15ª Aula - A Cannabis sativa L. como Redutora de Danos na Dependência Química - Prof. Paulo Morais

Introduction to the Therapeutic Use of Cannabis

Welcome and Course Overview

• The session is part of the 11th edition of a course on therapeutic cannabis use, presented by AAB, one of the coordinators alongside Professor Daí.

• AAB introduces Professor Paulo from the Federal University of Rondônia, who has been involved since the course's inception and has contributed significantly in previous editions.

Today's Topic: Cannabis as a Harm Reduction Strategy

• The focus today is on using cannabis as a harm reduction strategy for other drug dependencies, especially relevant amid current political debates regarding drug policies.

• AAB encourages participants to pay close attention due to the dense content that will be covered in this session.

Professor Paulo's Introduction

Background and Expertise

• Professor Paulo Morais introduces himself as a psychology professor at the Federal University of Rondônia and discusses his post-doctoral work related to addiction treatment.

• He is also affiliated with ABRANDEN (Brazilian Multidisciplinary Association for Drug Studies), emphasizing his expertise in substance use issues.

Understanding Psychoactive Substances

Cannabis in Context

• The discussion begins with an exploration of cannabis (marijuana) as a potential treatment for chemical dependency and abuse of psychoactive substances.

• Despite its historical use, cannabis has been demonized over time, often labeled as a gateway drug leading to more severe addictions.

Definitions and Spectrum of Use

• The lecture will define psychoactive substances and discuss their various uses—from beneficial applications to harmful dependencies.

• It highlights that substance use exists on a spectrum; some individuals may benefit from moderate use while others may develop abusive patterns or dependencies.

Complexities Surrounding Substance Use

Historical Perspective

• Psychoactive substances have been integral to human experience throughout history, often valued for spiritual or economic reasons but misunderstood in modern contexts.

Misinterpretations and Stigmas

• Discussions around drugs are often oversimplified—viewed through religious lenses as sinful or treated purely as health issues without considering broader societal implications.

Defining Drugs: WHO Perspectives

Official Definitions

• According to WHO definitions, drugs are any chemical entities that alter biological functions. This definition emphasizes their impact on human physiology rather than moral judgments about their use.

Broader Implications

Understanding Psychoactive Substances

Definition and Purpose of Psychoactive Substances

• A psychoactive substance is defined as a chemical molecule that individuals deliberately choose to consume for specific effects.

• An example is clonazepam, commercially known as Rivotril, which people use primarily for its anxiolytic (anxiety-reducing) or sleep-inducing effects.

Classification of Psychoactive Drugs

• Drugs are classified into different categories based on their effects: stimulants, depressants, and perturbing substances.

• Stimulants increase brain activity and communication between neurons, leading to heightened behavioral expression and accelerated thoughts.

• Depressants reduce neuronal activity, resulting in slower cognitive processes and decreased physical movement.

• Perturbing substances alter consciousness qualitatively rather than just accelerating or slowing mental processes.

Common Examples of Psychoactive Substances

• Caffeine and nicotine are widely used stimulants; caffeine is the most consumed psychoactive substance globally.

• Depressants include Rivotril, morphine, heroin, and alcohol (ethanol), which are commonly encountered in society.

• Perturbing substances often referred to as hallucinogens include cannabis.

Cultural Context of Alcohol Use

• The Bible contains one of the earliest accounts of intoxication with Noah's drunkenness described in Genesis.

• Alcohol is easily produced through fermentation from various plants; it has been part of human culture for centuries.

Historical Changes in Alcohol Consumption

• The term "cannabis" has evolved over time; it was originally referred to as "kes bosm" in Hebrew but now appears as "aromatic cane" in modern translations.

• The advent of distillation during the Middle Ages changed alcohol consumption by allowing higher alcohol content in smaller volumes.

The Impact of Alcohol Prohibition in the United States

Historical Context and Social Conditions

• The Industrial Revolution in the late 15th to early 16th century created social conditions that favored both adaptive and maladaptive alcohol use, leading to growing concerns over its negative effects on productivity.

Temperance Movement Emergence

• In the 19th century, particularly in the U.S., a temperance movement emerged, borrowing from Aristotelian virtue ethics but transforming it into a call for abstinence from alcohol.

Prohibition Campaigns

• By the late 19th and early 20th centuries, campaigns aimed at criminalizing alcohol consumption intensified, portraying bar owners as traitors to national productivity.

• A significant plebiscite was held in the early 20th century regarding the prohibition of alcoholic beverages, with campaigns emphasizing child purity influencing public opinion.

Implementation of Prohibition

• The resulting "Prohibition" law began in 1919 and lasted until around 1932 or 1933, marking a decade where various activities related to alcohol became illegal.

Consequences of Prohibition

• During this period, numerous activities associated with alcohol were criminalized; scenes reminiscent of modern drug busts occurred frequently as authorities seized illicit substances.

• The enforcement led to increased violence linked to illegal alcohol trade, similar to contemporary issues surrounding other banned substances like marijuana and cocaine.

The Rise of Organized Crime

Criminal Enterprises Flourish

• The rise of organized crime during Prohibition was marked by figures like Al Capone; without this era's context, such notoriety may not have existed.

Public Health and Economic Impacts

• Prohibition proved disastrous for public health and the economy; clandestine production continued despite legal restrictions, leading to rampant corruption among law enforcement.

Demand vs. Supply Dynamics

• Despite being illegal, there remained a strong societal demand for alcohol which fueled organized crime syndicates' growth during this time.

Reevaluation of Alcohol Policies

Erosion of Trust in Authorities

• The failure of prohibition led to widespread disillusionment with authorities as people found ways around restrictions while still accessing alcohol easily.

Shift Towards Legalization

• Similarities can be drawn between past movements against alcohol and current debates on marijuana legalization; public dissatisfaction eventually contributed to repealing prohibition in 1933.

Historical Use of Cannabis

Early Medicinal Use

• Cannabis has been utilized by humans for centuries primarily for medicinal purposes before its recreational use gained prominence by the late 19th century.

Cultural Significance

• In addition to medicinal applications, cannabis served practical uses such as fiber production for textiles; advertisements from historical periods reflect its commonality in pharmacies.

Opioids: A Historical Perspective

Introduction of Morphine

• Morphine was one of the first active compounds isolated from opium poppy extracts in the early 19th century; it represented significant advancements in pain management practices.

Development of Heroin

The Use and Dependency of Morphine

Morphine in Pain Management

• Morphine is still used today for treating intense pain, despite its effectiveness leading to dependency issues.

• Regular use of morphine can lead to organic accommodation, where the body requires the substance to avoid adverse reactions.

Dependency and Abuse

• Short-term use of morphine can quickly result in physical dependence, with users experiencing withdrawal symptoms without it.

• The historical context shows that substances like heroin were once viewed similarly to modern concerns about crack cocaine in Brazil.

Historical Perspectives on Opioids

• In 1925, a Brazilian doctor presented at an international conference discussing opium, highlighting concerns over morphine's dependency risks.

• This doctor claimed that marijuana was more dangerous than morphine in Brazil due to high rates of hashish addiction.

Cultural Perceptions and Propaganda

• During the early 20th century, there was significant concern regarding marijuana compared to opium and morphine.

• In the U.S., propaganda began portraying marijuana as a threat, particularly targeting minority communities using racially charged narratives.

Legislative Actions Against Marijuana

• The term "Marijuana" became associated with negative stereotypes during campaigns against its use among African Americans and Latinos.

• A pseudo-documentary titled "Reefer Madness" exaggerated the dangers of marijuana, influencing public perception significantly.

Misleading Claims About Marijuana

• The portrayal of marijuana effects in media often misrepresented its actual impact compared to stimulants familiar to American audiences.

Legislative Developments

• In 1937, Harry Anslinger presented misleading arguments for prohibiting marijuana based on unfounded claims about its users' demographics and behaviors.

• His statements included xenophobic views linking marijuana use with racial minorities and moral decay within society.

Alcoholism Contextualization

• Eric Jelinek published work on alcohol consumption patterns which influenced early Alcoholics Anonymous principles during the mid-20th century.

Understanding Substance Use and Its Psychological Implications

The Nature of Alcohol Use and Dependence

• The discussion highlights that while excessive alcohol use can lead to problems, the primary concern often lies in underlying psychological or personality disorders rather than the substance itself.

• Historically, treatment for substance dependence focused solely on stopping substance use, neglecting other motivating factors behind excessive consumption.

Classification of Substance Abuse

• Modern classifications like DSM and ICD recognize substance abuse as a pathology, including withdrawal syndrome characterized by physical symptoms when the substance is absent.

• Withdrawal symptoms can also encompass psychological effects, indicating a complex relationship between continuous use and subsequent cessation.

Cultural Shifts in Drug Perception

• In the 1950s and 60s, post-WWII youth began challenging industrial societal values, leading to a rise in communal living and civil rights movements.

• This era saw an increase in drug use among young people as a form of resistance against societal norms, particularly with substances like marijuana gaining popularity.

Legislative Changes and Global Impact

• The 1961 UN Single Convention on Narcotic Drugs included cannabis among prohibited substances despite its questionable classification regarding dependency and medical utility.

• By 1971, cannabis remained classified as having high abuse potential without recognized therapeutic benefits, which contradicted emerging evidence of its medical uses.

The Rise of Cocaine in Society

• The 1970s marked the beginning of the "War on Drugs" in the U.S., which influenced global drug policies and led to increased cocaine trafficking.

• Cocaine's commercialization surged during this period; it transitioned from medicinal use to becoming central to narcotrafficking dynamics across America.

Societal Responses to Drug Use

• As individualism grew in the 1970s culture, many sought psychoactive substances as coping mechanisms for loneliness or emotional distress.

Historical Context of Drug Prohibition

Overview of Drug Literature in the 1980s

• In the 1980s, literature on drugs was more commonly found in public school libraries than scientific texts, with works like those by Ferrarini being prevalent.

• Many texts discussing drug use and alcoholism were more sensationalized rather than based on scientific knowledge, overshadowing research from authors like Kaline and Mazur.

The Rise of Prohibitionist Science

• A 2020 study highlighted that the prohibitionist approach to science emerged from moralistic campaigns rooted in xenophobia and racism.

• Legislative movements aimed at banning substances were often based on falsehoods, such as claims that marijuana was more addictive than heroin or morphine.

Financial Bias in Research

• The concept of "scientific prohibitionism" arose due to financial biases favoring research that demonstrated harm from psychoactive substances over studies exploring their potential benefits.

• Researchers proposing studies linking marijuana use to negative outcomes had a higher chance of securing funding compared to those investigating its therapeutic effects.

Role of Anti-Drug Specialists

• The emergence of anti-drug specialists primarily stemmed from law enforcement backgrounds rather than health sectors, although some health professionals are also involved today.

• These specialists perpetuate the narrative that drugs are dangerous, serving as scapegoats for broader social inequalities.

Social Implications of Drug Policies

Scapegoating and Social Inequality

• The focus on drug issues diverts attention from systemic problems like income inequality and exploitation within society.

• Nixon's war on drugs is cited as a strategy for social control targeting non-white populations rather than genuinely addressing public health concerns.

Racial Disparities in Drug Enforcement

• Media narratives have framed the war on drugs as a conflict against Black communities, highlighting racial disparities in enforcement practices.

• Data shows significant racial disparities in arrests for marijuana possession, with Black individuals facing much higher rates compared to white individuals even where legalization has occurred.

Comparative Risks Associated with Substances

Expert Assessments of Substance Risks

• A 2010 study asked toxicology experts to evaluate risks associated with various substances; alcohol ranked highest for both individual and societal harm.

• Alcohol scored 72 points out of 100 for risk assessment, while heroin and cocaine scored around 54 points. In contrast, marijuana received only 20 points.

Insights into Psychedelics

The Therapeutic Potential of Cannabis and Other Psychoactive Substances

Understanding the Risks Associated with Cannabis

• Current research indicates that cannabis, while illegal, shows therapeutic potential, particularly for post-traumatic stress disorder (PTSD), with risks rated below 10 on a scale of 0 to 100.

• Historical knowledge suggests that cannabis was recognized for having fewer associated risks even before its prohibition in 1961, as evidenced by sociological studies from New York City.

Historical Context and Misconceptions

• A study commissioned in the 1950s by the Mayor of New York highlighted various aspects of cannabis use but was overshadowed by later prohibitions labeling it as highly addictive and without therapeutic value.

• It is noted that smoking cannabis does not lead to medical dependency or withdrawal symptoms like those caused by alcohol or morphine.

Cannabis Use and Crime Correlation

• Cannabis use is not linked to juvenile delinquency; serious crimes are influenced by other factors rather than marijuana consumption.

Psychedelics in Treatment

• LSD has been studied for its effectiveness in treating alcoholism, showing that participants treated with LSD had double the chances of remaining abstinent compared to placebo groups.

Historical Usage Patterns of Psychoactive Substances

• The use of psychoactive substances dates back to prehistoric times, serving various functions such as work stimulation and social facilitation.

• Different classes and ages utilize drugs variably; older adults tend to consume more substances than younger individuals.

Positive vs. Negative Uses of Psychoactive Substances

• There exists a spectrum where psychoactive substance use can be beneficial (e.g., medicinal uses like psychotropic medications or caffeine for alertness).

• Recreational use may not always have negative health impacts but can lead to risky behaviors during binge drinking scenarios.

Dependency and Abuse Considerations

• Patterns of substance use can vary from occasional recreational use to habitual dependence, which requires attention from health professionals due to potential negative consequences.

Understanding Substance Use and Dependence

Overview of Drug Use Patterns

• Not all drug use is problematic; maladaptive or problematic use occurs in about 15% of individuals who try a substance, with variations depending on the drug.

• The statistical norm indicates that recreational or functional use of substances is more prevalent than problematic use, as shown in data from the UN Office on Drugs and Crime's World Drug Report (2010-2020).

• Approximately 5-6% of the global population reports using illicit substances annually, while less than 2% show signs of potential substance dependence.

Understanding Dependence

• The development of dependence on illicit substances is relatively low compared to usage rates; only a small fraction becomes dependent.

• Chemical dependence is characterized by compulsive behavior to seek and use a substance, loss of control over its consumption, and negative emotional states when not available.

Diagnostic Criteria for Substance Use Disorder

• Current psychiatric diagnosis for dependence includes "Substance Use Disorder," which encompasses 11 symptoms related to control issues, social problems due to use, risk-taking behaviors, tolerance, and withdrawal symptoms.

Variability in Addiction Rates Among Substances

• Different substances have varying addiction rates: tobacco (1 in 3), heroin (1 in 5), cocaine (1 in 6), alcohol (1 in 7), cannabis (1 in 10), and psychedelics (1 in 20).

Factors Influencing Substance Dependence

• Dependency does not solely depend on the substance itself but also involves individual characteristics such as age, sex, emotional state, knowledge about the substance, intent behind its use, and socio-economic factors.

Biopsychosocial Model of Substance Abuse

Understanding Substance Use and Treatment Approaches

The Stigma of Substance Use

• The discussion highlights how character weakness is often attributed to substance users, contributing to stigma. This perspective aligns with a disease model where drug use is seen as a form of dependency or substance use disorder.

Disease Model vs. Harm Reduction

• The disease model suggests that drug use leads to neurobiological changes, making voluntary use compulsive. Abstinence becomes the expected outcome in treatment approaches.

• A more humane approach focuses on health promotion and harm reduction, emphasizing individual autonomy and rights regarding body choices without harming others.

Understanding Harm Reduction

• Harm reduction does not equate to encouraging drug use; rather, it aims to minimize problems associated with usage. In some cases, abstinence may be necessary for damage control.

• For instance, individuals diagnosed with cirrhosis from alcohol consumption would need abstinence as part of their harm reduction strategy.

Comorbidities and Integrated Treatment

• Substance use often correlates with comorbid conditions like anxiety disorders. Effective treatment must address both substance use and these underlying issues.

Acute Intoxication vs. Long-term Treatment

• Acute intoxication (e.g., excessive alcohol consumption) can be treated effectively in emergency services but requires ongoing motivation for long-term recovery.

• Long-term treatment ideally occurs in outpatient settings rather than through hospitalization, which is often used for detoxification from depressant substances.

Challenges in Medication-Assisted Treatment

• Many medications exist for treating dependencies (e.g., tobacco, alcohol), but there are no known effective drugs for certain addictions like cocaine or behavioral addictions such as gambling or pornography.

Cannabinoids in Dependency Treatment

• Most medications prescribed for substance dependence target psychiatric comorbidities like depression and anxiety rather than the addiction itself.

• Research indicates potential therapeutic effects of cannabinoids on various dependencies, including alcohol-related disorders.

Historical Context of Cannabis Use in Treatment

• Historical references show that cannabis was considered a treatment option for severe dependencies as early as the late 19th century.

Maconha e Dependência: Uma Abordagem Terapêutica

Uso de Maconha em Pacientes Dependentes

• Pacientes dependentes de crack relataram sentir menos fissura ao usar maconha, que não foi estigmatizada ou proibida pelos médicos. A orientação era que se a maconha ajudava, os pacientes deveriam usá-la.

• Aproximadamente 70% dos pacientes que foram incentivados a usar maconha abandonaram o crack. Desses, muitos também pararam de usar maconha após um ano.

Evidências Recentes sobre Canabinoides

• Um estudo recente (2023) por João Fernandes e outros sugere que canabinoides isolados e maconha podem ser benéficos no tratamento de transtornos por uso de substâncias.

• O tratamento da dependência deve considerar fatores relacionados à droga, ao indivíduo e ao contexto social do uso.

Efeitos dos Canabinoides na Dependência

• Os endocanabinoides presentes no sistema nervoso podem modular sistemas relacionados à dependência. A ativação desses receptores pode influenciar estados mentais e comportamentais.

• Além dos efeitos nos neurônios, canabinoides podem induzir estados alterados de consciência, promovendo mudanças positivas na personalidade e motivação dos usuários.

Abordagens Terapêuticas Não Julgadoras

• Intervenções não farmacológicas como terapia individual e em grupo são comuns no tratamento das dependências. É crucial ter uma postura não julgadora em relação ao uso de substâncias.

• Uma abordagem empática aumenta a aliança terapêutica entre terapeuta e paciente, essencial para resultados positivos no tratamento.

Importância da Individualização do Tratamento

• O sucesso do tratamento está mais associado às qualidades pessoais dos terapeutas do que à escola terapêutica utilizada. Flexibilidade, honestidade e respeito são fundamentais na relação com o paciente.

• Cada plano terapêutico deve ser ajustado às circunstâncias individuais do paciente; não existe um único tratamento eficaz para todos os casos de dependência.

Educação sobre Uso de Substâncias

• É importante educar as pessoas sobre o uso seguro das drogas. Informações adequadas podem tornar o uso mais saudável e menos problemático.

• Diferentes substâncias têm efeitos variados; entender esses efeitos é crucial para evitar problemas associados ao seu uso inadequado.

• Fatores como dosagem, via de administração e frequência de uso impactam significativamente os efeitos das substâncias no corpo humano.

Insights on Drug Use Education and Harm Reduction

Importance of Informative Resources

• The speaker references interesting information about substances from a Dutch channel, suggesting viewers seek out educational materials online.

• Recommendations include pamphlets and booklets produced by the Ed Lei group, which focuses on harm reduction in São Paulo.

Psychoeducation and Self-Care

• Emphasizes the principle of psychoeducation, stating that informed individuals can better manage their health conditions.

• Highlights that having knowledge about one's pathology and lifestyle choices enhances self-care capabilities.