is
sometimes actively SERVED in
the workplace!
Consider cigarettes which are
detrimental to health
Amphetamines/stimulants
Opioids
Benzodiazepines
Antidepressants
Antihistamines
Gabapentin/Lyrica
Seizure medication
Beta blockers

32. Summary
• Medicinal Cannabis has the potential to replace several pharmaceuticals that may be
highly toxic and even lethal and that may impair workers
• Medical Cannabis has the potential for analgesia, neuromodulatory, antiepileptic, and
effects for PTSD
• Cannabis is also misused as a drug of abuse and needs to be kept out of young
hands, there is a difference between heavy and light, occasional use.
• The role of medical cannabis is difficult to study due to variability of formulation and
existing laws
• Consider racial inequality in prosecution of drug crimes and the role of gang violence
in illicit cannabis. Before dismissing recreational cannabis, consider both sides.
• Occupational Medicine experts generally recommend banning marijuana in the
workplace as there are so many variables.
• Consider neuropsychiatric testing if there is a concern
• Positive screens should be handled on a case-by-case basis, taking into account the
potential for bias in these decisions. Decisions should be color-blind.
• An attitude of “harm reduction” may be considered