Transcript General-Session-2

Medical Marijuana: Pros
and Cons
A “Prescription” for Trouble?
Elizabeth ‘Libby’ Stuyt, MD
University of Colorado, Department of Psychiatry
Medical Director, Circle Program
Colorado Mental Health Institute at Pueblo
2012 Colorado Behavioral Healthcare Council
Annual Training Conference, Sept 28, 2012
Conflicts
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The Circle Program is now funded in part
by Medical Marijuana Tax proceeds
Cannabis
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Complex alkaloid mixture of more than
400 compounds derived from the
Cannabis sativa plant
60 different compounds described with
activity on the cannabinergic system
Most abundant cannabinoids are
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Delta-9 tetrahydrocannabinol (most psychoactive)
Cannabidiol
Cannabinol
Cannabinergic system
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Two main cannabis receptors
CB1–present throughout CNS
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Hippocampus
Cortex
Olfactory areas
Basal ganglia
Cerebellum
Spinal cord
CB2 – located peripherally,
linked with immune system
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Spleen
macrophages
History of Marijuana
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6000 BC – Cannabis seeds used as food in
China
4000 BC – Textiles made of hemp in China
2727 BC – first recorded medicinal use in
Chinese Pharmacopoeia
1400 BC to AD – trade moves product
through India, Mediterranean countries,
Europe – numerous medicinal uses
reported
History of Marijuana
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1378 – Emir of the Ottoman Empire makes
the first edict against eating hashish or
smoking cannabis – 1st “War on Drugs”
1798 – Napoleon declared total prohibition
on marijuana after realizing much of the
Egyptian lower class were habitual
smokers
1868 – Egypt – 1st modern country to
outlaw cannabis ingestion
1890 – Hashish made illegal in Turkey
History of Marijuana
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Introduced to North America in 1600s by
Puritans – Hemp for ropes, sails, clothing;
cannabis a common ingredient in medicines,
sold openly in pharmacies
1937 – Marijuana Tax Act – transfer of cannabis
illegal throughout US except for medicinal and
industrial use, expensive excise tax and detailed
logs required
1969 – found to be unconstitutional since it
violated 5th Amendment privilege against selfrecrimination
History continued
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1970 – Controlled Substance Act – classified
cannabis as having:
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High abuse potential
No medical use
Not safe to use under medical supervision
1975 – FDA establishes Compassionate Use
Program for Medical Marijuana – Glaucoma,
Multiple Sclerosis, Cancer
1986 – Dronabinol placed into Schedule II by
DEA
2003 – Canada – 1st country in world to offer
medical marijuana to patients
Compassionate Use – not based
on any research
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Glaucoma - #1 cause of blindness
1992 – American Academy of
Ophthalmology’s Committee on Drugs –
no scientific verifiable evidence that the
use of marijuana is safe and effective in
the treatment of glaucoma
1997 – NEI – no studies have
demonstrated that marijuana can safely
and effectively lower IOP any more than a
variety of drugs on the market
Glaucoma
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1999 – Institute of Medicine – although
IOP can be reduced by using cannabinoids
and marijuana, the effect is too short lived
and requires too high doses.
There are too many side effects to
recommend lifelong use in the treatment
of glaucoma
Would have to smoke 10-12 joints per 24
hours to maintain low IOP through out the
day
Indications
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Dronabinol (Marinol) and nabilone (Cesamet)
indicated for chemotherapy-induced nausea and
vomiting
Dronabinol (Marinol) approved for HIVassociated anorexia
Sativex (oromucosal spray) conditionally
approved for neuropathic pain in multiple
sclerosis and cancer pain
Herbal smoked marijuana – found to be safe
and effective for HIV-associated disorders
Canada
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Four cannabinoid products available
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Herbal cannabis extract, “Sativex”, delta-9THC and cannabidiol in oromucosal spray
Dronabinol synthetic delta-9-THC, “Marinol”
Nabilone synthetic derivative of delta-9-THC,
“Cesamet”
Herbal form of cannabis – “medical
marijuana”
Research Issues
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MJ is a Schedule I drug – a barrier to conducting prospective RCTs,
DB w/ placebo
Studies are short - two weeks average, ranging from a few hours to
one year
Most studies conducted with oral TCH preps rather than smoked
cannabis
Most studies exclude anyone with a history of major psychiatric
disorder other than depression and/or history of substance abuse
Most studies done to date:
 Short in length (average two weeks)
 Small N (lacking power)
 Retrospective in nature
 Confounded by uncontrolled variables
 Concomitant tobacco use
 Comorbid illnesses
Studies of Effects on Pain
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Lit review of cannabinoids given by any route for
treatment of pain Campbell et al. BMJ 2001;323:1-6
9 RCTs, 222 patients, 5 trials cancer pain; 2
chronic non-malignant pain; 2 post-operative
pain; none evaluated cannabis
“Cannabinoids are no more effective than
codeine in controlling pain and have depressant
effects on the CNS that limit their use. In acute
postoperative pain they should not be used.
Before cannabinoids can be considered for
treating spasticity and neuropathic pain, further
valid randomized controlled studies are needed.”
Side Effects of Cannabis
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Most of our knowledge about the negative
effects of marijuana come from
recreational use
Literature review of safety studies of
medical cannabinoids over past 40 years –
23 RCTs (median exposure to
cannabinoids 2 weeks, range 8 hrs to 12
months) Wang et al. CMAJ 2008;17:16691678
Side Effects
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4779 adverse events reported in those
assigned to the intervention
96.6% were not serious
164 serious events – no different from
controls (RR) 1.04
Rate of nonserious events higher among
those assigned medical cannabinoids than
controls (RR)1.86 – dizziness most
common event
Studies with Smoked Cannabis
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Double-blind, placebo controlled,
crossover trial of smoked cannabis for the
short term treatment of neuropathic pain
associated with HIV – five study phases
over 7 weeks – five days of active or
placebo smoking with washout periods
Participants had documented HIV,
neuropathic pain refractory to a least two
previous analgesics, 5 or higher on pain
scale (Ellis et al. Neuropyschopharmacology
2009;34:672-680)
Studies of Smoked Cannabis
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Four smoking sessions per day, titrating dose (18% THC) to achieve maximum tolerable dose
Exclusion criteria
 Current substance use disorder
 Lifetime history of dependence on cannabis
 Concurrent use of medication with
cannabinoids
 Previous psychosis with or intolerance to
cannabinoids
Results
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“significantly reduced neuropathic pain intensity
compared to placebo”
46% with cannabis reported a ≥ 30% reduction
in pain versus 18% with placebo
Another study with almost identical outcomes –
52% vs 24%, >30% reduction in pain with 3
smoking sessions/day (Abrams et al. Neurology
2007:68:515-521)
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“All patients were required to have prior
experience smoking marijuana so they would
know how to inhale and what
neuropsychological effects to expect”
More Studies of Smoked Cannabis
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Ware et al. CMAJ. 2010;E694-E701.
 N=21
 Inclusion Criteria
 Outpatients with > 3 month hx neuropathic pain
 Pain caused by physical trauma or surgery
 Pain intensity > 4 (0 to 10 scale)
 Randomized, double-blind, placebo-controlled, fourperiod crossover design
 THC concentration = 0, 2.5%, 6% or 9.4%
 Three daily dosages x 5 days
 9 day washout period.
Participants advised not to drive a vehicle or operate
heavy machinery while on study drug
Ware et al. CMAJ. 2010;E694-E701(cont)
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Average daily pain intensity:
 5.4 on 9.4% THC cannabis
 6.1 on Placebo(0% THC)
 (p=0.023;difference = 0.7, 95% CI 0.02-1.4)
No difference observed between 2.5%, 6%, 0%
The reduction is modest when compared with
that from other drugs for neuropathic pain such
as gabapentin or pregabalin
A “joint” with a 9.4% THC content would impair
the majority of us
Dose-dependent effects of smoked cannabis on Capsaicininduced pain and hyperalgesia in healthy volunteers
(Wallace et al. Anesthesiology. 2007;107:785-796)
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Randomized, double-blinded, placebocontrolled, crossover design
High dose training session, 15 subjects
100 mg capsaicin injected intradermally
ventral forearm – spontaneous pain
Stroking and von Frey hair stimulation –
elicited pain
Low dose 2% THC, medium dose 4%THC,
high dose 8% THC
Results
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Capsaicin injections induced spontaneous and
elicited pain in all subjects
No difference in pain perception between any of
the cannabis doses and placebo during early
(right arm) course
Low dose did not differ from placebo at any time
point
During late course (left arm) medium dose
subjects reported decreased pain sensation, high
dose subjects reported increased perception of
pain – consistent with other reports that chronic
delivery of cannabinoids can cause thermal
hyperalgesia
So To Review
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Marijuana (smoked/oral) used as a therapeutic,
not recreational agent, is a drug as defined by
the FDA
All new drugs must be scientifically evaluated
before they may be allowed to enter the stream
of interstate commerce
The drug does not have to be proven superior to
already approved drugs, its benefits must
outweigh the risks when used for the purpose
for which it has been approved
The fact that it is a botanical does
not preclude scientific investigation
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Digitalis purpurea – fox glove - CHF
Papaver somniferum – opium poppy
Atropa belladonna – nightshade -IBS
Ephedra sinica – ephedrine - hypotension
Salix alba – willow tree - ASA
Taxis brevifolia – Pacific Yew tree – breast
cancer
DEA – Scheduling Drugs depends on:
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Does the drug have a currently accepted medical
use in the United States?
What is the drug’s safety under medical
supervision?
What is its addiction liability?
Is there a potential for significant diversion for
illegal use?
Are individuals using it on their own initiative or
only on physician’s prescription?
Is the drug similar in its pharmacology to other
controlled drugs?
“Rocky Mountain High”
Colorado
November 2000
Coloradoans passed Amendment 20
Colorado Department of Public Health and
Environment was tasked with implementing and
administrating the Medical Marijuana Registry
program
March 2001
Colorado Board of Health approved rules and
regulations
June 2001
MMJ Registry began accepting applications for
Registry Identification Cards.
The Flood Gates Opened
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February 2009
 Obama administration indicated that Medical Marijuana
prosecution would have low priority
October 2009
 Obama administration will not seek to arrest medical
marijuana users and suppliers as long as they conform
to state laws
Applications increased dramatically
 September 2009 – 3,523 applications received/month
 December 2009 – 10,585 applications received/month
Storefront “Medical” Marijuana dispensaries
sprouted like weeds!
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Marijuana Growers
Caregivers
Legal
Doctors making recommendations ($$$$)
Grow Lights
Vaporizers
Pipes
Edibles
Advertising (Westword has gone “green”)
Festivals
Delivery Services
September 30, 2009
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19,691 new patient
applications received
17,356 patients with valid ID
cards
73% male, average age 40, 8
minors <18
57% in the Denver/metro area
67% have designated primary
care-giver
Over 800 different physicians
have signed for patients in
Colorado
June 30, 2012
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184,002 new patient
applications received
99,960 patients with Valid ID
cards
68% male, average age 42, 47
minors <18
56% in the Denver/metro area
54% have designated primary
care-giver
Over 900 different physicians
have signed for patients in
Colorado
Conditions (as of June 2012)
Condition
# of Patients
Percentage
Cachexia
1,215
1%
Cancer
2,583
3%
Glaucoma
1,021
1%
632
1%
17,286
17%
1,708
2%
Severe Pain
93,679
94%
Severe Nausea
11,567
12%
HIV/AIDS
Muscle Spasms
Seizures
Rules and Regulations
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“Patient will be deemed to have established an
affirmative defense to such allegation”
(possession of marijuana) where:
Patient was previously diagnosed by a physician
as having a debilitating medical condition
Patient was advised by his or her physician, in
the context of a bona fide physician-patient
relationship, that the patient might benefit from
the medical use of marijuana in connection with
a debilitating medical condition
Conditions considered debilitating
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Cachexia
Severe Pain
Severe Nausea
Seizures
Persistent Muscle Spasms
Any other medical condition approved by
the state health agency
Lobbying for New Conditions
unsuccessful so far:
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Asthma
Atherosclerosis
Crohn’s Disease
Diabetes Mellitus
Hepatitis C
Hypertension
MRSA
Rheumatoid Arthritis
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Opioid Dependence
PTSD
Bipolar Disorder
Anxiety Disorders
Depression
Tourette’s Disorder
Rules and Regulations
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Patient may engage in the medical use of
marijuana with no more marijuana than is
medically necessary to address a
debilitating medical condition
No more than 2 ounces and no more than
six plants, 3 or fewer being mature
No patient shall engage in medical use of
marijuana in plain view of, or in a place
open to, the general public
Problems with the physicians
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In the fall of 2009 @ 900 doctors had
written approval letters (7% of licensed
MDs)
15 doctors – 72% of forms
5 doctors – 50 % of forms
One doctor signed 3,500 in a two day
period
SB 109 - 2010
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Defines a bona fide relationship
Physician must have an unrestricted
medical and DEA license
Addresses physician conflict of interest –
physician can not be employed by the
dispensary
Allows CMB to examine care of providers
Two physicians need to independently
examine those < 21.
Implications
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The vast majority of these patients don’t
have debilitating illnesses
The majority of the patients are young
males who will be exposed to the long
term effects of cannabis exposure
Studies conducted are all short term
Therefore their risks may be the same as
for recreational users and/or addicts
Therefore Physicians
Recommending Medical Marijuana
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Will need to get a thorough history - medically,
psychiatrically and substance abuse – keep a
chart and have a patient/physician relationship
Will need to attempt to decide what level of
marijuana use is most appropriate
Will need to recommend patients not drive etc.
when under the influence
Will need to follow patients closely for side
effects and unintended consequences
Marijuana use and Cancer risk
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Marijuana smoke contains several of the
same carcinogens and co-carcinogens as
tobacco smoke
Benzo[α]pyrene, a procarcinogenic
polycyclic aromatic hydrocarbon, is
present in marijuana tar at higher
concentrations than in tobacco tar
Marijuana smoking involves inhalation of 3
times the amount of tar as tobacco smoke
Cancer Studies involving Marijuana
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Studies are small in number and are
retrospective in nature
Confounded by concomitant use of
tobacco
Confounded by underreporting of
marijuana use because such use is often
illegal
Cannabis use and risk of Lung
Cancer Aldington et al. Eur Respir J. 2008;31:280-286
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Case-controlled study of lung cancer in adults <
55yrs of age in New Zealand
79 cases of lung cancer and 324 controls
Risk of lung cancer increased 8% for each jointyr (1 joint/day for one year) of cannabis
smoking after adjustment for confounding
variables including tobacco
Risk increased 7% for each pack-yr tobacco
“Long-term cannabis use increases risk of lung
cancer in young adults”
Head and Neck Cancers
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Retrospective, case-controlled study, 173
proven cases of head and neck cancer and
176 controls matched with respect to age,
sex, race, education, tobacco, alcohol use
Risk of cancer 2.6 fold greater in cannabis
users than non-users
3-fold greater increase in those < 55 yrs
Zhang et al. Cancer Epidemiol Biomark
Prev 1999;8:1071-1078.
Other Cancers
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In a cohort study – among non-tobacco
smokers, ever-marijuana smokers had
increased risk for prostate cancer RR=3.1, and cervical cancer - RR=1.4
Sidney et al. Cancer Causes Control 1997;8:722-728.
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Another cohort study found an increased
risk of malignant primary adult-onset
glioma for ever-marijuana smokers –
RR=1.9 Efird et al. J Neurooncol 2004;68:57-69
Metabolism of Marijuana
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Massive first pass metabolism via the oral route
– only 10-20% reaches systemic circulation
unchanged – takes 30 – 60 minutes to achieve
an effect – key side effect on CNS can be
dysphoria rather than euphoria
Via the lungs – onset of action within seconds –
“high” experienced with serum concentration of
3 ng/ml, produced by as little as 2-3 mg D9THC,
average “joint” contains 0.5 – 1.0 g of cannabis
Routes of Administration
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“Where there’s smoke, there’s harm”, “There is
no future in smoking marijuana as a
conventional medicine” Janet Joy PhD
Until there is an alternative, for a small segment
of the population – there is a modest clinical
benefit of smoked marijuana
Sound theoretical reasons for intrathecal or
epidural cannabinoids – may produce spinal cord
analgesia without effects on cerebral receptors
that are associated with psychotropic effects
Marijuana and Cognitive Impairment
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Use of 4 joints or more per week resulted
in a decrement in mental test
performance, subjects who smoked
regularly for a decade or more did the
worst Messinis et al. Neurology 2006;66:737
Long-term marijuana users were impaired
70% of the time on a decision making
test, compared to 55% for short-term
users and 8% for non-users
Marijuana and Cognitive Impairment
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Heavy marijuana use (daily for at least
one month) is associated with residual
neuropsychological effects even after a
day of supervised abstinence from the
drug Harrison et al. JAMA 1996;275:521
Unknown whether this is due to residue of
drug in the brain, withdrawal effects or
frank neurotoxic effect of the drug
How Drugs of Abuse affect the Learning
and Memory part of the Brain
Natural Rewards Elevate Dopamine Levels
200
% of Basal DA Output
NAc shell
150
100
Empty
50
Box Feeding
SEX
200
150
100
15
10
5
0
0
0
60
120
Time (min)
180
ScrScr
BasFemale 1 Present
Sample 1 2 3 4 5 6 7 8
Number
Scr
Scr
Female 2 Present
9 10 11 12 13 14 15 16 17
Mounts
Intromissions
Ejaculations
Source: Di Chiara et al.
Source: Fiorino and Phillips
Copulation Frequency
DA Concentration (% Baseline)
FOOD
Accumbens
1100
1000
900
800
700
600
500
400
300
200
100
0
AMPHETAMINE
250
Accumbens
MORPHINE
DA
DOPAC
HVA
1
2
3
4
Time After Amphetamine
5 hr
250
NICOTINE
200
Accumbens
Caudate
150
100
0
0
1
2
3 hr
Time After Nicotine
Source: Di Chiara and Imperato
% of Basal Release
Dose (mg/kg)
0
% of Basal Release
% of Basal Release
Effects of Drugs on Dopamine Levels
0.5
1.0
2.5
10
200
150
100
0
0
1
2
3
4
Time After Morphine
5hr
THC/Marijuana
Effects of Drug Use on the
Hippocampus
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Drugs of abuse are potent negative
regulators of adult neurogenesis in the
hippocampus
Chronic administration of opiates, THC,
ethanol or nicotine decreases hippocampal
function, decreasing ability of adult brain
to adapt to new information
Regional Brain Abnormalities Associated
with Long-term heavy Cannabis Use Arch Gen
Psychiatry 2008;65:694-701
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15 long term (>10 years) and heavy (>5 joints
daily) cannabis using men compared with 16 age
matched non using controls by MRIs of brains
Cannabis users had bilaterally reduced
hippocampal and amygdala volumes p=.001
Increase in positive symptoms (psychotic)
p<.001
Significantly worse performance on measures of
verbal learning p<.001
Multiple Sclerosis and Cannabis: A
cognitive and psychiatric study
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10 subjects with MS and current cannabis
users compared with 40 subjects with MS
who did not use cannabis
psychiatric diagnosis higher in cannabis
users p=0.04
Slower mean performance time on SDMT
(index of information processing speed,
working memory and sustained attention)
in the cannabis users p=0.006
Neurology 2008;71:164-169
Marijuana and Driving
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Laboratory tests and driving studies show that
cannabis may acutely impair several drivingrelated skills in a dose related fashion
Effects between individuals vary more than for
alcohol because of tolerance, differences in
smoking technique, and different absorptions of
THC Sewell et al. Am J Addictions 2009;18:185-193.
More pronounced with highly automatic driving
functions; less with complex tasks that require
conscious control – opposite from that seen with
alcohol
Effects of Marijuana Intoxication and
Pilot Performance Am J Psychiatry 1985;142:1325-1329
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Ten experienced licensed private pilots
trained for 8 hours on a flight stimulator
landing task
Each smoked a THC cigarette (19 mg)
24 hours later their mean performance on
the flight task showed trends toward
impairment in all variables, some tasks
showed significant impairment
Despite the deficits, the pilots reported no
awareness of impaired performance
Marijuana and Mental Illness
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Study in Australia tracked 1600 girls for 7 years
Arseneault et al. BMJ 2002;325:1212
Those who used marijuana every day were 5
times more likely to suffer from depression and
anxiety than non-users
Teenage girls who used the drug a least once a
week were twice as likely to develop depression
than those who did not use
Cannabis use increased the risk of developing
schizophrenia symptoms – specific to cannabis
and early onset – prior to age 15
Risk of Psychosis
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Increased by 40% in people who have
used cannabis Cohen et al. Australian New Zealand
J Psychiatry 2008;42:357-368.
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Dose-response effect leading to an
increased risk of 50-200% in the most
frequent users
Approximately 14% of psychotic outcomes
in young people would not have occurred
if cannabis had not been consumed
Early Cannabis use associated with
psychosis related outcomes in young
adults Arch Gen Psych 2010;67
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Sibling pair analysis within a prospective
birth cohort in Australia
3801 young adults – cannabis use and 3
psychosis-related outcomes (nonaffective
psychosis, hallucinations, and Delusional
Inventory score)
Early cannabis use is associated with
psychosis-related outcomes in young
adults
Marijuana and Schizophrenia
double-edged sword
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Low doses may improve frontal lobe functioning
by acutely increasing blood flow to cortices
concerned with cognition, mood and perception
– increasing availability and utilization of
dopamine
Continued use depresses cerebral flow and high
doses augment mesolimbic dopamine release,
opposing therapeutic effects of antipsychotic
drugs and exacerbating psychosis
It also suppresses PFC dopamine utilization
resulting in cognitive dysfunction
Spice
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Synthetic cannabinoids AM694 and HU210 found
in Spice products are 500 to 600 times more
potent than the THC found in traditional
marijuana
The THC in high potency marijuana and Spice
products are potentially harmful to embryonic
development as early as 2 weeks after
conception
Utero exposure to THC linked to anencephaly,
ADHD, Depression, Aggression
Rats exposed to nicotine as adolescents selfadminister more nicotine than rats exposed as
adults Levin ED et al. Psychopharm 2000;169:141-149
Rats First Exposed to Nicotine in Adolescence
Show Greater Sensitization to Cocaine Than
Rats First Exposed as Adults
*Activity level after cocaine administration was measured by counting the number of times in 10
minutes each rat crossed light beams projected in a grid across its cage.
Sources: Collins et al, 2004, Levin et al, 2003, NIDA Notes
v19.2
Marijuana and Addiction
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Approximately 10% of regular marijuana
users become addicted to it
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But this is old data, based on marijuana with
less THC concentrations
Some medicinal marijuana blends, ie “Connie
Chung” strain contain 20 times more THC
than marijuana found 40 years ago
Compared with 15% for alcohol, 32% for
nicotine and 26% for opiates
The number of adults with
substance use disorders is
trending upward and expected
to double by the year 2020
Colorado ranks 5th in the nation
for adolescent marijuana use.
Pros and Cons of Marijuana
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Not associated with
death
Not as addicting as
other drugs
Modest benefit
demonstrated for
small segment of the
population in short
term use
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Marked negative
cognitive effects
Very dangerous to
adolescent brain
development and
occurrence of mental
illness
Cancer risk
Driving impairment
What’s the going rate?
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One joint weighs @
0.9 grams with 3.56%
THC (Abrams study)
0.9 g = 0.03 oz
¼ oz = 7.1 g
1 oz = 28 g
1 oz = 31 joints; at 3
joints per day – need
3 oz per month
$900/month
The Hippocratic Oath


First……….do no harm
The practice of medicine is a
privilege……. not a right!
Malignant versus Non-malignant

There is definitely a place for Medical
Marijuana when people are suffering with
terminal conditions




Cachexia – appetite stimulant
Nausea – secondary to chemotherapy
Pain – mild improvement
Neither opioid medications nor medical
marijuana is the answer for chronic, nonmalignant pain
Physician Motives


Financial incentives and/or personal
political views should not influence
treatment recommendations
Conflicts of interest – ethically/legally
proscribed


Investment in dispensaries
“kickbacks for referrals”
Societal Costs

Public Safety
 Cognitive impairment in safety sensitive positions
 Workplace accidents
 Driving and Accidents
 National Transportation Safety Board
 Studied 182 fatal truck accidents in 1999
 Just as many accidents were caused by drivers
impaired by MJ as by drivers impaired by Etoh
 Increased criminal activity?
 A large percentage of those arrested for crimes
test positive for MJ
 Nationwide 40% of adult males tested positive for
MJ at the time of their arrest
Societal Costs

Sending the wrong message to children?
 Soda “pot”
 Edibles (colorful cookies, cupcakes,
candy)
 “It’s organic, green, natural”
 Wellness ads (promoting MJ)
 Case Example: Peanut Butter “spiced”
with MJ
Case Vignette
Denver Post – December 2009





44-year-old female, grandmother and advocate
for medical marijuana – used the drug for
chronic back pain most of her life
Gave her 3-year-old grandson a peanut butter
cookie made with cannabis butter
The next day she had trouble rousing the boy
and called an ambulance
Police seized the jar of cannabis butter and the
boy had the drug in his system
A week later the grandmother took her own life
In the End – Prevention is Key