Recreational Marijuana & Cannabis-Induced Psychosis in Arizona

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On November 30, 2020, the possession and cultivation of recreational marijuana, also known by a host of other names, including cannabis, grass, and weed, became legal in the state of Arizona after Proposition 207, known as the “Smart & Safe Act,” was passed with 60% majority vote.

Additionally, the Act approved state-licensed sales of recreational marijuana in Arizona, which only began last month (January 22, 2021), with the state’s medical marijuana dispensaries being granted permission to open sales of the now-legal drug, as well as vape pens and edible products, such as “gummies” and candies, to anyone aged 21 or older.

In fact, the state of Arizona was able to break a national record in the legalization process, too – it is the fastest that any of the 15 states with recreational marijuana has gone from voter approval to actual sales of the drug.

Legal Merijuana Arizona

The Brief & Confusing History of Marijuana Legality in the U.S.

In recent decades, after a long history of whether it should be seen as a legal or an illegal drug in the U.S., the last few decades have seen cannabis reinvent itself on the American stage, with many states opting to pursue the legislation needed to legalize the drug. 

However, it’s worth remembering at this point that not every U.S. state has given the green light to even the medicinal use of cannabis.

Much of that hesitancy is borne from the negative effects of cannabis use, both short-term and long-term. There are many existing, scientifically documented cases in recent years where marijuana users have had a severely negative reaction to using the psychotropic drug, which has led to ER visits caused by hallucinations, delusions, psychosis, the later development of schizophrenia, and actual brain damage, among others.

This ain’t your mother’s marijuana.” – Surgeon General Jerome Adams, August 20, 2019

Just like alcohol, another perfectly legal, tax revenue-generating substance, marijuana and cannabis use can be highly addictive, and, just like the addiction of alcoholism, known medically as alcohol use disorder (AUD), the use of cannabis can result in cannabis use disorder (CUD) – the addiction to cannabis.

However, this reinvention of marijuana and cannabis in the U.S. as “healthy,” “medicinal” and “natural” products has resulted in a general consensus that if the drug is legal, it’s not harmful, and, again just like alcohol, perhaps you just have to be careful. As we know, the disease of substance addiction doesn’t quite work in such a simple and straightforward way.

It’s an argument that has little effect on the “pro-marijuana” demographic.

For example, on Friday, January 22, 2021 – the day that actual sales began in Arizona – one Scottsdale resident, Sara Schuck, 29, excitedly waited in line to buy her first legal marijuana. She stated, “We all grew up being told it was a bad thing, and it’s not such a bad thing, so now we all get to experience that. It’s a plant at the end of the day, and it’s got a lot of medicinal properties, and a lot of good positive things it can do for everyone, and I think it’s a good thing the world is accepting that.”

Note: The local reporter who interviewed Sara failed to point out to her that the opium poppy is also “a plant at the end of the day.”

Furthermore, and to add even more confusion into the mix, if that were possible, the U.S. federal government (obviously, distinct from state-level government) still considers marijuana to be 100% illegal, and regularly cites the risk of cannabis-induced psychosis.

In fact, on August 20, 2019, Surgeon General Jerome Adams included the established link between cannabis and psychosis in his advisory marijuana’s effect on the developing brain – in both teenagers and the unborn human fetus. He reported that this has been worsened by the huge increase in the potency of THC in today’s cultivated plants, adding, “This ain’t your mother’s marijuana.”

Unsurprisingly, the Surgeon General was subsequently trashed and threatened on Twitter.

Marijuana in Arizona

Cannabis: The Beginner’s Guide

The term “cannabis” refers to the flowering cannabis plant and primarily means any products that use the plant in any way, shape or form, either for medicinal or recreational purposes. Cannabis plants contain many active chemical compounds (around 113, in total), called “cannabinoids,” and it is these that are responsible for the effects that are produced when consuming the plant. 

The most common cannabinoids are:

  • THC (short for “tetrahydrocannabinol”) is a psychoactive drug* that produces the “high” that recreational users experience, with a wide-ranging level of potency, and
  • CBD (short for “cannabidiol”), which has no intoxicating effects, and is used for medicinal and therapeutic purposes. Additionally, CBD may block or reduce some of the effects that THC has when they are co-present in a product (with at least a 1:1 ratio of THC to CBD)

*A psychoactive drug is “a chemical substance that directly changes brain function, and may alter a person’s perception, mood, consciousness, cognition, or behavior.”

Cannabinoids are known to affect the cell receptors that exist in the brain, central nervous system (CNS), and other areas of the body including the immune system, and how they interact with each other. It is this interaction that produces a variety of mental and physical effects on an individual.

Cannabis plants, like many plants and herbs, also contain “terpenes” – a compound that gives the plant its distinctive, aromatic smell.

If you’ve ever wondered if there is an actual difference between marijuana and cannabis, in general terms, there is none as they are both commonly used to describe the same thing. However, although cannabis is used to describe all cannabis products, marijuana specifically refers to those cannabis products that are made from the dried flowers, leaves, stems, and seeds of the cannabis plant (see below).

recriational marijuana use

How is Cannabis Used Recreationally?

The most popular forms of cannabis that are used for recreational purposes are marijuana, hashish, and hash oil:

  1. Marijuana refers to the dried flowers, leaves, stems, and seeds of the cannabis plant, and it’s most commonly smoked or vaped. As the least potent of all the cannabis products, however, the inhalation of the product usually results in its effects being felt quicker.
  1. Hashish is made from the resin of the cannabis plant, dried, and then pressed into small blocks. It can be smoked or ingested by being added to food, called “edibles”.
  1. Hash Oil is considered the most potent form of cannabis – a thick oil obtained from hashish. It can be smoked, added to edibles or used in liquid cannabis products, such as tea.

medical marijuana

What is Medical Marijuana?

Medical marijuana uses the marijuana plant or its chemical compounds to treat medical diseases or conditions. However, although it is used for a wide range of these, it has actually only been officially approved by the U.S. Food & Drug Administration (FDA) for the following:

  • Lennox-Gastaut syndrome and Dravet syndrome are two rare and severe forms of epilepsy, and the cannabidiol Epidiolex was approved in 2018 for treating their associated seizures, and 
  • Chemotherapy-related nausea and vomiting, treated with the man-made cannabinoid medicines dronabinol (sold as Marinol and Syndros) and nabilone (sold as Cesamet)

Medical research has shown there to be clear benefits in using medical marijuana in the following medical diseases or conditions, although these have yet to be officially approved by the FDA:

  • Chronic pain, and
  • Spasticity (muscular stiffness and/or tightness) in multiple sclerosis (MS) sufferers

Furthermore, research continues into whether medical marijuana can be used to treat a number of other conditions, which include, among others, Alzheimer’s disease, cancer, Crohn’s disease, eating disorders, glaucoma and cachexia (a “wasting” disorder). Side effects that have been identified in the use of medical marijuana include depression, dizziness, high heart rate, low blood pressure, and hallucinations.

marijuana induced psychosis

The “Settled Science” of Cannabis-Induced Psychosis

Many medical experts believe that the excessive use of high-level THC cannabis products, like hash oil, can be linked to severe psychotic episodes, and, in some cases, these episodes can later develop into full-blown schizophrenia. 

It is time for Americans to understand there are substantial risks with marijuana. This is not the government making up data. This has been settled science. This is something that has been known for many years, yet there has been virtually no attention paid to it.”  – Elinore McCance-Katz, Assistant Secretary, Department of Health and Human Services (2017-2021)

However, the various advocates on either side of the ongoing debate continue to refuse to agree on the main research studies, and their stated conclusions, of recent years that have investigated cannabis use; primarily, these research studies include:

These studies, among others, have created the arguments used by the different sides revolve; these arguments involve the following points:

  • How much of the psychosis is preceded or worsened by cannabis use,
  • How often marijuana is used in response to it, and
  • Whether the psychosis would have occurred anyway

The Lancet study actually states: “Our results show that in areas where daily use and use of high-potency cannabis are more prevalent in the general population, there is an excess of cases of psychotic disorder. Our findings need to be appraised in the context of limitations.”

McCance-Katz believes that the data provided on cannabis-induced psychosis demands that the government both discuss and manage fears around cannabis use. For example, it must be made clear that between 10 – 20% of marijuana users will develop a cannabis use disorder, and “be at risk for these other kinds of mental and physical adverse events.”

Previously, McCance-Katz has cited data that shows hospitalizations more than doubled for serious mental health disorders among 18-25-year-olds (2012 to 2018), and there has been a 77% increase in suicide deaths among Colorado 10-19-year-olds (2010-2015) with their autopsy toxicology reports stating marijuana was present

Cannabis-Induced Psychosis Case Study: Andrew Zorn, Phoenix, AZ.

Andrew, from the city of Phoenix in Arizona, was only 14 when he started smoking marijuana daily in high school. Later, at the age of 25, he confided to his mother that “something” was going on in his brain; “When he tried to read and study, his mind seemed to disappear on him.”

At that point, Andrew was diagnosed with the following disorders and conditions:

  • Severe cannabis use disorder
  • Bipolar disorder, and
  • Borderline personality disorder – all with auditory hallucinations, paranoia, and anxiety

His mother stated, “In a roomful of people, in the midst of conversation, his eyes would just go somewhere else. He later realized it was marijuana use causing that, but from that time on, it just grew and grew to where he was more and more disabled.”

In 2014, at the age of 31, after another 5 years of the downward spiral of his marijuana addiction, Andrew committed suicide. In his suicide note, he wrote, “I want to die. My soul is already dead. Marijuana killed my soul + ruined my brain.”

What is Cannabis-Induced Psychosis?

Cannabis-induced psychosis (abbreviated to CIP) is just one of a number of psychiatric conditions that have been proven, through evidence, to occur from the consumption of cannabis.

During the last decade, research studies have proved the potential of “psychotomimetic” effects of tetrahydrocannabinol (THC) in healthy subjects. The term “psychotomimetic” refers to drugs that are capable of producing a psychotic state in the user’s mind, eg. LSD.

As more and more U.S. states push for the legalization of marijuana, it is imperative that potential cases of CIP are not only identified quickly but that the necessary treatment is provided in a timely manner, too. Furthermore, research has shown a direct relationship between cannabis use and its increased risk for children, teenagers, and young adults, as the brain does not fully develop until around the age of 25.

Although it can be difficult to distinguish the condition from other psychoses, CIP causes distinctive symptoms which aid its diagnosis. The “Diagnostic & Statistical Manual for Mental Disorders,” 5th Edition, known as DSM-5,  categorizes CIP as a substance-induced psychotic disorder, and describes the distinguishing characteristics of CIP (differentiating it from other psychotic disorders, such as schizophrenia) as follows:

  • Sudden onset of mood lability and paranoid symptoms, within 1 week of use (but as early as 24 hours after use)
  • CIP is normally precipitated by a sudden increase in potency (eg, the percentage of THC content, or quantity of cannabis consumption)
  • Symptoms should be in excess of expected intoxication and the effects of withdrawal

The incidence of cannabis-induced psychotic disorder is believed to be 2.7 per 100,000 people, of which between one-third and one-half will go on to suffer from a schizophrenia-spectrum disorder. However, it is difficult to distinguish whether CIP is an early manifestation of schizophrenia, or simply a catalyst. Nonetheless, there is a clear and direct association between both disorders.

Your brain

Cannabis & The Developing Adolescent Brain

Medical researchers have also found that when cannabis is used by adolescents, either recreationally or medicinally, during the critical period when their brain is still developing and maturing, the actual structure and function of their brain can be severely affected.

Adolescence and young adulthood are critical periods in which the use of a high-THC product can have a big effect on the structure and function of the developing brain. Blood flow and glucose metabolism may be impaired in regions associated with maturation, especially when cannabis is being used together with alcohol.” – Thorsten Rudroff, Ph.D., Assistant Professor, Department of Health and Human Physiology & Department of Neurology, University of Iowa

According to professor Rudroff, cannabis has often been found to be involved in cases of psychosis, schizophrenia, and schizophreniform episodes. Although the exact neurobiological processes still need to be fully clarified, Rudroff believes that it is the combination of cannabis’s effects that damage the brain, and makes it more susceptible to future psychosis. These effects are:

  • Impacting the neuroplasticity of the developing brain (“neuroplasticity” is defined as “the ability of the brain to form and reorganize synaptic connections”)
  • The disruptions in brain development caused by the neurotoxic effects of regular cannabis use may significantly change neurochemical communication, and the genetic expression of neural development, and, furthermore, it may have a toxic effect on the brain tissue itself
  • Individuals at familial risk for psychosis have an increased sensitivity to the effects of cannabis, suggesting a biological interaction between cannabis use and an underlying genetic vulnerability

treating addiction and depression

Higher Self-Harm & Suicide Risk in Young People with Mood Disorders

However, CIP and other cannabis-related disorders are expected to increase across the U.S. as more and more states legalize marijuana, making it even more widely available – particularly to the younger members of society, for which it also poses an increased risk of self-harm and suicide.

A recent study, funded by the National Institute of Mental health, published in JAMA Pediatrics only last month (January 2021), and available online from the Wexner Medical Center, part of Ohio State University, investigated possible associations of cannabis use disorder (CUD) with self-harm, suicide, and overall mortality risk in young people suffering from mood disorders, eg. bipolar disorder.

Their analysis was based on the data derived from Ohio Medicaid claims data of 204,780 young people (aged between 10 to 24 years) with a clinical diagnosis of mood disorders, and linked to death certificates.

In addition to finding that that CUD was recorded in 10.3% of those with mood disorders, the researchers established that young people with mood disorders, and who actively use cannabis (marijuana), have a higher risk for self-harm, death by all causes, and death by unintentional overdose and homicide.

Arizona countryside

The “Cannabis-Induced” Outlook for Arizona & Beyond

The CDC defines an epidemic as “an increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area.”

For example, substance addiction and overdose in the U.S., with the continuing year-on-year rise in fentanyl use and associated deaths, is surely now at epidemic levels.

According to many addiction experts, the opioid epidemic, which covers prescription opioid medications and illicit opioids, like heroin and fentanyl, occurred primarily because of two clear and distinct factors – perceived safety and wide availability.

Therefore, the opioid epidemic can be considered as a prime example of what the future may hold for legalized cannabis, as when a substance is legalized, eg. alcohol, the public assumes it is safe and it is subsequently made widely available.

Lastly, it is important to remember that marijuana is considered a “gateway” drug, making legalized marijuana an accident just waiting to happen for those in recovery from other forms of substance addiction.

Sources:

  1. National Institute on Drug Abuse: https://www.drugabuse.gov/publications/drugfacts/marijuana
  2. U.S. Department of Health & Human Services: https://www.hhs.gov/surgeongeneral/reports-and-publications/addiction-and-substance-misuse/advisory-on-marijuana-use-and-developing-brain/index.html
  3. Epilepsy Foundation: https://www.epilepsy.com/learn/types-epilepsy-syndromes/lennox-gastaut-syndrome-lgs
  4. Epilepsy Foundation: https://www.epilepsy.com/learn/types-epilepsy-syndromes/dravet-syndrome
  5. Epilepsy Foundation: https://www.epilepsy.com/learn/treating-seizures-and-epilepsy/other-treatment-approaches/medical-marijuana-and-epilepsy
  6. MedlinePlus: https://medlineplus.gov/druginfo/meds/a607054.html
  7. MedlinePlus: https://medlineplus.gov/druginfo/meds/a607048.html
  8. The National Academies Press: https://www.nap.edu/catalog/24625/the-health-effects-of-cannabis-and-cannabinoids-the-current-state
  9. The Lancet: https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30048-3/fulltext
  10. Substance Abuse and Mental Health Services Administration: https://www.samhsa.gov/data/report/2018-nsduh-detailed-tables
  11. Western Journal of Emergency Medicine: https://westjem.com/articles/legalized-cannabis-in-colorado-emergency-departments-a-cautionary-review-of-negative-health-and-safety-effects.html
  12. US National Library of Medicine: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2910348/
  13. American Psychiatric Association: https://www.psychiatry.org/psychiatrists/practice/dsm/feedback-and-questions/frequently-asked-questions#:~:text=The%20Diagnostic%20and%20Statistical%20Manual,criteria%20for%20diagnosing%20mental%20disorders.
  14. WebMD: https://www.webmd.com/schizophrenia/schizophrenia-types
  15. The Ohio State University: https://wexnermedical.osu.edu/mediaroom/pressreleaselisting/youths-with-mood-disorders-who-use-marijuana-at-higher-risk-for-death-self-harm

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WRITTEN BY GERARD BULLEN
FEBRUARY 18, 2021

Gerard has been writing exclusively for the U.S. substance addiction treatment industry for many years, providing a range of medically-reviewed work, including white papers, long-form, and short-form content articles, and blog posts for accredited addiction treatment centers. A member of the American Medical Writers Association, Gerard’s specific focus is substance addiction (an area that has impacted Gerard’s personal life in several ways), and he is particularly drawn to the topics of professional, evidence-based treatment, new and alternative therapies, and enabling readers to find their own sustainable, long-term recovery. Gerard lives and works in Maryland, U.S., he’s happily married, and a proud father. His interests include hiking with the family, reading fiction (from the classics to virtually all of the current NYT bestseller list), American and British film classics, and his beloved dogs, Toby and Coco, both rescued from the local pound.

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