IEDIATRICS (ISSN 0031 4005). Copyright © 1980 by the American Academy of Pediatrics.
Committee on Drugs
Marijuana
In 1971 and 1975, the Committee on Drugs pro-vided information about marijuana for the Acad-emy membership.”2 Since that time, marijuana use by children and adolescents has continued to in-crease. Investigations of the biologic effects of the agent have expanded, and there is justification for concern about frequent, chronic use by youth. In addition, marijuana use and experimentation with other drugs are now being promoted to children in subtle and insidious ways which need to be identi-fled (Figs 1 to 5).
Pediatricians should be aware of the changing pattern of marijuana use in this country. Whereas occasional use by an adult may have little health consequence for the individual, frequent use by large numbers of children and adolescents raises different concerns. The National Institute on Drug Abuse (NIDA) conducts annual surveys of man-juana use in this country and reported in a recent publication’ that 10% of all high school seniors smoke marijuana daily. In the 12- to 17-year old group, 16% of those surveyed in 1977 used man-juana in the month preceding the survey. Even if the incidence figures are not entirely accurate, an increase in use by these two groups from 1976 to
1977, as determined by similar annual sampling techniques, is clear. Nationwide data since 1977 are not yet available, but in two states surveyed in 1978, 16% of high school seniors smoked marijuana daily (R. C. Peterson, PhD, personal communication,
1979). This information supports the conclusion
that use in youth had increased each year since
1975. Extrapolation of additional data collected by
NIDA revealed that in 1977 about 16 million Amen-icans were current users of marijuana (ie, used the drug during the month preceding the survey).
It is not altogether clean what factors are respon-sible for the expanding popularity of the agent in high school, junior high school and in younger
chil-dren. It is, perhaps, significant that concurrent with the emergence of use by younger children, the com-position of available marijuana has changed. In recent years, the primary source of marijuana has shifted from Mexico to Colombia. Consequently, most marijuana available in the United States is now about 4% or greater i-9-tetrahydrocannabinol
(z-9-THC), whereas for several years z-9-THC con-centration in the produce available in this country was 1%-2%.
Research involving marijuana and the primary active ingredient, t-9-THC, has focused upon ef-fects of the drug on normal physiologic systems and on psychosocial behavior. In reviewing research findings, it is important to distinguish between in-vestigations conducted in man and those carried out in experimental animals.5 Since marijuana is a crude material which contains more than fifty other cannabinoids and a few hundred other compounds,6 it is also often necessary to note whether the studies are conducted with marijuana, extracts of man-juana, or the single psychoactive compound,
i-9-THC. The pattern of inhalation may also be impor-tant since Americans characteristically inhale mar-ijuana smoke deeply and retain the material in the lungs for several seconds.7
Several organ systems have been investigated for adverse and beneficial pharmacologic effect. A striking effect of marijuana smoking is tachycardia which is accompanied by an increase in plasma catecholamines.8 The chronotropic effect of the agent was blocked by propranolol in some studies,t’ but other investigators were unable to demonstrate beta-agonist effect during marijuana At least one study has demonstrated that eight of ten subjects had a decrease in exercise tolerance after smoking one marijuana cigarette, whereas two of the subjects showed an increase in tolerance.”
Fig 1. Head shops sell ordinary-looking containers which have been converted as hiding places for pot.
Fig 2. Comic books, with appeal to young buyers,
pro-mote drug abuse.
bronchodilator properties when administered orally or by inhalation.’2 Both marijuana cigarette smok-ing and aerosolized -9-THC, however, produce bronchospasm in some individuals apparently be-cause of a local irritant effect of the particles.’3
With chronic, heavy smoking of marijuana, de-terioration of pulmonary function has been ob-served. This finding is likely related to other com-ponents of the marijuana cigarette and not due to \-9-THC. The impairment involves large airways primarily,’4 but is less than that described in heavy
users of hashish. In the latter group, bronchitis and severe tracheal lesions have been noted.’5
Microscopic evaluation of the airways in experi-mental animals chronically exposed to marijuana smoke revealed generalized pneumonitis and cellu-lar infiltrate into alveoli.’6 A cytotoxic effect on macrophages has also been noted.’7 Cholesterol clefts developed in the lungs of the animals after 90 days of exposure, but the signficance of this lesion is unknown at present.’6
A large number of in vivo and in vitro studies of the immune system have been carried out. IM-2()
Al-though there continue to be anecdotal reports of infectious mononucleosis associated with heavy marijuana use, no conclusive data are available.
Effects of i-9-THC and marijuana on the endo-crine-reproductive system have been reported by many. The clinical significance of the several oh-served effects is not clear. During heavy use of marijuana by the human female and in the monkey, an increase in anovulatory menstrual cycles was noted.2’22 In the human male, serum testosterone concentration was significantly reduced in at least one study but remained within the normal range.2’ Sperm morphology, mobility, and number were af-fected by heavy marijuana use, but three months after a period of repeated exposure, the observed abnormalities of sperm were no longer present.2425
Perinatal effects of marijuana were evaluated in rodents, and there was an increase in fetal resorp-tions but no increase in congenital malformations.2’ A study in primates exposed to daily -9-THC is underway.
Functional, morphologic and biochemical inves-tigations of marijuana and i-9-THC upon brain have been productive. Primates subjected to man-juana smoke or intravenous injections of -9-THC have exhibited acute changes in the electroenceph-alogram recorded from deep electrodes.27 After two months of exposure to the equivalent of about three cigarettes per day, the EEG changes were persist-ent. After six months of exposure, the changes persisted although marijuana administration was stopped.28 Electron microscopy of brain tissue in monkeys exposed in this way showed definite mor-phologic changes which involved the synaptic clefts, the storage vesicles for neurotransmitters, and the cell nucleus.”
Biochemical studies in rats exposed to cannabi-noids revealed inhibition of protein and nucleic acid synthesis in brain cells, which was more marked in immature rats than in the adult animals. Ultra-structure examination showed a reduction in nu-clear membrane-attached ribosomes.
ultrastruc-I I
I
V
.
Fig 3. Both driver and passenger can inhale marijuana smoke, using the device sold in a paraphernalia store.
Fig 4. Plastic discus has a clip, so that thrower and
catcher may share a joint. Christmas stocking contains a ‘how-to’ ‘ package explaining the niceties of rolling
reefers.
ture changes in the brain of these immature animals were similar to those observed in rodents that were administered the compound directly.29
The effect of marijuana in seizure disorders is not consistent. There are anecdotal reports of an in-crease in seizure frequency in patients with epilepsy during periods of heavy marijuana use. In the last century, however, marijuana was used at times as an anticonvulsant. In experimental animals treated with i-9-THC, a spiking pattern was recorded from electrodes implanted deeply in the brain. After -9-THC was administered to a group of epileptic bea-gles, this spiking pattern on electroencephalogram
was associated with myoclonic activity. On the other hand, the analog cannabidiol appeared to have anticonvulsant properties in the same sys-tem.”
The role of marijuana intoxication in fatal auto accidents is well known (Fig 3), and its detrimental effect on driving and flying performance was pointed out in the previous commentary.2 In that statement,2 reference was also made to the adverse effects of marijuana on memory and learning. Since that time additional publications have described the interference with recall that occurs during mar-ijuana intoxication.’2”
In addition to these scientific publications, there are scores of anecdotal reports in the files of many health care professionals that describe the effect of heavy marijuana use by adolescents on motivation, school performance, and family interaction. Al-though scientific evidence for justifiable concern about marijuana effect on youth is now accumulat-ing, there is no evidence that every user of man-juana is affected adversely. In fact, although it appears that the heavy user is at risk, there is little evidence than an individual who only rarely smokes marijuana will be harmed by that exposure. Since,
/
however, school-age children and adolescents ex-perience and respond to overwhelming peer pres-sure, the risk is that occasional users wifi increase their frequency of marijuana use or develop a pat-tern of frequent use of other psychoactive drugs that will accompany them into adulthood.
F
r,.
3:::
Fig 5. Space guns for inhaling pot, intended for the
younger buyer.
materials that are offered for sale in head shops or other businesses (such as record shops and clothing
stores) which appeal especially to the young
cus-tomer. Whereas the drug paraphernalia-publication
industry is entirely devoted to the promotion of drug use, at least a portion of another major indus-try, rock recording-broadcasting, devotes itself to
the same end. The lyrics of popular rock songs and the accompanying comments of many near-vener-ated disc jockeys are an insidious and pervasive influence in the environment of large numbers of children in American society.
Such commercial promotions, coupled with the effect of the drug itself, tend to produce frustration for the pediatrician who attempts to deal with the adolescent who is a heavy user of marijuana. Indeed there is no ready nor single solution to such a user’s problem. The pediatrician’s best recourse, at pres-ent, is to become active in efforts at prevention. Before they reach the age of greatest risk, school-age children should be well informed about physi-ologic and psychologic effects of marijuana, alcohol, and other psychoactive agents. The physician’s role
is to provide such information; his caveats must be
accurate and not over-stated if the child is to
con-tinue to look to the practitioner as a source of
truthful information.
COMMITFEE ON DRUGS
Sydney Segal, MD, Chairman Walter R. Anyan Jr, MD Reba M. Hill, MD Ralph E. Kauffman, MD
Howard Mofenson, MD
Albert W. Pruitt, MD Henry R. Shinefield, MD Harvey S. Singer, MD Miles M. Weinberger, MD
REFERENCES
Liaison Representatives: John C. Balm, PhD Charlotte Catz, MD Louis Farchione, MD Martha M. Freeman, MD
Arthur P. Herrmann, MD, PharmD Sam A. Licata, MD
Godfrey Oakley, MD Steven Sawchuk, MD Jack M. Schneider, MD Lester F. Soyka, MD
I. American Academy of Pediatrics Committee on Drugs: Drug
abuse legislation for the 1970’s. Pediatrics 48:990, 1971 2. American Academy of Pediatrics Committee on Drugs:
Ef-fect.s of marijuana on man. Pediatrics 56: 134, 1975 3. Marijuana and Health, Seventh Annual Report. National
Institute on I)rug Abuse, US Department of Health, Edu-cation and Welfare, 1977
4. Russell GK: Marihuana Today. New York, Myrin Institut,
1978
5. Nahas GG, Paton WDM (eds): Marihuana: Biological Ef. fects. New York, Oxford University Press, 1979
6. Waller CW, Hadiley KW, Turner CE: Detection and identi-fication of compounds in cannabis, in Nahas GG (ed): Mar.
ihuana: Chemistry, Biochemistry, and Cellular Effects.
New York, Springer-Verlag, 1976, p 15
7. Petersen RC: Importance of inhalation patterns in determin-ing effects of marihuana use. Lancet 1:727, 1979
8. Gash A, Karliner, JS, Janowsky D, et al: Effects of smoking marihuana on left ventricular performance and plasma nor-epinephrine. Ann Intern Med 89:448, 1978
9. Beaconsfield P, Ginsburg J, Rainsbury R: Marihuana smok-ing: Cardiovascular effects in man and possible mechanisms. N Engi J Med 287:209, 1972
10. Kanakis C, Jr, Pouget JM, Rosen KM: The effects of delta-9-tetrahydrocannabinol (cannabis) on cardiac performance with and without beta blockage. Circulation 53:703, 1976 1 1. Shapiro BJ: Cardiovascular effects of marijuana, in Tashkin
DP (moderator): Cannabis, 1977. Ann Intern Med 89:539,
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12. Tashkin DP, Shapiro BJ, Frank IM: Acute pulmonary phys-iologic effects of smoked marijuana and oral
-O-tetrahydro-cannabinol in healthy young men. N Engi J Med 289:336,
1973
13. Tashkin DP, Reiss 5, Shapiro BJ, et al: Bronchial effects of aerosolized -9-tetrahydrocannabinol in healthy and asth-matic subjects. Am Ret’ Respir Dis 115:57, 1977
14. Tashkin DP, Shapiro BJ, Lee YE, et al: Subacute effects of heavy marihuana smoking in pulmonary function in healthy men. NEnglJMed294:125, 1976
15. Henderson RL, Tennant FS, Guerry R: Respiratory mani-festations of hashish smoking. Arch Otolarvngol95:248, 1977 16. Rosenkrantz H: Experimental studies of long-term effects of
marijuana smoke on the lung (abstract), in Marijuana:
Biomedical Effects and Social Implications. Sponsored by The American Council on Marijuana, New York, June 28-29, 1979
17. Huber GL, Simmons GA, McCarthy CR, et al: Depressant effect of marihuana smoke on antibactericidal activity of pulmonary alveolar macrophages. Chest 68:769, 1975 18. Nahas GG, Suciu-Foca N, Armand JP, et al: Inhibition of
cellular mediated immunity in marihuana smokers. Science
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19. Cushman P, Khurana R: A controlled cycle of tetrahydro-cannabinol smoking: T and B cell rosette formation. Life Sci
20:971, 1977
-9-tetrahydrocannabinol, cannabidiol, and cannabinol effects
on the immune response of mice. Pharmacology 15:10, 1977 21. Bauman JE, Kolodny RC, Dornbush RL, et al: Effect of
chronic marijuana use on the endocrine function of the
human female (abstract), in Marijuana: Biomedical Effects and Social Implications. Sponsored by the American Coun-cil on Marijuana, New York, June 28-29, 1979
22. Smith CG: Effects of -9-tetrahydrocannabinol on female reproductive function (abstract), in Marijuana: Biomedical Effects and Sociallmplications. Sponsored by the American
Council on Marijuana, New York, June 28-29, 1979
23. Kolodny RC, Masters WH, Lolodner RM, et al: Depression
of plasma testosterone levels after chronic intensive man-huana use. N Engi J Med 290:872, 1974
24. Hembree WC, III, Zeidenberg P, Nahas GC: Marihuana’s effects on human gonadal function, in Nahas GC (ed): Mar-ihuana: Chemistry, Biochemistry, and Cellular Effects.
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25. Hembree WC: Effects of marihuana smoking on male go-nadal function (abstract), in Marijuana: Biomedical Effects and Social Implications. Sponsored by The American Coun-cii on Marijuana, New York, June 28-29, 1979
26. Rosenkrantz H: Embryotoxicity of cannabis (abstract), in
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27. Heath RG: Cannabis sativa derivatives: Effects on brain
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28. Heath RG: Chronic marihuana smoking: Effects on function and structure of primate brain (abstract), in Marijuana: Biomedical Effects and Social Implications. Sponsored by The American Council on Marijuana, New York, June 28-29, 1979
29. McGeer PL, Jakubovic A: Ultrastructural and biochemical changes in CNS induced by marihuana, in Nahas GG, Paton WDM (eds): Marihuana: Biological Effects. New York, Oxford University Press, 1979
30. Jakubovic A, Hattori T, McGeer PL: Radioactivity in suc-kled rats after giving ‘4C-tetrahydrocannabinol to the mother. Eur J Pharmacol 22:221, 1973
31. Feeney DM: Marijuana and epilepsy (abstract), in
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June 28-29, 1979
32. Miller LL, Cornett T, Drew W, et al: Marijuana: Dose-response effects on pulse rate, subjective estimates of po-tency, pleasantness, and recognition memory. Pharmacol-ogy 15:268, 1977
33. Miller L, Cornett T, Nallan G: Marijuana: Effect on nonver-bal free recall as a function of field dependence. Psycho-pharmacologie 58:297, 1978
IS ENGLAND THE RIGHT MODEL?
Whereas in England two-thirds of the physicians are general practitioners, in America today two-thirds are specialists. The difference stems from the Amen-ican pattern of policy accommodation. In England, the government limits the number of training programs in medical specialities in line with the number of specialists the country needs. In America, medical schools and teaching hospitals were allowed to create programs as they saw fit. Since such programs were in their interests (interns and residents represent a cheap source of professional labor), they established more than the society needed. Current manpower policy is trying to correct the imbalance by directing young doctors toward “primary” care. (Some specialists, afraid that their fields may now be getting overcrowded, welcome the shift; from the point of view of “need,” there have long been too many surgeons, but thus far the surgeons have kept up their incomes by working less and charging more.) The overspecialization of American medicine is a source of higher costs, since training programs are expensive and the trained specialists are able to charge more than general practitioners (partly because they control Blue Shield, but primarily because price competition is absent and consumers are unable to judge quality).
Submitted by Student
