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gible conversation, perhaps because of an inability to remember what was just said even a few words earlier.

The high associated with marijuana is not generally claimed to be integral to its therapeutic value. But mood enhancement, anxiety reduction, and mild sedation can be desirable qualities in medications—particularly for patients suffering pain and anxiety. Thus, although the psychological effects of marijuana are merely side effects in the treatment of some symptoms, they might contribute directly to relief of other symptoms. They also must be monitored in controlled clinical trials to discern which effect of cannabinoids is beneficial. These possibilities are discussed later under the discussions of specific symptoms in chapter 4.

The effects of various doses and routes of delivery of THC are shown in Table 3.1.

Adverse Mood Reactions

Although euphoria is the more common reaction to smoking marijuana, adverse mood reactions can occur. Such reactions occur most frequently in inexperienced users after large doses of smoked or oral marijuana. They usually disappear within hours and respond well to reassurance and a supportive environment. Anxiety and paranoia are the most common acute adverse reactions;59 others include panic, depression, dysphoria, depersonalization, delusions, illusions, and hallucinations.1,40,66,69 Of regular marijuana smokers, 17% report that they have experienced at least one of the symptoms, usually early in their use of marijuana.145 Those observations are particularly relevant for the use of medical marijuana in people who have not previously used marijuana.

Drug Dynamics

There are many misunderstandings about drug abuse and dependence (see reviews by O'Brien14 and Goldstein54). The terms and concepts used in this report are as defined in the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-IV ),3 the most influential system in the United States for diagnoses of mental disorders, including substance abuse (see Box 3.1). Tolerance, dependence, and withdrawal are often presumed to imply abuse or addiction, but this is not the case. Tolerance and dependence are normal physiological adaptations to repeated use of any drug. The correct use of prescribed medications for pain, anxiety, and even hypertension commonly produces tolerance and some measure of physiological dependence.

Even a patient who takes a medicine for appropriate medical indications and at the correct dosage can develop tolerance, physical depen-



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