In addition, commercialization may increase the Version Accepted for Publication availability of marijuana through diversion, increase exposure to aggressive marketing tactics by the emerging cannabis industry, or increase exposure to others who use or illicitly sell marijuana. Legalization of cultivation for personal use raises additional concerns about access and exposure. Although some studies have found positive associations between densities of medical marijuana dispensaries and marijuana use among adults, very little is known about the potential influence of adolescents’ exposure to marijuana dispensaries, recreational outlets, and marketing or the mechanisms through which such exposure may affect their marijuana use. Studies showing associations between adolescents’ exposure to alcohol and tobacco outlets and use of those substances, suggest the importance of investigating exposure to retail access and marketing of marijuana. The article by Shi et al., makes a timely contribution to this field of research by investigating associations of proximity and density of medical marijuana dispensaries, price of medical marijuana products, and variety of products sold in school neighborhoods with adolescents’ marijuana use and susceptibility. Results showed no associations between adolescents’ current use or susceptibility to use marijuana and proximity or density of medical marijuana dispensaries around schools, price, and product variety. Focusing on exposure around school neighborhoods, this study used traditional measures of proximity and density of outlets around schools. Such measures are often used in studies to assess influences of exposure to alcohol and tobacco outlets on use of those substances. However, research shows that the locations in which young people spend their time are varied and geographically dispersed,vertical grow rack and not captured by geographical boundaries such as school or home neighborhoods.

Activity spaces include all locations and the routes the individuals experience as a result of their Recent studies have found that adolescents’ activity spaces provide a more accurate measure of alcohol and tobacco outlet exposures than do traditional measures. Future research should consider marijuana retail availability in the broader environments where adolescents spend their time. Moreover, the cannabis market is evolving in ways that make it different than the tobacco and alcohol markets. In addition to marijuana, myriad cannabis products are available and heavily marketed. These products can be smoked, eaten, vaped, or used topically. Many of these products are easily transportable and readily concealed or disguised. Many of them can be used covertly , possibly making use by adolescents less risky than is the case for most alcohol or tobacco products. As noted by Shi et al.,future research should consider the range of cannabis products to more accurately assess the effects of marijuana commercialization on adolescents’ marijuana beliefs and use. In addition, unlike alcohol and tobacco, there remains a substantial illegal market. Given tax policies and the resulting price differentials, the underground market may remain a preferred source of marijuana for adolescents. The situation is further complicated by provisions allowing individuals to grow marijuana for personal use, possibly providing access for adolescents directly from family members, friends, and acquaintances who grow it or by providing increased opportunities to steal it. Although the legal market may not be a primary source of marijuana for adolescents, it nonetheless may have an influence by increasing open consumption in public and the home, by normalizing marijuana use, and by increasing exposure to marketing. Importantly, some adolescents may be more susceptible to exposure to marijuana outlets in their daily lives, and therefore at greater risk for marijuana use, susceptibility and problems. The lack of As the national landscape regarding marijuana legalization changes in the US, more research is needed to understand adolescents’ exposures to marijuana commercialization and the mechanisms by which exposures to marijuana dispensaries, recreational outlets, and marketing may affect marijuana use and beliefs.

Such research is important to guide policies and prevention efforts to reduce the potential negative effects of marijuana commercialization. Psychiatric disorders and substance abuse commonly cooccur. Population-based studies have provided documentation that, of all patients with major psychiatric disorders, those with bipolar disorder show the highest prevalence of comorbid substance abuse and dependence. The cause of this high comorbidity rate has not been clearly established, and the relationship is probably bidirectional. One explanation for this co-occurrence is the ‘self-medication hypothesis’, which states that some patients experience improvement in psychiatric symptoms as a result of substance use. It has been found that about 50% of individuals with bipolar disorder have a lifetime history of substance abuse or dependence. Furthermore, bipolar I subjects appear to have higher rates of these comorbid conditions than bipolar II subjects. Research has consistently shown that substance abuse in bipolar patients may have negative consequences both on clinical characteristics and long-term course: drug addiction is associated with medication non-compliance, a higher frequency of mixed or dysphoric mania and, possibly, an earlier onset of affective symptoms, more severe impairment of social functioning, greater subjective distress and less resourcefulness in coping, more hospitalizations and poorer prognoses, together with a higher frequency of suicide attempts. Alcohol and cannabis are the substances most often abused, followed by cocaine and then opioids. In terms of specificity, a link seems to exist between cocaine use, as evaluated among poly-abusers of different categories, and bipolar disorders. When abusing cocaine, bipolar patients showed significantly higher rates of post-traumatic stress disorder and antisocial personality disorder, and were more likely to present in a mixed mood state. Alcohol abuse and dependence show a lifetime prevalence 3–4 times higher in patients with bipolar disorders than in the general population, while the lifetime prevalence of mood disorders in alcohol-dependent subjects is approximately 10 times higher than in the general population.

Most bipolar patients run the risk of developing lifetime drug or alcohol-related problems, which may in their turn contribute to more varied and complex clinical presentations, so increasing the risk of a depressive episode in the near term, poorer lithium response, functional disability and elevated suicide risk, as well as high rates of suicide attempts. Moreover, alcohol addiction may exacerbate impulsive behaviours and risk-taking propensities in bipolar patients. With respect to cannabis use, some papers have pointed out that marijuana is not only often abused by patients suffering from bipolar disorder, but also induces manic symptoms. Additionally, cannabis-using bipolar patients experienced less satisfaction with life, had a lower probability of having a romantic relationship compared with non-users, and also had more severe alcohol and other drug use. Regarding heroin use, very few studies have been conducted on the specific effects of its abuse in the clinical course of bipolar patients. Studies on the self-medication hypothesis have focused on the use of heroin and cocaine dependence as an attempt to alleviate emotional suffering. Most addicts do not choose drugs randomly to alleviate painful affective states and their underlying psychiatric disorders. Rather, drugs are chosen because an individual discovers a specific psychopharmacological action that helps to alleviate an individual’s suffering. Recently, greater emphasis has been placed on understanding addiction as a form of ‘self-medication’ to alleviate suffering, with less emphasis on its severe psychopathology. As the ‘self-medication’ theory suggests, patients to modulate their mood by decreasing their dysphoria may use heroin. In other words, patients appear to select substances that they expect to have a ‘healing’ effect. In bipolar patients cocaine appears to exercise an appeal because of its ability to relieve distress associated with depression. Recently Khantzian revised his theory and expanded the number of affective states to be examined, including alexithymia, to better operationalize SMH, but some authors indicated that affective measures did not have the expected relationship with reported substance use. In this study, to further test the validity of Khantzian’s hypothesis, we compared concomitant substances of abuse in bipolar heroin addicts according to their clinical presentation . Bipolar patients have been chosen because,cannabis grow racks as compared with patients suffering for other mental illnesses, they are more likely to clearly show various different identifiable affective states. We considered heroin-dependent bipolar patients as Khantzian developed his hypothesis treating heroin addicts. Moreover, bipolar patients are generally multi-drug abusers. The choice of these patients is also interesting for the fact that heroin use in bipolar disorder is perhaps the least understood and researched groups of patients with bipolar disorder and substance use. Khantzian’s hypothesis would be supported if the use of CNS stimulants were prominent in the depressive phase and CNS depressants in hypomanic or manic phases, at least when patients complain of altered mood or insufficient balance of affective symptoms despite putative self-medication by substance use.This is a retrospective, observational, case–control study. The research study was implemented using a dataset from previous studies on MMTP carried out in Italy and used in previous published articles . The study included patients treated at Santa Chiara University Hospital, Department of Psychiatry, University of Pisa, Italy during the period 1994–2010. All patients gave their informed consent to the anonymous use of their personal data records for research purposes.Addiction-related information was collected by means of DAH-Q administered by a psychiatrist. The DAHQ is a multi-scale questionnaire that comprises the following categories: demographic data, physical health , mental health , substance abuse , social adjustment and environmental factors , clinical characteristics as frequency of drug use, patterns of use, phase, nosology, treatment history .

Items are set up so as to elicit dichotomous answers .Regarding toxicological urinalyses, we utilized the routine analyses as used for all hospitalized patients. The enzyme-multiplied immuno techniques for opiates, methadone, benzodiazepines, hypnotics, cocaine, amphetamines, hallucinogens, cannabinoids and inhalants were used. Problematic alcohol use was defined according to a lifetime history of frequent intoxication and/or negative consequences of habitual use on their social adjustment .Table 1 shows the demographic and clinical characteristics of our patients according to their present episode polarity. No statistically significant differences among the four groups were observed as regards age, sex, educational level, marital status, job and financial need. Nor were any statistically significant differences observed either among the majority of DAH-RS factors . Table 2 shows differences regarding concomitant substance abuse between the four groups of patients. No statistically significant differences were observed regarding the abuse of heroin. Patients with a depressive episode at clinical presentations showed more frequent use of unprescribed anxiolytic-hypnotics. During a hypomanic episode, patients more frequently used cocaine-amphetamines, while, during a manic episode, patients more frequently used cannabis and cocaine-amphetamines. The associated use of alcohol, cocaine-amphetamines and cannabinoids was more frequently encountered during a mixed episode.As we observed in our sample, patients take anxiolytichypnotics, which belong to the class of central nervous system depressants, with greater frequency during a depressive episode. They take CNS stimulants at a greater frequency during a hypomanic episode, whereas they tend to take both CNS stimulants and cannabinoids with a greater frequency during a manic episode; lastly, during a mixed episode they take CNS depressants , stimulants, and hallucinogens together. In the case of depressed patients, the use of CNS depressants is consistent with their toxicological status. It should be noted that benzodiazepine use in heroin addicts could be correlated with a condition of opiate dependence improperly compensated by street heroin. From a psychopathological standpoint, depressants may aggravate the slowing of cognitive and physical functions caused by depression, but it remains true that these medications are effective in treating insomnia and anxiety, which are often symptoms of depression. Also, patients may not be seeking an actual ‘lift’ of their depression but be searching for a state of ‘oblivion’ in which the pain of depression is cancelled. In depression, what is seen is not a higher use of stimulant substances, but the use of CNS Depressants that may sometimes relieve some aspects of depression – a situation that fails to provide support to Khantzian’s hypothesis. More clearly, Khantzian’s hypothesis does not seem to be supported by the other three kinds of clinical presentations. Patients during a hypomanic, manic or mixed episode, despite experiencing a state of excitement, tend to continue their abuse of psychostimulants, further reinforcing and elevating their mental state. This is consistent with a proposed bipolar-stimulant spectrum where sub-threshold bipolar traits are aggravated by stimulant abuse. If we focus on heroin-dependent subjects, the concomitant use of cocaine is reported to be a relevant phenomenon that will determine negative consequences on social adjustment and outcome.