Microsoft word - adhd1.doc
Cannabis and ADD
The primary symptoms of the most commonly recognized combined-type of ADHD are(1) motor overactivity, (2) inattention, and (3) impulsivity (American PsychiatricAssociation, 1994).
Symptoms may decrease after adolescence, although they often
Our understanding of the pathophysiology of ADHD and the
mechanisms of therapeutic action of stimulants is clearly still in its infancy.
During the past several years, cannabinoid biology has witnessed marked advances thathas propelled endocannabinoid research to the forefront of biomedical research. In orderto appreciate the role of cannabinoids in treating ADD, ADHD, and adult ADD, a reviewof these conditions, a brief overview of neuroantomy and the endocannabinoidneurochemical anandamide.
• ADHD is Serious and Current Treatment Options are Controversial
ADHD is a serious condition. There is controversy over the use of stimulants as
treatment. There is agreement that we need to continue to search for other effective
treatment with fewer side effects. Cannabis has been suggested as being both a sequelae
of ADD, ADHD and adult ADD as well as a form of self-medication.
Let's review the medicinal potential for cannabinoids in the treatment of ADD, ADHDand adult ADD. A good place to start as we assess the efficacy of cannabis or othercannabinoid for ADD. The NIH Consensus statement of the NIH DevelopmentConference of November 1998:
"Attention deficit hyperactivity disorder or ADHD is a commonlydiagnosed behavioral disorder of childhood that represents a costly majorpublic health problem. Children with ADHD have pronouncedimpairments and can experience long-term adverse effects on academicperformance, vocational success, and social-emotional development whichhave a profound impact on individuals, families, schools, and society.
Despite progress in the assessment, diagnosis and treatment of ADHD, thisdisorder and its treatment have remained controversial, especially the useof psychostimulants for both short- and long-term treatment."
They point out that in regard to treatment, that there is:
"No consensus regarding which ADHD patients should be treated withpsychostimulants. These problems point to the need for improvedassessment, treatment, and follow-up of patients with ADHD."
They go on to say that there is:"One of the major controversies regarding ADHD concerns the use of psychostimulantsto treat the condition. Because psychostimulants are more readily available and are beingprescribed more frequently, concerns have intensified over their potential overuse and
abuse." When adverse drug reactions do occur, they are usually related to dose. Effectsassociated with moderate doses may include decreased appetite and insomnia. Further,"A wide variety of treatments have been used for ADHD including, but not limited to,various psychotropic medications, psychosocial treatment, dietary management, herbaland homeopathic treatments, biofeedback, meditation, and perceptualstimulation/training." Even more importantly the NIH consensus statement says that:"There are no conclusive data on treatment in adolescents and adults with ADHD."
The consensus statement is clear on the scope of the problem:"In the larger world, these individuals consume a disproportionate share of resources andattention from the health care system, criminal justice system, schools, and other socialservice agencies. Methodological problems preclude precise estimates of the cost ofADHD to society. However, these costs are large."
The statement continues:"The impact of ADHD on individuals, families, schools, and society is profound andnecessitates immediate attention. A considerable share of resources from the health caresystem and various social service agencies is currently devoted to individuals withADHD."
The risks of treatment, particularly the use of stimulant medication, are of considerableprofessional and lay interest. Substantial evidence exists of wide variations in the use ofpsychostimulants across communities and physicians, suggesting no consensus amongpractitioners regarding which ADHD patients should be treated with psychostimulants.
Existing diagnostic and treatment practices, in combination with the potential risksassociated with medication, point to the need for improved awareness by the healthservice sector concerning an appropriate assessment, treatment, and follow-up.
• What is ADHD?
Lately several physicians who recommend/approve medicinal cannabis have seen an
increase in the number of patients coming in who have been diagnosed with AttentionDeficit Disorder (ADD) or Attention Deficit with Hyperactivity Disorder (ADHD).
Before we discuss some possible ways of dealing with this problem I'd like to discusswhat we mean by these diagnoses. The first and foremost thing we need to remember isthat these diagnoses don't correspond to any recognized pathology. For example, if wesay somebody has appendicitis, we can look at the removed appendix under themicroscope and see some specific changes like a lot of a certain type of cells that createan inflammatory response. Somebody with asthma will have certain easily identifiablechanges in their lungs, etc. A person with ADD/ADHD does not have any such changesas far as we know. The cause of ADHD is unknown, although in some cases thereappears to be a genetic component. It has been shown that people with ADHD have lessactivity in areas of the brain that control attention. What ADD/ADHD have is a certaingroup of symptoms, like difficulty concentrating, hyperactivity, behavior issues, etc. Butthere appears to be a deficiency in free dopamine.
Attention Deficit Hyperactivity Disorder (ADHD), was formerly called hyperkinesis orminimal brain dysfunction. It is described as a chronic, neurologically based syndromecharacterized by any or all of three types of behavior: hyperactivity, distractibility, andimpulsivity. Hyperactivity refers to feelings of restlessness, fidgeting, or inappropriateactivity (running, wandering) when one is expected to be quiet; distractibility toheightened distraction by irrelevant sights and sounds or carelessness and inability tocarry simple tasks to completion; and impulsivity to socially inappropriate speech (e.g.,blurting out something without thinking) or striking out. Unlike similar behaviors causedby emotional problems or anxiety, ADHD does not fluctuate with emotional states.
While the three typical behaviors occur in nearly everyone from time to time, in thosewith ADHD they are excessive, long-term, and pervasive and create difficulties in school,at home, or at work.
ADHD is usually diagnosed before age seven.
accompanied by a learning disability. More recently there has also been described adultADHD.
While we strongly suspect an important role of dopamine deficiency, we don't really
know the cause of the symptoms, and there is no routine test for dopamine levels, so the
diagnosis becomes what we call a diagnosis of exclusion. That is, we make sure the
person does not have some other identifiable condition, such as depression or some
learning disabilities or a physical problem causing the symptoms, and if they don't, and
have a certain number of symptoms from a predefined list, we label them with
ADD/ADHD and give a drug that tends to make them a bit more manageable. The
accepted drug treatments tell that Ritalin cures nothing but in many cases many make the
patient more manageable.
Conventional ADD treatment usually includes behavioral therapy and emotionalcounseling combined with sympathominetic medications such as methyphenidatehydrochloride (Ritalin) or dextroamphetamine (Dexedrine), Atomoxetine (Strattera),Amphetamine mixture (Adderal) or long-acting methylphenidate (e.g., Metadate LD,Concerta, Ritalin LA), that in many cases make the patient more manageable. They alsohave many unacceptable side effects.
The first dictum of medicine is "first, do no harm." Another bedrock principal is that aprescriber must balance off the side effects of the treatment with the benefits. WithADD, the use of Ritalin and other stimulants has been routinely and repeatedly criticizedbecause of its side effects profile. All of my patients with ADD have been critical ofeither the side effects of these drugs, the lack of effectiveness or both. They have foundcannabis to be both more effective and have far fewer side effects.
No less an authority than DEA Administrative Law Judge, Francis L. Young, in 1988,after a two-year hearing to reschedule cannabis said:
"Nearly all medicines have toxic, potentially lethal effects. But marijuanais not such a substance.
There is no record in the extensive medical
literature describing a proven, documented cannabis-induced fatality .
Simply stated, researchers have been unable to give animals enoughmarijuana to induce death . In practical terms, marijuana cannot induce alethal response as a result of drug-related toxicity . In strict medical termsmarijuana is far safer than many foods we commonly consume .
Marijuana, in its natural form, is one of the safest therapeutically activesubstances known to man."
When a medication gives you a symptom that you did not want, we call that symptom aside effect. When it comes to treatment of ADHD for many, cannabinoids have far fewerand less annoying side effects than the stimulants that are often used to treat AD/HD andother conditions. The most common stimulants are methyphenidate (Ritalin, Concerta,Metadate-ER) and amphetamine (Dexedrine, Dexedrine Spansules, Adderall). Someindividuals who take stimulants experience mild problems, some much more significant,unpleasant side effects. Some are simply unable to tolerate stimulants. Many peoplesimply stop their prescribed stimulant medication instead of working with their physicianto find a way to decrease side effects. Cannabinoids offer another viable option.
A study reported in Clinician reviews in 2000 entitled "Treating ADHD May PreventSubstance Abuse" found that:
". untreated ADHD presents a significant risk factor for Substance UseDisorder (SUD) in adolescence, whereas treating ADHD may reduce thisrisk."
I have no idea why substance use - as opposed to
substance abuse- is a disorder.) At any rate, the authors "point to previousstudies in which they found ADHD-SUD associations in adults withADHD who had never been diagnosed or treated as children.
examination is necessary in order to evaluate the risk factors for girls andnonwhite boys.
However, these findings may reduce apprehension in
treating children who have ADHD and promote earlier intervention. This,in turn, may prevent the academic, psychiatric, and interpersonalcomplications of ADHD in adolescents, and subsequently, in adults.
• Cannabis Studies
In some cases where Ritalin is ineffective or unacceptable, cannabis has been found to be
helpful. Much of the evidence about the use of cannabis is anecdotal, however that is
changing. On 11/19/2000 Daniel Q. Haney of the Associated Press wrote:
"maybe the smoke is about to clear in the debate over medical marijuana.
Few ideas, it seems, are so firmly held by the public and so doubted by themedical profession as the healing powers of pot. But at last, researchersare tiptoeing into this field, hoping to prove once and for all whethermarijuana really is good medicine.
To believers, marijuana's benefits are already beyond discussion:
eases pain, settles the stomach, builds weight and steadies spastic muscles.
And that's hardly the beginning. They speak of relief from MS, glaucoma,itching, insomnia, arthritis, depression, childbirth, attention deficitdisorder and ringing in the ears.
Marijuana is a powerful and needed medicine, they say, tragically withheldby misplaced phobia about drug addiction."
He points out that while many are not impressed with these anecdotal reports stretchingover centuries funding from the State of California to the Center for Medicinal CannabisResearch the questions as to cannabis' medical efficacy will be scientifically studied. InHaney's words:
"Pot has many effects on the body, including some that are probablyworthwhile. But does it substantially relieve human suffering, they ask?And if so, is it any better than medicines already in drugstores?
For the first time in at least two decades, marijuana the medicine is beingput to the test. Scientists say they will try to hold marijuana to the samestandard as any other drug, to settle whether its benefits match itsmystique.
One way to buff up a pharmaceuticals' raffish image -- especially one that'sa drug in more than one sense of the word -- is to call it something else.
When the University of California at San Diego started the country's firstinstitute to study the medical sues of marijuana this year, they named it theCenter for Medicinal Cannabis Research. Cannabis is the botanical termfor pot.
"We talked about it a lot," says Dr. Igor Grant, the psychiatrist who headsthe new center. "Marijuana is such a polarizing name. We don't want thisinstitute to be caught in the crossfire between proponents and antagonists.
Ultimately, if cannabis drugs become medicine, they will almost certainlybe known by that name, not marijuana."
The center appears to be living up to its expectations. It was authorized to give out $9million to California researchers over the three years from 2000-2003. This has beenenough funding to underwrite 18 NIDA/FDA-approved studies. At least one or two arelooking at cannabis and ADHD.
Here's my take on the implication of the brain studies related to cannabinoids.
• Cannabinoid ReceptorsThere are two cannabdinoid receptors in the body – CB1 located in the brain, and CB2 inthe periphery.
• for CB1 there are two natural ligands in the body anandamide (arachidonyl
ethanolamide) and 2-AG (2 arachidonyl glyceride)
• palmitylethanolamide is the natural ligand for CB2
• Cannabis/TetrahydrocannabinolThere are over 400 different chemicals in marijuana, about 60 of which are known ascannabinoids. These chemicals are found nowhere else in nature. The most importantcannabinoid in marijuana is known as delta-9-tetrahydrocannabinol (THC). THC is themain psychoactive (mind-altering) ingredient in marijuana. These plant cannabinoids canstimulate the body's endocannabinoid system.
• Endocannabinoid SystemCannabinoid CB(1) receptors are highly localized in the central nervous system. A 2000report of the work of Martin, Ledent, et.al. in Feb. 2002 issue of Psycho Pharmacologyconcluded that endogenous cannabinoids through the activation of CB1 receptors areimplicated in the control of emotional behavior and participate in the physiologicalprocesses of learning and memory.
The highest concentration of CB1 THC receptors in the brain are found in thehippocampus (where memory is formed), cerebellum (deals with coordinatingmovements and balance), the striatum, amygdala (emotion), cerebral cortex (highercenters of reasoning) and the basal ganglia. An important class of neurons that expresshigh levels of CB(1) receptors are GABAergic interneurons in the hippocampus,amygdala and cerebral cortex. They may act as retrograde synaptic mediators of thephenomena of depolarization-induced suppression of inhibition or excitation inhippocampus and cerebellum. In other words, they may mediate by decreasing sensoryinput. Signaling by the endocannabinoid system represents a mechanism by whichneurons can communicate backwards across synapses to modulate their inputs.
Cannabinoid receptors are co-localized with dopamine receptors suggesting thatcannabinoids influence dopaminergic processes.
The active ingredient in marijuana is delta-9-tetrahydrocannabinol (9-THC). It binds toCB1 receptors (G-protein-coupled receptors) that are present on presynaptic membranesin several parts of the brain.
• CannabinoidsIt is possible that, in part at least, cannabis' effects are due to the cannabinoids, a majornonpsychotropic constituent of cannabis. It was recently discovered that the cannabinoids(as opposed to THC) effect the inhibition of anandamide uptake.
The prefrontal cortex (PFC) is essential for attentional control, organization and planning.
Lesions to the PFC in humans can produce distractibility, hyperactivity, and impulsivity(Stuss, Eskes, & Foster, 1994). The PFC projects to many subcortical regions, includingthe dorsal and ventral striatum, thalamus, amygdala, substantia nigra, and ventraltegmental area (Alexander, DeLong, & Strick, 1986) all areas with high concentration ofTHC receptors. The motor dysregulation characteristic of ADHD and neuroimaging datasuggest that dysfunction in striatum or in the cortical regulation of striatum is involved inthe pathophysiology of ADHD. This dysregulation may be associated with lower thannormal levels of free dopamine.
• DopamineThat is the neuro anatomy but the power for the getting neural impulses around the brainare the neurotransmittors. These cross the synapse and stimulate receptors in the nextneuron
norepinephrone, seratonin, acetylcholine, dopamine and anandamide (the naturallyoccurring cannabinoid).
Catecholamines: (Dopamine), Norepinephrine, Epinephrine (adrenalin) control the so-called adrenergic systems. Some of these neurons radiate from the limbic system anddischarge neurotransmitters in a diffuse manner into the frontal cortex, i.e. into broadareas of brain tissue as opposed to delivering the chemical to specific synapses. Theythus account for "global vigilance" (staying awake), mood, fight or flight response, etc.
Chocolate, coffee, nicotine, THC and stress all increase Dopamine.
Haldol block Dopamine action (less learning, remembering and motivation).
Attention-Deficit Disorder (ADD) and Attention-Deficit Hyperactivity Disorder (ADHD)patients may have less dopamine produced than those who do not have this condition.
Also a preliminary study reveals that adults with ADD/ADHD have 70 percent moredopamine transporters in their brains than normal subjects. These transporters tie updopamine leaving less free dopamine available for neuro stimulation.
• Low DopamineIn 2000 Grace proposed a model of dopaminergic dysfunction in ADHD at the cellularlevel that explain many of the symptoms of ADHD. He suggests that, possibly because ofreduced stimulation from PFC, children with ADHD have low tonic dopaminergicactivity. Low tonic stimulation of inhibitory autoreceptors produces high phasic activityin the nucleus accumbens, and possibly other subcortial sites as well, that may result indysregulated motor and impulse control,
Dopamine receptor oversensitivity (whatever that is) also may cause the body to decreasethe amount of dopamine being produced. A shortage of dopamine in the frontal lobe cancontribute to poor working memory.
• Stimulants May Inhibit Dopamine Breakdown
Dopamine also contributes to the feelings of bliss and regulates feeling of pain in thebody. There is strong evidence that the catecholamines dopamine and norepinephrine areimportant in the pathophysiology of ADHD, as well in the mechanism of therapeuticaction of stimulant drugs.
Because of the known effects of stimulants in blocking
reuptake of catecholamines and (in the case of d-amphetamine) facilitating their release, ithas traditionally been believed that the stimulants compensate for catecholaminedeficiency in ADHD.
By blocking dopamine reuptake, stimulants increase tonic levels of dopamine in theextracellular space, increasing the stimulation of impulse-regulating presynapticautoreceptors and thereby reducing phasic dopamine release.
Hyperactivity, and possibly poor motor impulse control, in ADHD may result fromexcess dopaminergic activity in the limbic system.
Stimulant drugs may reduce hyperactivity by reducing
activation of the striatum, possibly through a mechanism that involves stimulation ofinhibitory pre-synaptic autoreceptors.
• Cannabinoids Regulate Neural TrafficThere are essentially two kinds of brain cells, according to Stanford Universityneuroscientist Dan Madison. There are the principal cells that make up what he likenedto a superhighway system of long-range information movement, and there are"interneurons," which are like traffic signals along that highway.
"Cannabinoids are a way for the principal cells to regulate the traffic lights," Madisonsaid. After two years of laboratory study and frustrating dead ends, Wilson and Nicollfound that the role of the brain's cannabis is to make the feedback system work. Harvardresearchers, working independently, found an essentially identical role for endogenouscannabinoids in another part of the brain, called the cerebellum, which helps to controlmotor function.
"It's a way for a nerve cell to adjust the gain or intensity of the information coming intoit," Nicoll said.
"It turns up the amplifier, in a way, and allows more input to get
These adjustments seem to have an important role in the brain's uncanny ability tosynchronize the firing of nerve cells scattered throughout the brain linking behavior withmood and memory with vision or hearing. Thousands of signals thus become moldedinto vast oscillations, helping the brain bind together different aspects of perception intocoherent state of mind -- a feeling of being in love, perhaps, when we look at someone.
• Retrograde Messenger SystemExperiments in the last few years have shown that in any neural circuits whereendocannabinoids
are present these endocannabinoids may participate in a retrogrademessenger system whose goal is presynaptic inhibition
. Endocannabinoids serve as the
messengers in this system, and CB1 serves as the receptor that initiates the inhibition.
This is especially important in signaling between neurons in the hippocampus, wherestrengthening and weakening of neural connections, thereby reorganizing neural circuits,is thought to be a cellular correlate of learning and memory.
Cannabis appears to treat ADD and ADHD by increasing the availability of dopamine.
This then has the same effect but is a different mechanism of action than stimulants likeRitalin (methylphenidate) and dexedrine (1) amphetamine which act by binding to thedopamine and interfering with the metabolic breakdown of dopamine. Cannabis (THC)is an anandamide agonist, that is it stimulates the anandamide (CB1) receptor sites.
Researchers working on Tourette's Syndrome (TS) favorable response to 9-THC said:"neuroanatomical structures which are probably involved in TS pathology are heavilyassociated with the CB1 receptor system. Considering an involvement of the dopaminesystem in TS pathophysiology it can be speculated that tic improvement might be causedby an interaction between cannabinoid and dopamine mechanisms. I believe that this isliterally true for the rather closely related ADHD.
What does research say about cannabinoids controlling ADD or hyperactivity. An animal
model study, published in the May 2000 issue of the Journal of Neuroscience, reports that
synthetic compounds developed to block the way anandamide – the body's own cannabis-
like compound or cannabinoid – is inactivated or broken down could correct forms of
hyperactivity, such as attention deficit disorder.
Research by Dr. Daniel Piomelli at UCI also suggests a possible mechanism of action forcannabis in treating ADD.
Dr. Piomelli, professor of pharmacology, led a team that
found that a chemical called AM404 reversed the normal inactivation of a naturallyoccurring chemical in the brain called anandamide, which is related to marijuana's activeingredient and opposes or counteracts the actions of dopamine. According to Reutersarticle, Piomelli's study showed that: A chemical that boosts a marijuana-like substancein the brain may insure new treatments for brain disorders such as schizophrenia,Parkinson's disease, and attention-deficit/hyperactivity disorder (ADHD).
Arachidonoyl ethanolamide (AEA) was the first endogenous cannabinoid to be isolatedand characterized as an agonist acting on the same receptors (CB1 and CB2) astetrahydrocannabinols (THC).
This means that stimulating the anandamide receptors
Piomelli and his colleagues found that AM404 targeted nerves that produced unusuallyhigh levels of dopamine and caused exaggerated movements and other problems in rats.
Instead of directly encouraging the production of dopamine-curbing anandamide, AM404was found to discourage the disintegration of existing anandamide. More anandamidewas then available to bind to receptors on nerve cells and reduce the stimulation of nervecells by dopamine.
What I believe is happening is two things. One is that release of anandamide slows downthe rate of neurotransmission. This is one of Piomelli's principle findings. Others havesuggested a second action of stimulating anandamide receptor sites and that is they fireRenshaw cells. Renshaw cells are in the midbrain and their neurons go downward in thebrain. Their function is to turn off some of the cells which provide sensory input. In the______ studies by reversing the inactivation of anandamide, AM404 is able to gently curbthe exaggerated movements and other disorders caused by too much dopamine activity innerve cells.
In the case of Parkinson's disease, patients have too little dopamine, while people withADHD, schizophrenia or Tourette's syndrome may have too much. The hope is thatAM404 will lay the groundwork for a new class of drugs that either boost or blockdopamine, without the side effects linked to current treatments, Piomelli told ReutersHealth in an interview. "Our results are interesting," he said, "because they show that youcan modulate dopamine without acting on the dopamine system." Instead of directlyencouraging the production of dopamine-curbing anandamide, AM404 was found todiscourage the disintegration of existing anandamide.
available to bind to receptors on nerve cells and reduce the stimulation of nerve cells bydopamine.
Piomelli and his colleagues showed for the first time that in rats, anandamide naturallycounters dopamine. Usually, though, anandamide is inactive in the brain. The Californiateam's latest experiments in rats reveal that AM404 stops anandamide from being"drained from the brain," which allows it to suppress dopamine.
Although dopamine's role in brain disorders is not completely understood, an elevatedlevel is a "common element" in conditions such as ADHD, schizophrenia and Tourette'ssyndrome, Piomelli explained.
These disorders are all marked by hyperactive
"intrusions" into normal brain function, he said. For example, people with Tourette'sexperience physical "tics," while schizophrenics suffer from delusions.
A UCI news release of May 1, 2000 states that:"If further research proves successful, the chemical could be used to treat schizophrenia,Tourette's, Parkinson's, autism and attention-deficit disorder, all of which are currentlytreated by drugs that attack the dopamine system in the brain." Piomelli's research shows"you can modulate dopamine without acting on the dopamine system." These conditionsare treated with drugs that affect the dopamine system. Piomelli points out that theseexisting treatments have side effects such as lethargy and impaired sexual activity. Thepotential for anandamide-boosting drugs to work against these disorders has someanecdotal
schizophrenics who report that it relieves their symptoms, Piomelli noted.
"But," he said, "we are not implying that marijuana is use for these conditions."
"Marijuana has a lot of pharmaceutical and
The potential now is becoming very, very clear."
decades-old prejudices are being lifted and that is reflected by the considerable fundingthat the federal government is giving to research marijuana.
Marijuana, according to Piomelli, is far less selective than anandamide in activating braincells. Because pot smoking overstimulates the brain, he said, cells eventually becomedesensitized to any benefits the drug initially brings.
SOURCE: Journal of Neuroscience May 2000.
"I would be very surprised that if in the next 10 years there isn't an important newmedicine developed from our better understanding of the cannabis system in the body,"says Piomelli.
While Piomelli himself has discounted the use of cannabis for these disorders, thisresearch clearly lays out a potential mechanism of action. An article by UCI staff writerAndreas Von Bubroff states that:
"Anandamide is similar to marijuana's active
ingredient, THC and belongs to a class of neurotransmitters called endogenouscannabinoids since it is naturally produced by some of the brain's nerve cells." It isknown that cannabis is neuroprotective and in practice it has shown to provide relief forsome epilepsy, Tourette's and some ADD sufferers. I myself have had several patientswho have benefited from cannabis for ADD and with far fewer side effects than Ritalin.
Lastly, there is a six (6) page paper by Kurt E. Patterson discussing marijuana and ADD.
In it he states that "There is some evidence available that medical marijuana has beenfound to be an effective medication for some types of ADD by other researchers in thefield. (1) Unfortunately, ADD encompasses such a variety of conditions that the limitedamount of research in the field leaves many of the effective therapeutic mechanismsunder-investigated. Considering the regulatory difficulties in researching the effects ofmedical marijuana, it isn't surprising that the information regarding medical marijuanaand ADD is largely anecdotal(2)."
What does 215 mean – not being an attorney it is difficult to parse the language where on
the one hand the preamble talks "about" serious and on the other Prop 215 gives a list of
conditions including nausea, glaucoma, migraine, pain and then adds for any other
condition that a physician feels that cannabis may be useful for. The argument is made
for a broad interpretation of 215 approvals and recommendations by no less an authority
than the California DAs Association, California Sheriffs Association, and California
Narcotics Officers Association in their ballot argument against 215. They argue that if
215 passed, cannabis could be recommended for anything. A broad reading is argued for
by the brief of the CMA arguing that basically 215 protects a physician's first amendment
right to communication with his patient concerning whether some medications best
prescription, herbal, vitamins or alternatives and complementing medicine may be helpfulto that included.
Insofar as ADD goes it appears that it qualifies under a reasonable interpretation of eithera narrow or broad interpretation of 215.
interpretation whereas CMA and the DA's take a broader interpretation.
ADD has been termed a serious enough condition that hundreds of thousands of schoolchildren are treated with (some would say subjected to) the not so benign medicationRitalin. ADD as well as ADHD and adult ADD or ADHD have been shown to be verydisruptive on people's lives – their self-esteem, their ability to succeed in life, their abilityto do well in school. There are numerous websites on ADD and ADHD which assert thatthis is a serious condition.
Several physicians in California who regularly made 215 recommendation (Dr. FrankLuceria, Dr. Tom O'Connell, Dr. Tod Mikuriya) have indicated that they have made manyrecommendations for the medical use of cannabis to treat ADD. Dr. Lester Grinspoon,emeritus professor of psychiatry at Harvard School of Medicine and author of Marijuana,The Forbidden Medicine, has a website which lists anecdotal reports of the medicinalbenefits of cannabis.
Out of a sample of 25 displayed 3, or 12% were describing
cannabis' benefits for treatment of ADD.
As recently as March 5, 2002, a 48-Hours TV program chronicled the effectiveness of amedical recommendation for the treatment of ADD in an eight year old child.
California court determined that this constituted an appropriate treatment for this child.
There appears to be overwhelming anecdotal evidence not only is of benefit in treatingADD with cannabinoids but also that many view ADD as a serious condition. Further, itis clear that the FDA in the person of Administrative law judge has officially found thatmarijuana is safer than Ritalin.
In order to discuss this, let's have a brief and superficial review of how the brain works.
4 big regions:1) Cerebrum: the largest part of the brain, it contains deep grooves (called sulci)
Cortex: 3 functional categories: Sensory, Motor and Associative
The Cerebrum controls learning, intelligence,
1) The right half is thought to house artistic ability and controls the left
2) The left half houses mathematical ability and controls the right side
a) located behind the parietal lobe and temporal lobe.
b) Concerned with vision.
a) located in front of the central sulcus.
b) The frontal lobe is concerned with functions such as reasoning,
planning, part of speech and movement (motor cortex), emotions, and problem-solving.
a) located below the lateral fissure.
b) Concerned with hearing and memory.
b) Concerned with perceptions related to touch, pressure,
E) Basal Nuclei have motor control/pattern generators;
F) Limbic system for initial memory, emotion--
1) On top of the brainstem and buried underneath the cerebral cortex,
there is a set of more evolutionary primitive brain structures called the limbic system.
The limbic system components are involved in many of our
emotions and motivations, especially those related to survival such as fear, anger andemotions relating to sexual behavior, and feelings of pleasure such as those experiencedfrom eating and sex.
3) There are two important limbic system structures.
a) The amygdala which is involved in emotion or feelingsb) The hippocampus which is involved in memory.
a) thalamus (=sensory processing, relay) + pineal;b)
hypothalmus with pituitary gland=reflex integrators for many autonomic
reflexes such as temperature, reproduction, appetite.
3) Cerebellum: pattern generators/procedural memory for coordination of motor cortex:learns repetitive skilled motions. The Cerebellum is the second largest part of the brain.
It coordinates muscles and maintains balance.
Brainstem -- Pons & Medulla Oblongata -- reflex integrators for autonomic
cardiovascular, and respiratory reflexes. The Medulla connects brain to the spinal cordand controls involuntary actions, (i.e., heartrate, breathing, B.P.)
Divisions of the Brain -1) Prosencephalon - (forebrain) integrates sensory information2) Mesencephalon - (midbrain) coordinates sensory information3) Rhombencephalon - (hindbrain) reflex actions.
CYP2C19 Genotyping Assay: Test Ordering Information Test Information: CYP2C19 Genotyping Assay (CMGDL test code 4001) CPT Codes 83891x1, 83892 x1, 83900 x1, 83901 x1, 88384 x1, 83912-Report & Interpretation For additional information please refer to the CMGDL www.medgen.med.miami.edu. Indications for Testing Clinical Sensitivity -Patients candidate for or
Door County Kewaunee Consortium FAQs 1. Newly Added FAQ: If a member’s primary care physician is unavailable, the member can see a partner at their PCP’s office and it will be covered. The claim would need to be billed with the same taxpayer identification number. That “fill-in” provider can also do any necessary referrals. 2. When is the next open enrollment period