Oakland Cannabis Buyers' Cooperative

Exhibit D

Medical Admissions Criteria

Tod H. Mikuriya, M.D.
Medical Coordinator

Because of the vacuum of clinical knowledge about the therapeutic applications of cannabis caused by marijuana prohibition a widespread condition of ignorance exists. While it is acknowledged that there exists a range of illnesses on the dimension of seriousness objectively, there is none to the person afflicted who is seeking relief. Exclusion because the condition does not appear on a list developed by a group of non-medical politicians or bureaucrats merely perpetuate this clinical ignorance. Therefore the medical criteria are to be inclusive limited only by contemporary classifications of illness.

Medical Criteria

Persons shall have a verified specific diagnosis by a licensed physician that is included within the latest revision of the International Classification of Diseases ICD-9. Or the Diagnostic Statistical Manual DSM-IV vague statements about conditions, disorders, or syndromes without specific information or not recognized by either ICD-9 or DSM-IV are not acceptable.

Mental Disorders Admissions Protocol

Since the inception of cannabis buyers clubs some have expressed concern about the possibility of adverse effects on individuals suffering from emotional or mental disorders.

In clinical interviews I have conducted with members and patients in my psychiatric practice it is my impression that while many definitely benefit from cannabis there are others for whom use of cannabis is contraindicated.

The buyers cooperative procedures seek to both address these concerns and study more fully the effects of cannabis on emotional and mental disorders.

All persons seeking membership in the cooperative for treatment of conditions listed in DSM-IV or emotional or mental conditions listed in ICD-9 shall be reviewed by mental health professional after verification by intake staff.

Individuals in whom the use of cannabis is or has been problematic shall be excluded. This group includes persons suffering from cannabis related disorders.

Additionally, other emotional and mental conditions may be worsened by the use of cannabis. Some persons are involved in treatment requiring abstinence from cannabis especially those involved in twelve step recovery programs.

Cases where verification or suitability for the program is in dispute shall be reviewed by a panel of volunteer psychiatrists who will make final determination.

Adverse Effects of Cannabis

As with any drug, cannabis is a tool. There will always be individuals that experience adverse consequences from any drug use. The abuse of cannabis had been recognized for millennia. These problems were described by O'Shaughnessey during his observations in India in 1839, which included references in the Persian medical literature. With widespread non medical use of the drug for the past thirty years, psychiatrists have developed classifications of cannabis presented in the latest Diagnostic and Statistical Manual, Revision IV (DSM-IV).

Intoxication/Overdose

Overdose is most common by the oral route since the time from taking the drug until the experience of effects begin is from one to three or more hours. Inexperienced and ignorant first time users will have an unforgettable experience.

The effects of overdose have been numerously described in general, clinical, and scientific literature. Cannabis overdose comprises the majority of listings in the Surgeon General's list, 19th century precursor of the Indicus Medicus. American literary accounts in books: Fitz Hugh Ludlow's Hashish Eater and an essay on Hashish by Victor Robinson, M.D., are expressly devoted to cannabis. Descriptions of experience with the drug as part of travel to areas of indigenous use may be found in English and European literature over the past three centuries. Scientific and medical descriptions of effects of cannabis overdose have been numerous extensive. Before and after its removal in 1937.

The effects of overdose are from the stimulation and sedation of the central nervous system. Stimulation with a flooding of ideas and images that are vivid and rapidly changing. Attention and concentration are markedly impaired. Time perception is significantly altered with minutes seeming like hours. There may be distortion of spatial perception. Secondary physical effects, aside from a speeding up of the heart rate is generally no more than that associated with mild to moderate exercise.

Cannabis-Induced Disorders

Cannabis Intoxication

  1. Recent use of cannabis.
  2. Clinically significant maladaptive behavior or psychological changes (e.g. impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgment, social withdrawal) that developed during, or shortly after, cannabis use.
  3. Two (or more) of the following signs, developing within 2 hours of cannabis use: (1) conjunctivae injection (2) increased appetite (3) dry mouth (4) tachycardia. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.
  4. Specify if:
    With Perceptual Disturbances: This specifier may be noted when hallucinations with intact reality testing or auditory, visual, or tactile illusions occur in the absence of delirium. Intact reality testing means that the person knows that the hallucinations are induced by the substance and do not represent external reality. When hallucinations occur in the absence of intact reality testing, a diagnosis of Substance-Induced Psychotic Disorder, with Hallucinations should be considered.

292.81 Cannabis Intoxication Delirium
292.11 Cannabis-Induced Psychotic Disorder,
With Delusions Specify if with onset during intoxication.
292.89 Cannabis-Induced Anxiety Disorder, Specify if: with onset during Intoxication.

Continuing or chronic use.

Use or abuse? Cannabis, like any other drug, is a tool. Properly utilized with realistic expectations and awareness of its properties, cannabis is a safe and effective medicine. Improperly used with unrealistic expectations and ignorance, adverse effects may result. The onset of unwanted effects may be obvious or insidious. The general etiology is some emotional discomfort for which cannabis is taken to relieve producing undesirable consequences from using the drug itself.

Paranoia and delusional thinking are not uncommon effects of cannabis both acute and chronically. In the acute experience it appears to be from the perceptual distortions of space, time and feelings of detachment.

In chronic use paranoid and delusional thinking appear to be the consequences of the suppression of feelings, the dulling of feelings may alienate the cannabis users from others by diminishing empathetic capabilities. This emotional insensitivity then results in conflict through misperception. Misperception results from the dulling of affect that is important contextual collateral information source. An effective relief of emotional distress then becomes an impediment to relationships with the cannabis user. Feelings are an integral dimension of social perception that convey important contextual information. Cannabis, as an effective sedative and antidepressant, has this undesirable side effect when misused. The relief afforded by the drug may be paid for by complications caused by avoiding dealing with the causes of the emotional pain as well as diminished functioning while under its influence.

Cognitive impairment by continuing or overuse of cannabis creates a form of mild dementia that may persist for up to several weeks after discontinuing the drug. Individuals sensitive to the drug report a persistent ì hangoverî that diminishes the ability to pay attention and concentrate. The onset may be insidious, subtle, and gradual. This condition is reversible with abstinence from cannabis.

304.30 Cannabis Dependence

A maladaptive pattern of cannabis use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12 month period:

  1. tolerance, as defined by either of the following;
    1. a need for markedly increased amounts of the substance to achieve intoxication or desired effect.
    2. markedly diminished by either of the following;
  2. withdrawal, as manifested by either of the following:
    1. the characteristic withdrawal syndrome for the substance.
    2. the same (or a closely related) substance is take to relieve or avoid withdrawal symptoms.
  3. cannabis is often taken in larger amounts or over a longer period than was intended.
  4. there is a persistent desire or unsuccessful efforts to cut down or control cannabis use.
  5. a great deal of time is spent in activities necessary to obtain cannabis (e.g. visiting multiple dealers or driving long distances), use the substance (e.g. chain smoking) or recover from its effects
  6. important social, occupational, or recreational activities are given up or reduced because of cannabis use
  7. cannabis use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been cause or exacerbated by the substance.

305.20 Cannabis Abuse

A. maladaptive pattern of cannabis use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12 month period:

  1. recurrent cannabis use resulting in a failure to fulfill major role obligations at work, school, or home (e.g. repeated absences or poor work performance related to substance use; cannabis related absences, suspensions, or expulsions from school; neglect of children or household)
  2. recurrent cannabis use in situations in which it is physically hazardous ( e.g. driving an automobile or operating a machine when impaired by cannabis use)
  3. recurrent cannabis related legal problems (e.g. arrests for cannabis relate disorderly conduct)
  4. continued cannabis use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g. arguments with spouse about consequences of intoxication, forgotten promises)

B. The symptoms have never met the criteria for Cannabis Dependence for this class of substance.

232.9 Cannabis Related Disorder not Otherwise Specified

The Cannabis Related not Otherwise Specified category is for disorders associated with the use of cannabis that are not classifiable as one of the disorders listed above.

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