Acute marijuana effects on rCBF and cognition: a PET study

Task-independent acute effects of delta-9-tetrahydrocannabinol on human brain function and its relationship with cannabinoid receptor gene expression: A neuroimaging meta-regression analysis

The neurobiological mechanisms underlying the effects of delta-9-tetrahydrocannabinol (THC) remain unclear. Here, we examined the spatial acute effect of THC on human regional brain activation or blood flow (hereafter called 'activation signal') in a 'core' network of brain regions from 372 participants, tested using a within-subject repeated measures design under experimental conditions. We also investigated whether the neuromodulatory effects of THC are related to the local expression of the cannabinoid-type-1 (CB1R) and type-2 (CB2R) receptors. Finally, we investigated the dose-response relationship between THC and key brain substrates. These meta-analytic findings shed new light on the localisation of the effects of THC in the human brain, suggesting that THC has neuromodulatory effects in regions central to many cognitive tasks and processes, related to dose, with greater effects in regions with higher levels of CB1R expression.

Acute Exercise Improves Inhibitory Control but Not Error Detection in Male Violent Perpetrators: An ERPs Study With the Emotional Stop Signal Task

Violence has been linked to the co-occurrence of cognitive dysfunction and altered activations in several brain regions. Empirical evidence demonstrated the benefits of acute exercise on motor inhibition and error detection and their neuronal processing. However, whether such effects also hold for the population with violent behaviors remains unknown. This study examined the effects of acute aerobic exercise on inhibitory control and error monitoring among violent offenders. Fifteen male violent offenders were counterbalanced into experimental protocols, which comprised a 30-min moderately aerobic exercise [60% heart rate (HR) reserve] and a 30-min reading control session. After each session, participants performed an emotional stop signal task while event-related potentials (ERPs) were recorded simultaneously. Results showed insignificant changes in ERPs components [i.e., N2, P3, error-related negativity (ERN), and error-positivity (Pe) amplitudes] and the behavioral performance in go condition, stop accuracy, and post-error adjustments by exercise. However, the current study demonstrated that the acute exercise facilitated stop signal reaction time (SSRT) when compared to the control session regardless of emotional conditions. This is the first research to exhibit the improvements in inhibitory performance by acute exercise for violent offenders. Most importantly, this effect was independent of affective settings, expanding the existing knowledge of the influences of acute exercise on cognition. Our findings implicate the perspective of acute exercise for clinical and correctional practices.

The Yin and Yang of Cannabis: A Systematic Review of Human Neuroimaging Evidence of the Differential Effects of Δ9-Tetrahydrocannabinol and Cannabidiol

Cannabidiol (CBD) and Δ9-tetrahydrocannabinol (THC) have been the most investigated cannabinoids at the human and preclinical levels, although the neurobiological mechanisms underlying their effects remain unclear. Human experimental evidence complemented by observational studies suggests that THC may have psychotogenic effects while CBD may have antipsychotic effects. However, whether their effects on brain function are consistent with their opposing behavioral effects remains unclear. To address this, here we synthesize neuroimaging evidence investigating the acute effects of THC and CBD on human brain function using a range of neuroimaging techniques, with an aim to identify the key brain substrates where THC and CBD have opposing effects. After a systematic search, a review of the available studies indicated marked heterogeneity. However, an overall pattern of opposite effect profiles of the two cannabinoids was evident with some degree of consistency, primarily attributed to the head-to-head challenge studies of THC and CBD. While head-to-head comparisons are relatively few, collectively the evidence suggests that opposite effects of THC and CBD may be present in the striatum, parahippocampus, anterior cingulate/medial prefrontal cortex, and amygdala, with opposite effects less consistently identified in other regions. Broadly, THC seems to increase brain activation and blood flow, whereas CBD seems to decrease brain activation and blood flow. Given the sparse evidence, there is a particular need to understand the mechanisms underlying their opposite behavioral effects because it may not only offer insights into the underlying pathophysiological mechanisms of psychotic disorders but also suggest potentially novel targets and biomarkers for drug discovery.

Acute and chronic effects of Δ9-tetrahydrocannabinol (THC) on cerebral blood flow: A systematic review

Acute and chronic exposure to cannabis and its main psychoactive component, Δ⁹-tetrahydrocannabinol (THC), is associated with changes in brain function and cerebral blood flow (CBF). We therefore sought to systematically review the literature on the effects of THC on CBF following PRISMA guidelines. Studies assessing the acute and chronic effects of THC on CBF, perfusion and volume were searched in the PubMed database between January 1972 and June 2019. We included thirty-four studies, which altogether investigated 1259 humans and 28 animals. Acute and chronic THC exposure have contrasting and regionally specific effects on CBF. While acute THC causes an overall increase in CBF in the anterior cingulate cortex, frontal cortex and insula, in a dose-dependent manner, chronic cannabis use results in an overall reduction in CBF, especially in the prefrontal cortex, which may be reversed upon prolonged abstinence from the drug. Future studies should focus on standardised methodology and longitudinal assessment to strengthen our understanding of the region-specific effects of THC on CBF and its clinical and functional significance.

Cerebellar alterations in cannabis users: A systematic review

Cannabis is the most used illicit substance in the world. As many countries are moving towards decriminalization, it is crucial to determine whether and how cannabis use affects human brain and behavior. The role of the cerebellum in cognition, emotion, learning, and addiction is increasingly recognized. Because of its high density in CB1 receptors, it is expected to be highly affected by cannabis use. The aim of this systematic review is to investigate how cannabis use affects cerebellar structure and function, as well as cerebellar-dependent behavioral tasks. Three databases were searched for peer-reviewed literature published until March 2018. We included studies that focused on cannabis effects on cerebellar structure, function, or cerebellar-dependent behavioral tasks. A total of 348 unique records were screened, and 40 studies were included in the qualitative synthesis. The most consistent findings include (1) increases in cerebellar gray matter volume after chronic cannabis use, (2) alteration of cerebellar resting state activity after acute or chronic use, and (3) deficits in memory, decision making, and associative learning. Age of onset and higher exposure to cannabis use were frequently associated with increased cannabis-induced alterations. Chronic cannabis use is associated with alterations in cerebellar structure and function, as well as with deficits in behavioral paradigms that involve the cerebellum (eg, eyeblink conditioning, memory, and decision making). Future studies should consider tobacco as confounding factor and use standardized methods for assessing cannabis use. Paradigms exploring the functional activity of the cerebellum may prove useful as monitoring tools of cannabis-induced impairment.

The neuropsychopharmacology of cannabis: A review of human imaging studies

The laws governing cannabis are evolving worldwide and associated with changing patterns of use. The main psychoactive drug in cannabis is Δ⁹-tetrahydrocannabinol (THC), a partial agonist at the endocannabinoid CB₁ receptor. Acutely, cannabis and THC produce a range of effects on several neurocognitive and pharmacological systems. These include effects on executive, emotional, reward and memory processing via direct interactions with the endocannabinoid system and indirect effects on the glutamatergic, GABAergic and dopaminergic systems. Cannabidiol, a non-intoxicating cannabinoid found in some forms of cannabis, may offset some of these acute effects. Heavy repeated cannabis use, particularly during adolescence, has been associated with adverse effects on these systems, which increase the risk of mental illnesses including addiction and psychosis. Here, we provide a comprehensive state of the art review on the acute and chronic neuropsychopharmacology of cannabis by synthesizing the available neuroimaging research in humans. We describe the effects of drug exposure during development, implications for understanding psychosis and cannabis use disorder, and methodological considerations. Greater understanding of the precise mechanisms underlying the effects of cannabis may also give rise to new treatment targets.

Regular cannabis and alcohol use is associated with resting-state time course power spectra in incarcerated adolescents

Cannabis and alcohol are believed to have widespread effects on the brain. Although adolescents are at increased risk for substance use, the adolescent brain may also be particularly vulnerable to the effects of drug exposure due to its rapid maturation. Here, we examined the association between cannabis and alcohol use duration and resting-state functional connectivity in a large sample of male juvenile delinquents. The present sample was drawn from the Southwest Advanced Neuroimaging Cohort, Youth sample, and from a youth detention facility in Wisconsin. All participants were scanned at the maximum-security facilities using The Mind Research Network's 1.5T Avanto SQ Mobile MRI scanner. Information on cannabis and alcohol regular use duration was collected using self-report. Resting-state networks were computed using group independent component analysis in 201 participants. Associations with cannabis and alcohol use were assessed using Mancova analyses controlling for age, IQ, smoking and psychopathy scores in the complete case sample of 180 male juvenile delinquents. No associations between alcohol or cannabis use and network spatial maps were found. Longer cannabis use was associated with decreased low frequency power of the default mode network, the executive control networks (ECNs), and several sensory networks, and with decreased functional network connectivity. Duration of alcohol use was associated with decreased low frequency power of the right frontoparietal network, salience network, dorsal attention network, and several sensory networks. Our findings suggest that adolescent cannabis and alcohol use are associated with widespread differences in resting-state time course power spectra, which may persist even after abstinence.

Medical marijuana and driving: a review

Medical marijuana remains a highly debated treatment regimen despite removal of state penalties against care providers prescribing the drug and patients treated with the drug in many areas of the USA. The utility of marijuana in specific medical conditions has been studied at length, but its effects on driving performance and risk of motor vehicle collision remain unclear. As with other medications that affect psychomotor function, the healthcare provider should be informed of the potential risks of driver safety prior to prescribing this psychotropic drug to give appropriate anticipatory guidance for appropriate use. The goal of this narrative review is to assess the current literature regarding marijuana as it relates to driving performance and traffic safety. With a foundation in the pharmacology of cannabinoids, we consider the limitations of testing cannabinoid and metabolite concentration. In addition, we will review studies on driving performance and epidemiological studies implicating marijuana in motor vehicle collisions. The increasing prevalence of medical marijuana laws in the USA suggests that clinicians should be aware of marijuana's influence on public safety. Patients should abstain from driving for 8 h if they achieve a subjective "high" from self-treatment with smoked marijuana and should be aware of the cumulative effects of alcohol and other psychoactive xenobiotics.

Reward salience and risk aversion underlie differential ACC activity in substance dependence

The medial prefrontal cortex, especially the dorsal anterior cingulate cortex (ACC), has long been implicated in cognitive control and error processing. Although the association between ACC and behavior has been established, it is less clear how ACC contributes to dysfunctional behavior such as substance dependence. Evidence from neuroimaging studies investigating ACC function in substance users is mixed, with some studies showing disengagement of ACC in substance dependent individuals (SDs), while others show increased ACC activity related to substance use. In this study, we investigate ACC function in SDs and healthy individuals performing a change signal task for monetary rewards. Using a priori predictions derived from a recent computational model of ACC, we find that ACC activity differs between SDs and controls in factors related to reward salience and risk aversion between SDs and healthy individuals. Quantitative fits of a computational model to fMRI data reveal significant differences in best fit parameters for reward salience and risk preferences. Specifically, the ACC in SDs shows greater risk aversion, defined as concavity in the utility function, and greater attention to rewards relative to reward omission. Furthermore, across participants risk aversion and reward salience are positively correlated. The results clarify the role that ACC plays in both the reduced sensitivity to omitted rewards and greater reward valuation in SDs. Clinical implications of applying computational modeling in psychiatry are also discussed.

Treatment approaches for interoceptive dysfunctions in drug addiction

There is emerging evidence that individuals with drug addiction have dysfunctions in brain systems that are important for interoceptive processing, which include, among others, the insular and the anterior cingulate cortices. These individuals may not be expending sufficient neural resources to process perturbations of the interoceptive state but may exert over-activation of these systems when processing drug-related stimuli. As a consequence, insufficient detection and processing of interoceptive state changes may result in inadequate anticipation and preparation to adapt to environmental challenges, e.g., adapt to abstinence in the presence of withdrawal symptoms. Here, we integrate interoceptive dysfunction in drug-addicted individuals, with the neural basis for meditation and exercise to develop a heuristic to target the interoceptive system as potential treatments for drug addiction. First, it is suggested that mindfulness-based approaches can modulate both interoceptive function and insular activation patterns. Second, there is an emerging literature showing that the regulation of physical exercise in the brain involves the insula and anterior cingulate cortex and that intense physical exercise is associated with a insula changes that may provide a window to attenuate the increased interoceptive response to drug-related stimuli. It is concluded that the conceptual framework of interoceptive dysfunctions in drug addiction and the experimental findings in meditation and exercise provide a useful approach to develop new interventions for drug addiction.

Interoception and drug addiction

The role of interoception and its neural basis with relevance to drug addiction is reviewed. Interoception consists of the receiving, processing, and integrating body-relevant signals with external stimuli to affect ongoing motivated behavior. The insular cortex is the central nervous system hub to process and integrate these signals. Interoception is an important component of several addiction relevant constructs including arousal, attention, stress, reward, and conditioning. Imaging studies with drug-addicted individuals show that the insular cortex is hypo-active during cognitive control processes but hyperactive during cue reactivity and drug-specific, reward-related processes. It is proposed that interoception contributes to drug addiction by incorporating an "embodied" experience of drug uses together with the individual's predicted versus actual internal state to modulate approach or avoidance behavior, i.e. whether to take or not to take drugs. This opens the possibility of two types of interventions. First, one may be able to modulate the embodied experience by enhancing insula reactivity where necessary, e.g. when engaging in drug seeking behavior, or attenuating insula when exposed to drug-relevant cues. Second, one may be able to reduce the urge to act by increasing the frontal control network, i.e. inhibiting the urge to use by employing cognitive training. This article is part of a Special Issue entitled 'NIDA 40th Anniversary Issue'.

Structural and functional imaging studies in chronic cannabis users: a systematic review of adolescent and adult findings

Background

The growing concern about cannabis use, the most commonly used illicit drug worldwide, has led to a significant increase in the number of human studies using neuroimaging techniques to determine the effect of cannabis on brain structure and function. We conducted a systematic review to assess the evidence of the impact of chronic cannabis use on brain structure and function in adults and adolescents.

Methods

Papers published until August 2012 were included from EMBASE, Medline, PubMed and LILACS databases following a comprehensive search strategy and pre-determined set of criteria for article selection. Only neuroimaging studies involving chronic cannabis users with a matched control group were considered.

Results

One hundred and forty-two studies were identified, of which 43 met the established criteria. Eight studies were in adolescent population. Neuroimaging studies provide evidence of morphological brain alterations in both population groups, particularly in the medial temporal and frontal cortices, as well as the cerebellum. These effects may be related to the amount of cannabis exposure. Functional neuroimaging studies suggest different patterns of resting global and brain activity during the performance of several cognitive tasks both in adolescents and adults, which may indicate compensatory effects in response to chronic cannabis exposure.

Limitations

However, the results pointed out methodological limitations of the work conducted to date and considerable heterogeneity in the findings.

Conclusion

Chronic cannabis use may alter brain structure and function in adult and adolescent population. Further studies should consider the use of convergent methodology, prospective large samples involving adolescent to adulthood subjects, and data-sharing initiatives.

Structural network topology revealed by white matter tractography in cannabis users: a graph theoretical analysis

Endocannabinoid receptors modulate synaptic plasticity in the brain and may therefore impact cortical connectivity not only during development but also in response to substance abuse in later life. Such alterations may not be evident in volumetric measures utilized in brain imaging, but could affect the local and global organization of brain networks. To test this hypothesis, we used a novel computational approach to estimate network measures of structural brain connectivity derived from diffusion tensor imaging (DTI) and white matter tractography. Twelve adult cannabis (CB) users and 13 healthy subjects were evaluated using a graph theoretic analysis of both global and local brain network properties. Structural brain networks in both CB subjects and controls exhibited robust small-world network attributes in both groups. However, CB subjects showed significantly decreased global network efficiency and significantly increased clustering coefficients (degree to which nodes tend to cluster around individual nodes). CB subjects also exhibited altered patterns of local network organization in the cingulate region. Among all subjects, schizotypal and impulsive personality characteristics correlated with global efficiency but not with the clustering coefficient. Our data indicate that structural brain networks in CB subjects are less efficiently integrated and exhibit altered regional connectivity. These differences in network properties may reflect physiological processes secondary to substance abuse-induced synaptic plasticity, or differences in brain organization that increase vulnerability to substance use.

Neuroanatomical substrates involved in cannabinoid modulation of defensive responses

Administration of Cannabis sativa derivatives causes anxiolytic or anxiogenic effects in humans and laboratory animals, depending on the specific compound and dosage used. In agreement with these findings, several studies in the last decade have indicated that the endocannabinoid system modulates neuronal activity in areas involved in defensive responses. The mechanisms of these effects, however, are still not clear. The present review summarizes recent data suggesting that they involve modulation of glutamate and GABA-mediated neurotransmission in brain sites such as the medial prefrontal cortex, amygdaloid complex, bed nucleus of the stria terminalis, hippocampus and dorsal periaqueductal gray. Moreover, we also discuss results indicating that, in these regions, the endocannabinoid system could be particularly engaged by highly stressful situations.

Modulation of auditory and visual processing by delta-9-tetrahydrocannabinol and cannabidiol: an FMRI study

Although the effects of cannabis on perception are well documented, little is known about their neural basis or how these may contribute to the formation of psychotic symptoms. We used functional magnetic resonance imaging (fMRI) to assess the effects of Delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) during visual and auditory processing in healthy volunteers. In total, 14 healthy volunteers were scanned on three occasions. Identical 10 mg THC, 600 mg CBD, and placebo capsules were allocated in a balanced double-blinded pseudo-randomized crossover design. Plasma levels of each substance, physiological parameters, and measures of psychopathology were taken at baseline and at regular intervals following ingestion of substances. Volunteers listened passively to words read and viewed a radial visual checkerboard in alternating blocks during fMRI scanning. Administration of THC was associated with increases in anxiety, intoxication, and positive psychotic symptoms, whereas CBD had no significant symptomatic effects. THC decreased activation relative to placebo in bilateral temporal cortices during auditory processing, and increased and decreased activation in different visual areas during visual processing. CBD was associated with activation in right temporal cortex during auditory processing, and when contrasted, THC and CBD had opposite effects in the right posterior superior temporal gyrus, the right-sided homolog to Wernicke's area. Moreover, the attenuation of activation in this area (maximum 61, -15, -2) by THC during auditory processing was correlated with its acute effect on psychotic symptoms. Single doses of THC and CBD differently modulate brain function in areas that process auditory and visual stimuli and relate to induced psychotic symptoms.

Sex, drugs, and cognition: effects of marijuana

Despite the knowledge that many drugs affect men and women differently, few studies exploring the effects of marijuana use on cognition have included women. Findings from both animal and human studies suggest marijuana may have more marked effects in women. This study examined sex differences in the acute effects of marijuana on cognition in 70 (n=35 male, 35 female) occasional users of marijuana. Tasks were chosen to tap a wide variety of cognitive domains affected by sex and/or marijuana including attention, cognitive flexibility, time estimation, and visuospatial processing. As expected, acute marijuana use impaired performance on selective and divided attention, time estimation, and cognitive flexibility. While there did not appear to be sex differences in marijuana's effects on cognition, women requested to discontinue the smoking session more often than men, likely leading to an underestimation of differences. Further study of psychological differences in marijuana's effects on men and women following both acute and residual effects of marijuana is warranted.

Abnormal cerebellar morphometry in abstinent adolescent marijuana users

Functional neuroimaging data from adults have, in general, revealed frontocerebellar dysfunction associated with acute and chronic marijuana (MJ) use. The goal of this study was to characterize cerebellar volume in adolescent chronic MJ users following 1 month of monitored abstinence. Participants were MJ users (n=16) and controls (n=16) aged 16-18 years. Extensive exclusionary criteria included history of psychiatric or neurologic disorders. Drug use history, neuropsychological data, and structural brain scans were collected after 28 days of monitored abstinence. Trained research staff defined cerebellar volumes (including three cerebellar vermis lobes and both cerebellar hemispheres) on high-resolution T1-weighted magnetic resonance images. Adolescent MJ users demonstrated significantly larger inferior posterior (lobules VIII-X) vermis volume than controls, above and beyond effects of lifetime alcohol and other drug use, gender, and intracranial volume. Larger vermis volumes were associated with poorer executive functioning. Following 1 month of abstinence, adolescent MJ users had significantly larger posterior cerebellar vermis volumes than non-using controls. These greater volumes are suggested to be pathological based on linkage to poorer executive functioning. Longitudinal studies are needed to examine typical cerebellar development during adolescence and the influence of marijuana use.

Comorbid mood, psychosis, and marijuana abuse disorders: a theoretical review

There is a need to bridge the gap between the fields of addiction psychiatry and general psychiatry to effectively treat co-morbid substance abuse and psychiatric disorders. This alarming epidemic transcends communities and severely impacts healthcare worldwide, yielding poor treatment outcomes and prognoses for afflicted patients. Because substance abuse can exacerbate or trigger psychosis and mood disorders, it is important to keep these issues in the forefront when evaluating patients. To address some of the complications stemming from not enough interactions between various groups of practitioners, this review addresses the neurobehavioral effects of cannabis use and their impact on patients who suffer from psychotic or affective disorders. The hope is that this article will serve as a spring board for further discussions among practitioners who treat these patients. Greater interactions between caretakers are bound to impact the care of our patients in a very positive way.

Neuroimaging in cannabis use: a systematic review of the literature

BACKGROUND

We conducted a systematic review to assess the evidence for specific effects of cannabis on brain structure and function. The review focuses on the cognitive changes associated with acute and chronic use of the drug.

METHOD

We reviewed literature reporting neuroimaging studies of chronic or acute cannabis use published up until January 2009. The search was conducted using Medline, EMBASE, LILACS and PsycLIT indexing services using the following key words: cannabis, marijuana, delta-9-tetrahydrocannabinol, THC, cannabidiol, CBD, neuroimaging, brain imaging, computerized tomography, CT, magnetic resonance, MRI, single photon emission tomography, SPECT, functional magnetic resonance, fMRI, positron emission tomography, PET, diffusion tensor MRI, DTI-MRI, MRS and spectroscopy.

RESULTS

Sixty-six studies were identified, of which 41 met the inclusion criteria. Thirty-three were functional (SPECT/PET/fMRI) and eight structural (volumetric/DTI) imaging studies. The high degree of heterogeneity across studies precluded a meta-analysis. The functional studies suggest that resting global and prefrontal blood flow are lower in cannabis users than in controls. The results from the activation studies using a cognitive task are inconsistent because of the heterogeneity of the methods used. Studies of acute administration of THC or marijuana report increased resting activity and activation of the frontal and anterior cingulate cortex during cognitive tasks. Only three of the structural imaging studies found differences between users and controls.

CONCLUSIONS

Functional neuroimaging studies suggest a modulation of global and prefrontal metabolism both during the resting state and after the administration of THC/marijuana cigarettes. Minimal evidence of major effects of cannabis on brain structure has been reported.

Imaging cognitive deficits in drug abuse

The neuropsychological network is a complex structure. To identify processes location and network capacity the brain imaging techniques together and in combination with other neuropsychological techniques and the expanding of well elaborated designs provide us with a multidimensional understanding, and contributes to the understanding of each illicit drug's character, which is of importance in designing of new treatment programs and clinical practice. Cannabis, MDMA, amphetamine, cocaine, and heroin abusers display both acute effects and chronic effects, deficits in attention, memory, and executive functioning. These deficits may last beyond the period of intoxication and cumulate with years of use. Cannabis users may recruit an alternative neural network as a compensatory mechanism during performance of tasks of attention. There is some evidence indicating the detrimental effects of cannabis on the maturing adolescent brain. Stimulant dependence is characterized by a distributed alteration of functional activation. Attenuated anterior and posterior cingulate activation, reduced inferior frontal and dorsolateral prefrontal cortex activation, and altered posterior parietal activation point towards an inadequate demand-specific processing of information. On an individual level they exhibit process-related brain activation differences that are consistent with a shift from context-specific, effortful processing to more stereotyped, habitual response generation. Finally, opiate use appears to decrease the ability to shift cognitive set and inhibit inappropriate response tendencies.

The endocannabinoid system as a target for modelling psychosis

INTRODUCTION

Model psychosis is characterised by experimentally induced symptoms of withdrawal from reality, frequently accompanied by perceptual disturbances, thought disorders, delusional ideas and sometimes by hallucinations. These "altered states of consciousness" provide a long-standing and valid approach to enhance our understanding of certain aspects of schizophrenia.

DISCUSSION

Targeting the endocannabinoid system to investigate its involvement in the pathophysiology of schizophrenia became increasingly relevant with the discovery of this system and amounting epidemiological evidence for a deleterious influence of cannabis use on both manifestation and course of the disease. The majority of studies in the field are targeted to investigate drug effect of cannabis and cannabinoids not immediately related to psychosis.

CONCLUSION

In this review, we summarise studies relevant for or designed as model psychosis experiments. Based on the data available, we examine the contribution of these studies to an improved neurobiological assessment of endocannabinoid functioning in psychosis and schizophrenia. An outline for future studies in the field and cross-links to other approaches to model psychosis is provided.

Altered affective response in marijuana smokers: an FMRI study

More than 94 million Americans have tried marijuana, and it remains the most widely used illicit drug in the nation. Investigations of the cognitive effects of marijuana report alterations in brain function during tasks requiring executive control, including inhibition and decision-making. Endogenous cannabinoids regulate a variety of emotional responses, including anxiety, mood control, and aggression; nevertheless, little is known about smokers' responses to affective stimuli. The anterior cingulate and amygdala play key roles in the inhibition of impulsive behavior and affective regulation, and studies using PET and fMRI have demonstrated changes within these regions in marijuana smokers. Given alterations in mood and perception often observed in smokers, we hypothesized altered fMRI patterns of response in 15 chronic heavy marijuana smokers relative to 15 non-marijuana smoking control subjects during the viewing of masked happy and fearful faces. Despite no between-group differences on clinical or demographic measures, smokers demonstrated a relative decrease in both anterior cingulate and amygdalar activity during masked affective stimuli compared to controls, who showed relative increases in activation within these regions during the viewing of masked faces. Findings indicate that chronic heavy marijuana smokers demonstrate altered activation of frontal and limbic systems while viewing masked faces, consistent with autoradiographic studies reporting high CB-1 receptor density in these regions. These data suggest differences in affective processing in chronic smokers, even when stimuli are presented below the level of conscious processing, and underscore the likelihood that marijuana smokers process emotional information differently from those who do not smoke, which may result in negative consequences.

Cannabis, cannabinoids and schizophrenia: integration of the evidence

Understanding of the neurophysiological basis of cognitive, behavioural and perceptual disturbances associated with long-term cannabis use has grown dramatically. Exogenous cannabinoids alter the normative functioning of the endogenous cannabinoid system. This system is an important regulator of neurotransmission. Recent research has demonstrated abnormalities of the cannabinoid system in schizophrenia. The purpose of the present paper was to selectively review the links between cannabis use and psychosis, drawing upon recent epidemiological, clinical, cognitive, brain imaging and neurobiological research. The aim is to assist clinicians to probe more deeply into the newly unfolding world of cannabinoid physiology and to critically evaluate the potential role of cannabis in the onset and persistence of cognitive impairments and psychosis in otherwise healthy users and in schizophrenia.

Acute and non-acute effects of cannabis on brain functioning and neuropsychological performance

Cannabis has an ancient history of human use and is currently one of the most commonly used drugs worldwide. Understanding its impact on neurobehavioral functioning is of significant public health concern. In recent decades, substantial progress has been made in understanding the impact of cannabis use on neurobehavioral functioning. This has been fueled, in part, by characterization of an endocannabinoid signaling system in the brain through which cannabis exerts its psychoactive effects. Acute intoxication with cannabis causes marked changes in subjective mental status, brain functioning, and neuropsychological performance. Some of these changes are consistently detected and well characterized, yet others are not. Changes in brain functioning and neuropsychological performance are also reported after abstinence, but appear to be mild, circumscribed, and transient. On the other hand, functional neuroimaging often reveals subtle differences in the brain functioning of abstinent cannabis users compared with controls. The persistence and clinical significance of these differences, however, remains to be determined. Neuropsychological deficits and differences in brain functioning are most consistently observed only among frequent, heavy users, who are those most likely addicted to cannabis. The dire impact of drug addiction on a person's life and everyday functioning suggests that the large number of individuals addicted to cannabis experience substantial negative effects from its use. This manuscript reviews the scientific literature on the aforementioned topics in detail, providing evidence for converging findings, and highlighting areas in need of further investigation.

Brain imaging study of the acute effects of Delta9-tetrahydrocannabinol (THC) on attention and motor coordination in regular users of marijuana

PROCEDURE

Twelve regular users of marijuana underwent two positron emission tomography (PET) scans using [18F] Fluorodeoxyglucose (FDG), one while subject to the effects of 17 mg THC, the other without THC. In both sessions, a virtual reality maze task was performed during the FDG uptake period.

RESULTS

When subject to the effects of 17 mg THC, regular marijuana smokers hit the walls more often on the virtual maze task than without THC. Compared to results without THC, 17 mg THC increased brain metabolism during task performance in areas that are associated with motor coordination and attention in the middle and medial frontal cortices and anterior cingulate, and reduced metabolism in areas that are related to visual integration of motion in the occipital lobes.

CONCLUSION

These findings suggest that in regular marijuana users, the immediate effects of marijuana may impact on cognitive-motor skills and brain mechanisms that modulate coordinated movement and driving.

Functional imaging studies in cannabis users

Cannabis remains the most widely used illegal drug in the United States. This update examines the available literature on neuroimaging studies of the brains of cannabis users. The majority of studies examining the acute effects of delta-9-tetrahydrocannabinol (THC) administration used PET methods and concluded that administration of THC leads to increased activation in frontal and paralimbic regions and the cerebellum. These increases in activation are broadly consistent with the behavioral effects of the drug. Although there is only equivocal evidence that chronic cannabis use might result in structural brain changes, blood-oxygenation-level-dependent-fMRI studies in chronic users consistently show alterations, or neuroadaptation, in the activation of brain networks responsible for higher cognitive functions. It is not yet certain whether these changes are reversible with abstinence. Given the high prevalence of cannabis use among adolescents, studies are needed to evaluate whether cannabis use might affect the developing brain. Considerable further work, employing longitudinal designs, is also required to determine whether cannabis use causes permanent functional alterations in the brains of adults.

A classroom-administered simulation of a television campaign on adolescent smoking: testing an activation model of information exposure

In recent years, research has shown that mass media can be used effectively either alone or in conjunction with interpersonal and institutional channels, such as schools. Much has yet been be learned about the application of newer, more effective strategies for media campaigns for adolescent smoking prevention interventions. This article describes a study applying an activation model of information exposure and a sensation-seeking targeting approach to the design of a smoking prevention campaign for adolescents. The participants were 1,272 middle school students aged 12-14 from across the Colorado Front Range who were stratified by their level of sensation seeking and then exposed to both high and low sensation value anti tobacco public service announcements (PSAs) at three time points. Hypothesized effects of the intervention on the primary dependent measures--attitudes (against smoking) and behavioral intentions not to smoke--were strongly supported for high sensation seekers. Further support is offered from the secondary indicators, self-efficacy, perceived message effectiveness, and perceived risk from smoking. No differences were demonstrated, however, in message effects between those selected by focus groups to be high in sensation value and those selected to be low in sensation value.

Effects of smoking marijuana on focal attention and brain blood flow

Using an attention task to control cognitive state, we previously found that smoking marijuana changes regional cerebral blood flow (rCBF). The present study measured rCBF during tasks requiring attention to left and right ears in different conditions. Twelve occasional marijuana users (mean age 23.5 years) were imaged with PET using [15O]water after smoking marijuana or placebo cigarettes as they performed a reaction time (RT) baseline task, and a dichotic listening task with attend-right- and attend-left-ear instructions. Smoking marijuana, but not placebo, resulted in increased normalized rCBF in orbital frontal cortex, anterior cingulate, temporal pole, insula, and cerebellum. RCBF was reduced in visual and auditory cortices. These changes occurred in all three tasks and replicated our earlier studies. They appear to reflect the direct effects of marijuana on the brain. Smoking marijuana lowered rCBF in auditory cortices compared to placebo but did not alter the normal pattern of attention-related rCBF asymmetry (i.e., greater rCBF in the temporal lobe contralateral to the direction of attention) that was also observed after placebo. These data indicate that marijuana has dramatic direct effects on rCBF, but causes relatively little change in the normal pattern of task-related rCBF on this auditory focused attention task.

Cannabinoids and prefrontal cortical function: Insights from preclinical studies

Marijuana use has been associated with disordered cognition across several domains influenced by the prefrontal cortex (PFC). Here, we review the contribution of preclinical research to understanding the effects of cannabinoids on cognitive ability, and the mechanisms by which cannabinoids may affect the neurochemical processes in the PFC that are associated with these impairments. In rodents, acute administration of cannabinoid agonists produces deficits in working memory, attentional function and reversal learning. These effects appear to be largely dependent on CB1 cannabinoid receptor activation. Preclinical studies also indicate that the endogenous cannabinoid system may tonically regulate some mnemonic processes. Effects of cannabinoids on cognition may be mediated via interaction with neurochemical processes in the PFC and hippocampus. In the PFC, cannabinoids may alter dopaminergic, cholinergic and serotonergic transmission. These mechanisms may underlie cognitive impairments observed following marijuana intake in humans, and may also be relevant to other disorders of cognition. Preclinical research will further enhance our understanding of the interactions between the cannabinoid system and cognitive functioning.

Imaging of the brain cannabinoid system

This review covers two major strategies for imaging of the brain cannabinoid system: autoradiography and in vivo neuroimaging. Cannabinoid receptors can be imaged directly with autoradiography in brain slices using radiolabeled cannabinoid receptor ligands. In addition, the effects of pharmacologic doses of unlabeled cannabinoid drugs can be autoradiographically imaged using indicators of blood flow or indicators of metabolism such as glucose analogs. Although cannabinoid imaging is a relatively new topic of research compared to imaging of other drugs of abuse, autoradiographic strategies have produced high-quality information about the distribution of brain cannabinoid receptors and the effects of cannabinoid drugs on brain metabolism. In vivo neuroimaging, in contrast to autoradiography, utilizes noninvasive techniques such as positron emission tomography (PET), single photon emission computed tomography (SPECT), and magnetic resonance imaging (MRI) to image both the binding and the effects of drugs within living brain. These techniques are well developed; however, in vivo imaging of cannabinoid systems is in a very preliminary state. Early results have been promising yet hard to generalize. Definitive answers to some of the most important questions about cannabinoid drugs and their effects await development of suitable in vivo neuroimaging ligands for cannabinoid systems.

Acute delta9-tetrahydrocannabinol-induced deficits in reversal learning: neural correlates of affective inflexibility

Despite concerns surrounding the possible adverse effects of marijuana on complex cognitive function, the processes contributing to the observed cognitive deficits are unclear, as are the causal relationships between these impairments and marijuana exposure. In particular, marijuana-related deficits in cognitive flexibility may affect the social functioning of the individual and may contribute to continued marijuana use. We therefore examined the ability of rats to perform affective and attentional shifts following acute administration of Delta(9)-tetrahydrocannabinol (THC), the primary psychoactive marijuana constituent. Administration of 1 mg/kg THC produced marked impairments in the ability to reverse previously relevant associations between stimulus features and reward presentation, while the ability to transfer attentional set between dimensional stimulus properties was unaffected. Concurrent in situ hybridization analysis of regional c-fos and ngfi-b expression highlighted areas of the prefrontal cortex and striatum that were recruited in response to both THC administration and task performance. Furthermore, the alterations in mRNA expression in the orbitofrontal cortex and striatum were associated with the ability to perform the reversal discriminations. These findings suggest that marijuana use may produce inelasticity in updating affective associations between stimuli and reinforcement value, and that this effect may arise through dysregulation of orbitofrontal and striatal circuitry.

Treatment of substance use disorders in schizophrenia: a unifying neurobiological mechanism?

Substance use disorders (SUDs) are highly prevalent and are associated with poor outcomes among individuals with schizophrenia. Integrating treatments for both disorders improves outcomes. Numerous individual pharmacologic and psychosocial treatments have shown effectiveness at reducing substance use in individuals with a primary diagnosis of schizophrenia and co-occurring substance use disorders. Of these treatments, medications such as certain atypical antipsychotics and naltrexone, and psychosocial treatments such as contingency management, seem to be particularly promising. The development and evaluation of psychopharmacologic and psychosocial treatments for SUDs in schizophrenia would benefit from a better understanding of the neurobiological mechanisms underlying the effectiveness of such treatments. Several theories have been put forth to explain the heightened risk for SUDs in schizophrenia. Of these, brain reward circuitry dysfunction, hypothesized to be etiologically important in SUDs, may be an especially salient target for treatments aimed at the reduction of substance use in patients with schizophrenia. We review current pharmacologic and psychosocial treatments for SUDs in schizophrenia, and theoretical mechanisms underlying the increased risk for SUDs in this population. We propose that effective treatments may in part work through the modulation of brain reward circuitry dysfunction.

[Brain effects of cannabis--neuroimaging findings]

Cannabis is the most widely used illicit drug. Despite this, only a small number of studies have investigated the long-term neurotoxic consequences of cannabis use. Structural and functional neuroimaging techniques are powerful research tools to investigate possible cannabis-induced pathophysiological changes. A computer literature review was conducted in the MEDLINE and PsycLIT databases between 1966 and November of 2004 with the search terms 'cannabis', 'marijuana', 'neuroimaging', 'magnetic resonance', 'computed tomography', 'positron emission tomography', 'single photon emission computed tomography", 'SPET', 'MRI' and 'CT'. Structural neuroimaging studies have yielded conflicting results. Most studies report no evidence of cerebral atrophy or regional changes in tissue volumes, and one study suggested that long-term users who started regular use on early adolescence have cerebral atrophy as well as reduction in gray matter. However, several methodological shortcomings limit the interpretation of these results. Functional neuroimaging studies have reported increases in neural activity in regions that may be related with cannabis intoxication or mood-change effects (orbital and mesial frontal lobes, insula, and anterior cingulate) and decreases in activity of regions related with cognitive functions impaired during acute intoxication. The important question whether residual neurotoxic effects occur after prolonged and regular use of cannabis remains unclear, with no study addressing this question directly. Better designed neuroimaging studies, combined with cognitive evaluation, may be elucidative on this issue.

The out-of body experience: precipitating factors and neural correlates

Out-of-body experiences (OBEs) are defined as experiences in which a person seems to be awake and sees his body and the world from a location outside his physical body. More precisely, they can be defined by the presence of the following three phenomenological characteristics: (i) disembodiment (location of the self outside one's body); (ii) the impression of seeing the world from an elevated and distanced visuo-spatial perspective (extracorporeal, but egocentric visuo-spatial perspective); and (iii) the impression of seeing one's own body (autoscopy) from this perspective. OBEs have fascinated mankind from time immemorial and are abundant in folklore, mythology, and spiritual experiences of most ancient and modern societies. Here, we review some of the classical precipitating factors of OBEs such as sleep, drug abuse, and general anesthesia as well as their neurobiology and compare them with recent findings on neurological and neurocognitive mechanisms of OBEs. The reviewed data suggest that OBEs are due to functional disintegration of lower-level multisensory processing and abnormal higher-level self-processing at the temporo-parietal junction. We argue that the experimental investigation of the interactions between these multisensory and cognitive mechanisms in OBEs and related illusions in combination with neuroimaging and behavioral techniques might further our understanding of the central mechanisms of corporal awareness and self-consciousness much as previous research about the neural bases of complex body part illusions such as phantom limbs has done.

Spatial working memory in heavy cannabis users: a functional magnetic resonance imaging study

RATIONALE

Many neuropsychological studies have documented deficits in working memory among recent heavy cannabis users. However, little is known about the effects of cannabis on brain activity.

OBJECTIVE

We assessed brain function among recent heavy cannabis users while they performed a working memory task.

METHODS

Functional magnetic resonance imaging was used to examine brain activity in 12 long-term heavy cannabis users, 6-36 h after last use, and in 10 control subjects while they performed a spatial working memory task. Regional brain activation was analyzed and compared using statistical parametric mapping techniques.

RESULTS

Compared with controls, cannabis users exhibited increased activation of brain regions typically used for spatial working memory tasks (such as prefrontal cortex and anterior cingulate). Users also recruited additional regions not typically used for spatial working memory (such as regions in the basal ganglia). These findings remained essentially unchanged when re-analyzed using subjects' ages as a covariate. Brain activation showed little or no significant correlation with subjects' years of education, verbal IQ, lifetime episodes of cannabis use, or urinary cannabinoid levels at the time of scanning.

CONCLUSIONS

Recent cannabis users displayed greater and more widespread brain activation than normal subjects when attempting to perform a spatial working memory task. This observation suggests that recent cannabis users may experience subtle neurophysiological deficits, and that they compensate for these deficits by "working harder"-calling upon additional brain regions to meet the demands of the task.

Cannabis use and cerebrovascular disease

BACKGROUND

Cannabis is the most commonly abused illicit drug and is often considered innocuous. However, cases of acute onset neurologic dysfunction occurring in relation to cannabis use have been described and corresponding cerebral imaging studies have documented focal ischemic changes and vessel abnormalities.

REVIEW SUMMARY

This article reviews all reported cases of presumed cannabis related cerebral ischemic events in the medical literature, as well as pertinent human and animal experimental studies on the cardiovascular and cerebrovascular effects of cannabis.

CONCLUSIONS

Cannabis use seems to have been causally related to several instances of cerebral ischemia and infarction. Proposed etiologic mechanisms have included cerebral vasospasm, cardioembolization, and systemic hypotension with impaired cerebral autoregulation, but most of the available data points to a vasospastic process. The exact relation of cannabis to cerebrovascular disease remains to be determined.

Marijuana alters the human cerebellar clock

The effects of marijuana on brain perfusion and internal timing were assessed using [15O] water PET in occasional and chronic users. Twelve volunteers who smoked marijuana recreationally about once weekly, and 12 volunteers who smoked daily for a number of years performed a self-paced counting task during PET imaging, before and after smoking marijuana and placebo cigarettes. Smoking marijuana increased rCBF in the ventral forebrain and cerebellar cortex in both groups, but resulted in significantly less frontal lobe activation in chronic users. Counting rate increased after smoking marijuana in both groups, as did a behavioral measure of self-paced tapping, and both increases correlated with rCBF in the cerebellum. Smoking marijuana appears to accelerate a cerebellar clock altering self-paced behaviors.

Positron emission tomography and single-photon emission computed tomography in substance abuse research

Many advances in the conceptualization of addiction as a disease of the brain have come from the application of imaging technologies directly in the human drug abuser. New knowledge has been driven by advances in radiotracer design and chemistry and positron emission tomography (PET) and single-photon emission computed tomography (SPECT) instrumentation and the integration of these scientific tools with the tools of biochemistry, pharmacology, and medicine. This topic cuts across the medical specialties of neurology, psychiatry, oncology, and cardiology because of the high medical, social, and economic toll that drugs of abuse, including the legal drugs, cigarettes and alcohol, take on society. This article highlights recent advances in the use of PET and SPECT imaging to measure the pharmacokinetic and pharmacodynamic effects of drugs of abuse on the human brain.

Alcohol and marijuana: effects on epilepsy and use by patients with epilepsy

We review the safety of alcohol or marijuana use by patients with epilepsy. Alcohol intake in small amounts (one to two drinks per day) usually does not increase seizure frequency or significantly affect serum levels of antiepileptic drugs (AEDs). Adult patients with epilepsy should therefore be allowed to consume alcohol in limited amounts. However, exceptions may include patients with a history of alcohol or substance abuse, or those with a history of alcohol-related seizures. The most serious risk of seizures in connection with alcohol use is withdrawal. Alcohol withdrawal lowers the seizure threshold, an effect that may be related to alcohol dose, rapidity of withdrawal, and chronicity of exposure. Individuals who chronically abuse alcohol are at significantly increased risk of developing seizures, which can occur during withdrawal or intoxication. Alcohol abuse predisposes to medical and metabolic disorders that can lower the seizure threshold or cause symptoms that mimic seizures. Therefore, in evaluating a seizure in a patient who is inebriated or has abused alcohol, one must carefully investigate to determine the cause. Animal and human research on the effects of marijuana on seizure activity are inconclusive. There are currently insufficient data to determine whether occasional or chronic marijuana use influences seizure frequency. Some evidence suggests that marijuana and its active cannabinoids have antiepileptic effects, but these may be specific to partial or tonic-clonic seizures. In some animal models, marijuana or its constituents can lower the seizure threshold. Preliminary, uncontrolled clinical studies suggest that cannabidiol may have antiepileptic effects in humans. Marijuana use can transiently impair short-term memory, and like alcohol use, may increase noncompliance with AEDs. Marijuana use or withdrawal could potentially trigger seizures in susceptible patients.