Cannabis Grow

They further suggest that attentional bias to threat may mediate the association between CB1 receptor availability in the amygdala and threat symptomatology, with greater CB1 receptor availability being linked to greater attentional bias to threat that is in turn linked to greater severity of threat symptomatology. Results of the current study build on extant neurobiological studies that have implicated the endocannabinoid system in the amygdala as an important modulator of anxiety , as well as functional activation of the amygdala in mediating attentional bias to threat among individuals with PTSD . Specifically, results of this study suggest that CB1 receptor availability in the amygdala may directly mediate this endophenotype and its associated phenotypic expression of trauma-related threat symptomatology. Preclinical work suggests that the activation of membrane glucocorticoid receptors appears to engage a G-protein-mediated cascade through the activation of Gs proteins that, in turn, increases the activity of cAMP and protein kinase A. This increase in protein kinase A appears to induce the rapid synthesis of an endocannabinoid signal through an as yet unknown mechanism that may be an increase in intracellular calcium signaling that is then released from principal neurons in the amygdala and activates CB1 receptors localized on the terminals of GABAergic neurons in the amygdala. It should be noted, however, that other mechanisms than CB1 receptor stimulation by anandamide could contribute to the etiology of attentional bias to threat and threat symptomatology. First, the two endocannabinoids anandamide and 2-arachidonoylglycerol have differential roles in endocannabinoid and have distinctly different metabolic pathways fatty acid amide hydrolase for anandamide and monoacylglycerollipase for 2-arachidonoylglycerol; . To date, the relative contribution of these two endocannabinoids and their pathways in the modulation of anxiety remains unclear. Furthermore, recent evidence suggests that CB1 receptor signaling varies across brain regions , and that diverse effects of anandamide–CB1 receptor signaling mechanisms are evident even within the extended amygdala . Finally, the actions of anandamide are not restricted to CB1 receptors,mobile vertical rack as endocannabinoids also act on CB2 receptors , GPR55 , transient receptor potential vanilloid type 1 channels , and other G-protein subtypes .

Although additional research is needed to further evaluate how the endocannabinoid system mediates attentional bias to threat, the results of this study suggest that greater CB1 receptor availability in the amygdala, as well as lower levels of peripheral anandamide, are associated with a greater attentional bias to threat in trauma-exposed individuals. However, we acknowledge, that no human studies that we are aware of have found that anandamide concentrations directly influence CB1 receptor availability, and hence additional work is needed to ascertain how these variables are causally related. Nevertheless, the present data extend prior work linking attentional bias to threat to hyperarousal symptoms to suggest that the CB1 receptor system in the amygdala is implicated in modulating attentional bias to threat that is in turn linked to the transdiagnostic and dimensional phenotypic expression of trauma-related threat symptomatology. Further research will be useful in further elucidating molecular mechanisms that account for the observed association between CB1 receptor availability and the endophenotypic and phenotypic expression of threat processing in humans. An important question to be addressed in future work is whether pharmacotherapies that act on catabolic enzymes for endocannabinoids may be useful in the prevention and treatment of endophenotypic and phenotypic aspects of trauma-related threat symptomatology. Emerging evidence supports the potential utility of such targets, suggesting that variation in the FAAH gene is linked to reduced expression of FAAH that consequently results in elevations in circulating levels of anadamide , as well as decreased amygdala response to threat and more rapid habituation of the amygdala to repeated threat . Notably, elevating anandamide levels via FAAH inhibition appear to provide a more circumscribed spectrum of behavioral effects than blocking MAGL that could potentially result in a more beneficial side effect profile, as anandamide is less prone to CB1 receptor desensitization and resultant behavioral tolerance . These classes of compounds are currently being investigated for their potential efficacy in treating mood and anxiety disorders. Given that core aspects of threat symptomatology such as hyperarousal are key drivers of more disabling aspects of the trauma-related phenotype such as emotional numbing , pharmacotherapeutic targeting of threat symptomatology in symptomatic trauma survivors may have utility in reducing the chronicity and morbidity of trauma-related psychiatric disorders such as PTSD, MDD, and GAD. Methodological limitations of this study must be noted. First, we studied a cohort of individuals with heterogeneous trauma histories.

Although this is typical for most PTSD studies and we endeavored to recruit individuals who represented a broad and representative spectrum of traumarelated psychopathology, additional studies of samples with noncivilian trauma histories will be useful in extending these results. Second, 95% confidence intervals for coefficients in the mediation analysis were markedly wide, and hence additional studies in larger samples will be useful in ascertaining magnitudes of the observed associations. Third, we observed a high correlation between threat and loss symptomatology that may call into question the extent to which these symptom clusters reflect separable components of trauma-related psychopathology that are uniquely related to CB1 receptor availability in the amygdala and attentional bias to threat. Nevertheless, high correlations among symptom clusters of trauma-related psychopathology are not uncommon, with confirmatory factor analytic studies of substantially larger samples often observing intercorrelations among symptom clusters 40.80 . Furthermore, the finding that CB1 receptor availability in the amygdala was associated only with threat, but not loss symptomatology, suggests greater specificity of association that accords with prior work . Fourth, it is important to recognize that our outcome measure in this study, VT, represents specific plus nondisplaceable binding. Because of the lack of a suitable reference region devoid of CB1, we and others using different CB1 receptor ligands cannot directly calculate binding potential , a measure of specific binding. Thus, an implicit assumption in the interpretation of our results is that there are no group differences in VND, the distribution volume of nondisplaceable tracer uptake. An alternative assumption would be that the magnitude of nondisplaceable binding is small compared with the total binding. To definitively address this issue would require a blocking study in humans to estimate VND. To the best of our knowledge, such data are not currently available because of the lack of suitable selective CB1 antagonist drugs approved for human use. Blocking data with the CB1 receptor antagonist rimonabant in baboons , however, did show a large reduction in tracer uptake, suggesting that a substantial fraction of VT can be attributed to specific binding. Notwithstanding these limitations, the results of this study provide the first known in vivo molecular evidence of how a candidate neuroreceptor system—CB1—relates to attentional bias to threat and the dimensional expression of trauma-related psychopathology. Results revealed that greater CB1 receptor availability in the amygdala is associated with increased attentional bias to threat, as well as the phenotypic expression of threat-related symptomatology, particularly hyperarousal symptoms. Given that these results were based on a relatively small sample, further research in larger, transdiagnostic cohorts with elevated threat symptomatology will be useful in evaluating the generalizability of these results, as well as in examining the efficacy of candidate pharmacotherapies that target the anandamide–CB1 receptor system in mitigating both the endophenotypic and phenotypic expression of threat symptomatology in symptomatic trauma survivors.

SU initiation typically begins in the teens. According to the 2016 Monitoring the Future Survey, 7.3% of 8th graders have used alcohol, 5.4% have used marijuana, and 2.6% have used tobacco within the last 30 days. Marijuana,vertical grow rack alcohol and other substances of abuse are known to negatively impact neuro development in adolescents suggesting that the adolescent brain may have heightened vulnerability to toxic substance effects . The Adolescent Brain Cognitive Development Study is a large-scale, prospective, longitudinal, multi-site project designed to study brain and cognitive development in youth, as they transition into adolescence and young adulthood, across the United States . Participating families are recruited through school and community events at each respective ABCD study site, online and paper ads, and word of mouth. This is the first study of its kind in the US to focus on factors of critical importance to trajectories of developmental change in brain and cognition during a period of vulnerability to substance use and other mental health problems. Study outcomes will inform evidence based standards for normal cognitive and brain development, as well as provide large repositories of data and bio-materials for the study of experiential and environmental influences on brain and cognitive development in youth. Focus on the contributions of pubertal hormones, genomic and epigenomic factors, and the interactions across these many influences, are serving as key biological measures for informing our understanding of developmental and behavioral outcomes in the ABCD study. To this end, along with brain imaging, neurocognitive, and other measures, including a comprehensive battery of mental and physical heath, history of SU, behavioral assessments and key bio-samples are being obtained from participating youth . The present manuscript describes the rationales for inclusion and selection of the specific bio-specimens, methodological considerations for each measure, future plans for assessment of bio-specimens during follow-up visits, and preliminary ABCD data for some example topics. All procedures are approved by each site’s Institutional Review Board, and all participants undergo verbal and written consent/assent procedure.A description of the rationales for inclusion and selection of the specific bio-specimens, methodological considerations for each measure, future plans for assessment of bio-specimens during follow-up visits, and preliminary ABCD data to illustrate methodological considerations for all biological samples under collection from youth. These include breath, saliva, urine, hair, blood and baby teeth, collected for purposes of: screening for SU; measurement of pubertal hormone levels; characterization of genetic and epigenetic factors, and analyses of environmental exposures during development from baby teeth. Bio-material obtained from the ABCD Study are being stored in repositories, such as the Rutgers University Cell and DNA Repository , and baby teeth at the Icahn School of Medicine at Mount Sinai in the laboratory of Dr. Manish Arora. These stored bio-materials include measures from the assay of bio-specimens, genotyping, and bio-samples collected for future research. Preparation and processing of bio-samples at the ABCD data collection sites is occurring during or just following baseline assessment of youth, and is planned for follow-up assessments for utilization by members of the scientific community. Results from analyses of all ABCD bio-specimens will be made available through the ABCD Data Repository. Although we anticipate core specimens to be the same across the ten years of ABCD, the kinds and/or amounts of specimens to be collected in subsequent follow-up years may be adjusted to account for: 1. changes in technology; 2. shifts in the scientific questions being addressed ; or additional funding for analyses. Given these considerations, future specimen collections may include measures of the microbiome, parental specimens, or other types of specimens in subsequent follow-up years.The ABCD study baseline visits occur at 9–10 years of age, prior to initiation of SU for most youth allowing for measures of brain, cognitive, environmental, and genetic variability that may precede SU or other negative developmental influences. The ABCD study uses a combination of bio-specimens and self-report to evaluate consistency between biological testing, participant self-report and research assistant assessment of intoxication. Self-report alone may lead to biases due to under-reporting related to individualized motivations, or errors in recall . Further, as seen with youth self-reporting risky sexual behaviors, inaccurate self-reporting may vary as a function of race, gender or age . However, bio-specimen sampling itself is subject to experimental error, and therefore reporting bio-specimen measures in a thorough and standardized manner across published ABCD studies is important for accurate and reproducible results . Self- and parent/guardian-report of SU is conducted through interview and questionnaire survey. Bio-specimens include the annual collection of hair samples to evaluate recent and repeated use of alcohol and other drugs during the 1–3 months prior to testing, and testing of body fluids and breath prior to onsite assessment. Because of the low levels of SU among 9–10 year olds, only a small subset of youth participants are tested in the  first two years of the ABCD Study, with increasingly larger proportions of youth selected randomly for testing as the cohort ages into adolescence, when experimentation, regular, and problem use with substances becomes more prevalent .

The first column of Fig. 3 illustrates this data type using the Area Deprivation Index, a measurement of neighborhood deprivation derived from the American Community Survey. The second column in Fig. 3 illustrates traffic counts, which are point data that were obtained by surveying stations at various geographical locations. In contrast, raster data are usually obtained by model estimation, incorporating multiple sources such as satellite imaging and ground station surveys, as is seen for fine particulate matter in the third column of Fig. 3. The curated GIS database compiled by the ABCD Study LED Environment Working Group includes both vector and raster data of multiple built and natural environmental contextual variables. As shown in Table 1 and outlined in greater detail below, various environmental datasets have been used to map environmental factors to the state-, census-, residential-level for ABCD Study participants to date. Youth grow up in overlapping circles of cultural and socio-political contexts, from their local family and neighborhoods to the states and countries in which they live. We typically focus on the experience of stigma and bias at a relatively local level . Critically, there are also important indicators of more systemic or structural bias reflected in social norms at the community or institutionalized laws, policies and practices that may either reflect the behavior of individuals or shape the behavior of individuals in youths’ local environment. However, we rarely directly examine the relationship between objective measures of systemic/structural bias and function in youth. The ABCD Study provides a novel opportunity to address such critical questions with empirical data, given the geographic variability of the sites involved in the ABCD Study, which affords significant divergence across youth in their exposure to such systemic biases. To address such questions, colleagues at Harvard University created state-level indicators of three types of structural stigma : gender , race , and ethnicity . This information was linked to each youth in the ABCD Study as a function of their baseline site of participation and does not yet include information about whether the child moved to a different state, which may have different state level indicators, at later visits. To create these state-level measures, they used several types of data described in detail in . First, they obtained data about implicit and explicit attitudes about each of these three identity groups aggregated at the state-level, derived from large-scale projects that spanned several years: Project Implicit , the General Social Survey , and the American National Election Survey . Second, for information on gender, they obtained state-level data of women’s economic and political statuses and information about reproductive policies, such as information about availability of abortion providers. Third, for information on attitudes towards Latinx individuals, they examined state-level policies on immigration, recognizing that many Latinx individuals are not immigrants but that such state-level policies likely influence the experience of all individuals in the community with that identity.

These data can be used to examine how these state level biases interact with youth’s identities to predict a range of factors,mobile vertical rack such as educational experience, mental health, brain development, and substance use/abuse. In the United States, public acceptance of cannabis use has increased alongside increased access because of broader cannabis legalization. Currently, 36 states have legalized either recreational or medical cannabis use.However, among younger adolescents , greater exposure to cannabis advertisements was associated with greater use, intention to use, and positive expectancies . The difference in results as a function of age highlights the importance of understanding how cannabis regulations affect younger cohorts of children and adolescents who may have greater exposure to cannabis advertisement after living in an environment with legal access to cannabis for a longer period. Furthermore, the ABCD Study is an ideal dataset to examine the effects of cannabis legalization because there are 21 sites located in 17 states with various state cannabis policies. In addition, the ABCD Study is collecting detailed substance use data unlike other national surveys. Cannabis legalization categories were assigned to participants based on their state of residence. The four cannabis legalization categories are: 1. Recreational – allows adults to use cannabis for recreational purposes, 2. Medical – allows adults to use cannabis for medical conditions, 3. Low THC/CBD – allows adults to use cannabis that is low in THC and high in CBD for medical conditions, and 4. No legal access to cannabis – forbids access to cannabis. Urbanicity can provide information as to the impact of living in urban areas. Urbanicity indices may reflect the presence of environmental and social conditions that are more common in urban areas, such as pollution, congestion, and increased rates of social interactions. To date, various health factors have been linked to urbanicity, such as increases in overweight/obesity, increased calorie intake, decreased physical activity, increased drug and alcohol use, and mental health disorders, among many others . In the ABCD Study, we have linked five measures of urbanicity to residential addresses, including two density measures , census-tract derived metrics classifying the locations as urban or non-urban areas, walk ability, and motor vehicle information including distance to roadway and traffic volumes. Population density refers to the number of people living in a given unit of area . Differences in population density have been linked to psychological and environmental quality of life , and has been shown to moderate relationships between the built environment and health outcomes .

Thus, information about variability of population density may be important for contextualizing relationships between the build environment and health outcomes in the ABCD Study. As such, the population density from the Gridded Population of the World , provided by the Socioeconomic Data and Applications Center , has been linked to ABCD individual participant address information. National-level population estimates from 2010 used in this metric have been adjusted to the United Nations World Population estimates, which can often be corrected for over- or under-reporting and mapped to an ~1-km grid. Population density values represent persons per km2 . Similarly, gross residential density is a measure of housing units per acre on unprotected land and is an alternative measure of crowding. This measure was obtained from the Smart Location Database created by the United States Environmental Protection Agency based on the 2010 Census Data and also linked to ABCD Study individual addresses. While many studies have documented the effects of increased urbanicity on child and adolescent health outcomes, few studies have focused on differential risk associated with living in a rural area relative to an urban area . Although the number of studies devoted to this topic are few, linking this information to the ABCD Study may provide an opportunity to further investigate both positive and negative impacts of living in an rural area. To classify individuals as living in a rural or urban area, urban-rural census tract variables from 2010 were mapped to each address. Based on this external database, the Census Bureau identifies two types of urban areas, including Urbanized Areas of 50,000 or more people and Urban Clusters of at least 2500, but less than 50,000 people. Rural areas are those that encompass all population, housing, and territory not included within an urban area . In urban places, city planning designs have limited the walk ability between work, home, and recreational spaces, with distances too great to walk . Such reduction in walk ability leads to fewer opportunities for physical activity and a risk for health. Understanding potential links between the walk ability of the built environment of the child and physical and mental health outcomes is important in the context of the ABCD Study . A measure of walk ability was linked to ABCD participant addresses using the National Walk ability Index from the Smart Location Database created by the United States Environmental Protection Agency based on 2010 census data. Walk ability scores were calculated at the census-tract level,vertical grow rack ranking each census tract on a range from 1 to 20 according to relative walk ability. The walk ability score is based on a weighted formula that uses ranked indicators as related to the propensity of walk trips.

The ranked-indicator scores used in the weighted formula include a combination of diversity of employment types plus the number of occupied housing, pedestrian-oriented intersections, and proportion of workers who carpool. Beyond population density and walk ability, epidemiological studies have also reported associations between road proximity and brain health. Various neuro development, cognitive functioning, and mental health outcomes have been linked to living near major roadways . As such, the ABCD Study may be valuable to help understand how the distance of a child’s home to major roadways as well as the daily traffic patterns on nearby roadways impacts cognitive and neuro developmental trajectories over time. Therefore, we have mapped road proximity and traffic volume estimates to residential addresses of the child in the ABCD Study to provide insight into both the major roadways nearby and how many cars and trucks typically utilize these roads. the geospatial coordinates of the major roads were obtained through the North American Atlas for roads, as last updated July 2012 , and the shortest distance to a major roadway in meters was linked to participant’s residential addresses. In the field of developmental cognitive neuroscience, socioeconomic status has traditionally been treated as an individual-level variable, specific to each family or person. However, socioeconomic status can also be attributed to neighborhoods and communities, which may represent an independent construct from family-level socioeconomic status with considerable effects on child development . In the ABCD Study, detailed questions are asked about socioeconomic and social factors at the family-level. Thus, the ABCD Study is an ideal dataset to examine the independent and multiplicative associations of family- and neighborhood-level socioeconomic status on adolescent health. Investigations with these ABCD data can elucidate the underlying mechanisms by which various contexts uniquely influence development and potential emerging health disparities . Accordingly, the ABCD Study has incorporated the Area Deprivation Index measure of neighborhood-level socioeconomic status in past data releases, as well as information on crime and risk of lead exposure. Moving forward, three additional metrics, including the Social Vulnerability Index, Opportunity Atlas, and the Child Opportunity Index, have been linked in the 4.0 annual data release. The neighborhoods in which children in America grow up can influence outcomes in adulthood. As such, the Opportunity Atlas estimates measures of average outcomes across 20,000 people in adulthood according to the census tracts in which they grew up . The ABCD Study includes scores from the Opportunity Atlas that indicate the predicted 2014–2015 mean income earnings of adults aged 31–37 years that grew up in that census tract as children. Scores are provided based on the childhood census tracts of the Opportunity Atlas cohort, but we also provide the adult mean earnings disaggregated by parental household income percentiles based on the national income distribution during their childhood. For example, the mean income earnings at the 25th percentile rank correspond to the mean income earnings of adults whose parents were at the 25th percentile of the national income distribution.Although the outcomes for census tracts are based on children who were born in those tracts between 1978 and 1983, Chetty et al. suggest that these longitudinal outcomes are best suited for measuring stable outcomes in earnings in adulthood. Linking measures from the Opportunity Atlas to the ABCD Study allows for objective measures of neighborhood economic opportunity to study in relation to health outcomes in ABCD youth. However, while the Opportunity Atlas estimates can be used as predictors of economic opportunity for children today, it is important to combine these estimates with additional data to determine applicability to neighborhoods that have undergone substantial change in the last several decades. There are vast differences in neighborhood access to opportunities and quality of conditions for children across America, including access to good schools and healthy foods, green spaces such as safe parks and playgrounds, safe housing and cleaner air. These inequitable neighborhood differences can negatively influence the current living conditions of a child, as well as development throughout childhood and subsequent health outcomes in adulthood . Children who grow up in neighborhoods with access to more educational and health opportunities are more likely to grow up to be healthy adults.

Significant sex differences in these domain summary scores were followed by analyses of covariance adjusting for covariates and biopsychosocial factors. Lastly, among HIV-positive and HIV-negative participants, we examined the moderating role of sex in the relationship between HIV serostatus and the likelihood of NCI in two logistic regression approaches: inclusion of an HIV-serostatus by sex interaction term and examination of the HIV and NCI relationship in sex-stratified analyses. Significant effects were followed by stepwise logistic regressions adjusting for covariates and individual biopsychosocial factors . Significance was set at P value less than 0.05. Analyses were performed using SPSS . Given race/ethnicity differences in the prevalence of biopsychosocial factors and NCI, analyses were repeated within nonhispanic whites and blacks.Our findings present evidence supporting greater NCI among HIV-positive women than HIV-positive men. Race/ethnicity-stratified analyses indicated that this sex difference was primarily due to a higher proportion of black women in the HIV-positive, versus HIV-negative, group. We extend previous findings by determining whether discrepancies in biopsychosocial factors may explain higher rates of HIV-associated NCI in women. In partial support of hypotheses, adjusting for low reading level eliminated the sex difference in HIV-associated NCI. The race disparity in findings may be due to the overall higher rates and larger sex difference in biopsychosocial factors in blacks versus whites. The race disparity may also be partially due to race/ethnicity differences in health literacy, which have accounted for racial disparities in age-associated cognitive decline. Perhaps sex differences in HIV-associated NCI are more common in the context of low health literacy possibly due to sub-optimal engagement in HIV care/treatment. Alternatively, reading level may represent other NCI risk factors that show a female preponderance among black, HIV-positive individuals but were unmeasured.

Our race/ethnicity differences may explain inconsistent findings. Because our sample included more black women with lower reading level,grow cannabis the sex differences in HIV-related NCI may be more evident than in predominantly white samples. Low reading level was the only biopsychosocial factor to attenuate the sex difference in HIV-associated NCI in the overall sample and blacks. This may be because, among the biopsychosocial factors, low reading level demonstrated the strongest relationship with NCI and the largest sex difference. Low education was not associated with NCI likely because NCI was determined using education-adjusted, neurocognitive T-scores. SUDs were not associated with NCI possibly because most SUDs in our sample were not current . Furthermore, reading level may better reflect education quality than years of education, especially in lower socioeconomic populations because of the many factors impacting education quality. Notably, low reading level, but not education, was a risk factor for cognitive decline among ethnically diverse elders in the general population. In addition, reading level is associated with health outcomes, including hospitalizations and outpatient doctor visits, and, thus, may be a proxy for biopsychosocial factors underlying general health . Although mean syndemic count was higher in HIV positive women versus HIV-positive men, adjustment for syndemic count did not attenuate the sex difference in HIV-associated NCI, suggesting that the other biopsychosocial factors dilute the sex-related variance explained by reading level.Given findings that stress is more strongly associated with trajectories of cognitive impairment than depression in HIV-positive women, a syndemic count that included factors such as early life trauma and perceived stress may better capture biopsychosocial differences between HIV-positive men and women. Sex differences in the profile of HIV-associated NCI were only observed within race/ethnicity groups. Among whites, women demonstrated poorer learning than men, and this difference was attenuated after adjusting for reading level. White women also demonstrated poorer verbal fluency than white men and this difference was unchanged after adjustments. The sex difference in HIV associated NCI among blacks was not driven by specific cognitive domains. In fact, in contrast to whites, black women outperformed black men in verbal fluency and this difference was unchanged after adjustments. Sex differences in verbal fluency were likely masked in the overall sample due to differing associations within race/ ethnicity groups.

The sex by HIV interaction was not significant; however, sex-stratified analyses suggest a moderating role of sex in the HIV and NCI association, particularly in blacks. Compared with their HIV- counterparts, NCI was 3.5 times more likely in black, HIV-positive men but six times more likely in black, HIV-positive women. Adjustment for reading level marginally attenuated the HIV and NCI association in black women, suggesting that the large discrepancy in reading level between HIV positive and HIV-negative black women contributes to the higher risk of NCI in HIV-positive black women. Conversely, the HIV and NCI association was unchanged with adjustments in black men. Previously reported sex differences in disease characteristics unmeasured herein may contribute to sex differences in HIV and NCI associations. Overall, results suggest that HIV-positive black women are at the highest risk for NCI. Our study has limitations including the small proportion of women and, thereby, the potential of being under powered to detect an HIV by sex interaction. We were also unable to explore certain biopsychosocial factors . Study strengths include the large sample, an HIV-control group, race/ethnicity-stratified analyses and a comprehensive test battery that defined NCI. Demographically adjusted T-scores based on HIV- data allowed us to examine sex differences in HIV-specific cognitive profiles; however, by restricting this analysis to HIV-positive individuals with NCI, our statistical power was limited. In conclusion, we contribute evidence that HIV associated NCI is more prevalent in women versus men and indicate that this difference is accounted for by a lower reading level among HIV-positive women. The frequent sub-optimal educational experience of HIV positive women and the resulting lower cognitive reserve may make HIV-positive women more susceptible to HIV-associated NCI. The effect of HIV on NCI was also greater in women versus men, particularly among blacks. Adjusting for education quality rather than years of education may improve the specificity of neuropsychological tests for measuring cerebral dysfunction and sex differences in HIV. Clinically, practitioners should be advised that black HIV-positive women appear to be particularly at risk for NCI and provide resources to accommodate for these possible impairments.Alcohol and SUDs in general are associated with dysfunction, primarily in the domains of learning/memory, working memory, and other executive-based skills, including cognitive/inhibitory control . Persons with alcohol use disorder have been studied most, with the nature and level of impairment showing considerable variability. Approximately 55% of AUD manifest clinically significant neurocognitive deficits after acute detoxification , but some degree of recovery from these deficits is apparent with short-term , intermediate-term , and long-term abstinence from alcohol .

Some dysfunction has been reported to persist into long-term abstinence from alcohol, particularly in the domains of executive and visuospatial skills, learning and memory, and postural stability . The degree of cognitive dysfunction and the rate of recovery during abstinence appear to be influenced by many factors such as age, sex, family history of AUD, treatment history, pretreatment alcohol consumption level, number of detoxifications, nutritional status, comorbidpsychiatric and biomedical conditions, and comorbid SUD . Most treatment-seeking substance users today concurrently and/or simultaneously consume more than one illicit/licit compound, so-called poly substance users . Among PSU, comorbid tobacco use disorder is most prevalent in AUD , and chronic cigarette smoking itself is associated with significant neurocognitive deficiencies in both AUD and non-AUD cohorts . Smoking AUD performed worse than their nonsmoking counterparts on domains of auditory verbal learning and memory, processing speed, cognitive efficiency, and working memory during the first month of abstinence from alcohol . Smoking AUD also demonstrated poorer neurocognition with increasing age than never-smoking AUD, and the performance of former-smoking AUD on several domains was intermediate to that of never-smoking and actively smoking AUD . Particularly common among PSU is the simultaneous and/or concurrent abuse of alcohol, tobacco, and psychostimulants . Therefore, in many published research reports on the neurobiological and neurocognitive consequences of AUD, many individuals were also likely nicotine-dependent, and in studies of cocaine use disorder, participants were also likely heavy drinkers. This was both likely and most apparent in literature before about 2010, when poly substance abuse had not been attended to more widely in substance abuse research, and other substance use was largely treated as a nuisance variable. More recently,indoor cannabis grow system poorer health outcomes and greater treatment resistance have been reported for PSU compared to monosubstance users . Despite its prevalence, however, few studies have directly examined the neuropsychological or neurobiological consequences of poly substance abuse. In early studies, cocaine-dependent individuals with and without AUD showed cognitive deficits at 3 months of abstinence , and decision-making was still impaired in similar individuals abstinent for 8 months . Even after several years of abstinence, psycho stimulant-related deficits of episodic memory, planning, and cognitive flexibility were persistent in PSU . These relatively persistent cognitive deficits were associated with the amount of cocaine and cannabis consumed as well as with relapse risk .

Cognitive efficiency, processing speed, and visuospatial learning were less impaired in 1-month-abstinent PSU who continued to abstain versus those who subsequently relapsed between 1 and 4 months of abstinence ; similarly, 1-month-abstinent AUD with the lowest processing speed showed a significantly increased risk for relapse following treatment . In comparisons to 1-month-abstinent AUD, 1-month-abstinent PSU performed worse on measures of auditory verbal memory and learning and general intelligence , suggesting a diminished capacity of learning, memorizing, and integrating new skills presented in clinical treatment settings. In addition, PSU exhibited worse decision-making and higher self-reported impulsivity than AUD, potentially placing them at a greater relapse risk during early recovery. Finally, PSU between the ages of 25 and 70 years showed greater age-related declines in processing speed, general intelligence, cognitive efficiency, and global intelligence than controls, indicating the detrimental cumulative effects of poly substance use on neurocognition . As described, the degree and nature of neurocognitive deficits varies considerably among substance-using groups investigated, critically related to the combination of both illicit and licit substances abused and their use histories. However, it is noteworthy that even mild neurocognitive deficits can impact quality of life and relapse risk . Impaired neurocognition and inhibition may adversely affect maintenance of abstinence during treatment and long-term treatment efficacy ; specifically, neurocognitive deficits can interfere with treatment efficacy by reducing the individual’s ability to encode, process, recall, integrate, and apply program information during and following treatment . As such, assessment of cognitive abilities during treatment may improve treatment outcomes by providing clinicians an understanding of the individual’s capabilities during treatment and inform appropriate post treatment follow-up care . Studies of longitudinal neurocognitive changes during abstinence from alcohol and other substances are far less common than cross-sectional studies . Most longitudinal studies assessed neurocognition several weeks after detoxification and then 6–12 months later; they demonstrated several neurocognitive functions improve at least partially during sustained abstinence, whereas some cognitive dysfunction persists for years after detoxification . Psychological changes in AUD during a residential rehabilitation program have recently been documented and include significant decreases in anxiety, depression, and psychological distress within about 1 month of detoxification in those with substance-induced mood disorders . In studies on the effects of comorbid tobacco use on neurocognitive recovery in AUD , we found that smoking was associated with significantly diminished improvement of visuospatial learning and processing speed within the first year of abstinence from alcohol . We analyzed neurocognition across three different time points during abstinence from alcohol and as a function of smoking status . Over 8 months of abstinence, AUD as a group showed significant improvements of visuospatial learning and memory, processing speed, and working memory, with less pronounced changes in executive functions, postural stability, and auditory verbal learning and memory. Overall, the recovery rates were nonlinear over time, showing faster recovery between 1 and 4 weeks than between 1 and 8 months of abstinence. Improvements in the foregoing domains in AUD were driven by never-smoking AUD, where both former-smoking and actively smoking AUD showed significantly less recovery than never-smoking AUD. Additionally, active smokers showed significantly less improvement with increasing age than never-smoking AUD over 8 months on measures of processing speed and learning and memory. At 8 months of abstinence, currently smoking AUD remained inferior to controls and never-smoking AUD on multiple measures, former smokers performed worse than never-smoking AUD on several tests, but never-smoking AUD were not significantly different from controls on any measure.

We calculated change in both absolute and relative differences across race/ethnicity, because relative differences can increase, even as absolute differences narrow. Relative differences depend on the rate in the reference group ; as rates in the reference group decline, a shrinking absolute difference may correspond to a widening relative difference. To calculate the difference in expected vs. observed counts, we subtracted model-predicted counts from actual arrests during the corresponding period. Confidence intervals were obtained by bootstrapping using 1,000 replications. All analyses were conducted using Stata Version 15.Felony drug arrest rates dropped immediately and precipitously for all racial/ethnic groups during the first month, and continued to decrease over time . In the year prior to Prop 47, the proportion of drug arrests that were felonies was highest for Blacks , suggesting that Blacks would have the most to gain from reclassification of drug felonies to misdemeanors. However, Prop 47 did not reclassify all felony drug offenses, only drug possession. In the year before Prop 47 was passed, the proportion of felony drug arrests for offenses that would be reclassified was 73% among Blacks, vs. 86% among Whites and 83% among Latinos. Thus, relative to Whites and Latinos, we would expect a smaller percentage decline in felony drug arrests of Blacks resulting from Prop 47. Consistent with these predictions, the models adjusted for secular and seasonal trends showed a significant, immediate decline in monthly felony drug arrest rates of 81 per 100,000 among Blacks, compared to declines of 44 among both Whites and Latinos . As a result, the absolute disparity in Black-White felony arrest rates declined by 37 per 100,000 in the first month, from a difference of 81 per 100,000 in the month pre-passage ,vertical grow systems for sale and continued to decrease over time. Felony drug arrest rates among Whites and Latinos were nearly equivalent in the month pre-passage and no difference was evident by one year post-passage.

Though Blacks had the largest decline in absolute felony drug arrest rates, they had the least proportional decline, likely because they had lower proportions of felony drug offenses that were reclassified to misdemeanors by Prop 47. In the first month, felony drug arrests among Blacks declined by 60% , compared to 69% among Whites and Latinos . With a larger percentage decline among Whites, the relative Black-White disparity increased by 27% . Though proportional declines in felonies continued to grow over time for all racial/ethnic groups, differences in declines across groups grew as well. By one year post-passage, felony rates among Blacks were 3.09 times higher than those of Whites , compared to 2.16 times higher in the month pre-policy . The difference in the number of felony arrests made, compared to the number expected based on secular and seasonal trends, was substantial. During the first year of adoption, Prop 47 led to an estimated 51,985 fewer felony arrests among Whites, 15,028 fewer among Blacks, and 50,113 fewer among Latinos . These represent reductions of 75.9%, 66.1%, and 73.7%, respectively. Our analysis of 60 months of county, race, and offense-specific arrest rates in California point to several notable effects of Prop 47. There was little indication of elevated drug arrest rates in Latinos compared to Whites before or after Prop 47, while the large absolute Black-White difference in felony drug arrest rates was reduced. With a higher proportion of felony drug offenses affected by Prop 47 , Whites had the greatest proportional decline in drug felonies, contributing to an increase in the relative Black-White disparity. Prop 47 appears to have led to reductions in arrests for drug offenses overall , which saw a decrease in the absolute Black-White difference, while relative disparities remained the same. There has been little study of the impacts of reducing offense severity on racial disparities in criminal justice involvement. In one exception, researchers found that reforming marijuana laws reduced arrests across all racial/ethnic groups, with no change in relative disparities between Blacks and other racial/ethnic groups . This aligns with our finding on Prop 47’s effect on total drug arrests, though we find increases in relative disparities for felonies.

Why did reducing the classification of some drug offenses reduce drug arrests overall? Reductions in drug arrests were unlikely a reflection of underlying crime trends – violent and property crime rates increased during this period . Prop 47 was a ballot initiative and law enforcement may be responding to perceptions of public opinion about public safety priorities. In areas with high rates of violent crime, police agencies may welcome a freeing up of resources to focus on these offenses. Officers may use their discretion to opt out of drug arrests and focus on offenses their department prioritizes. The initial drop in total drug arrests followed by the rise in month three suggests officers may also be responding to feedback from the courts regarding how to interpret and act on the legislative change. Reductions in arrests for all drug offenses may also reflect fluid lines between drug possession and sale. One lieutenant explained to the first author that in his city, sellers typically plead out to possession up to the third arrest, while arrests for possession were used to get information on sellers . Reducing possession to a misdemeanor may have diminished tools police and prosecutors used to enforce drug laws, contributing to a de-emphasis on arrests. These impacts warrant further investigation. While the absolute Black-White disparity in felony drug arrests decreased, the relative disparity increased, in part because of differences in pre-existing felony offense composition by race/ethnicity. Blacks had larger proportions of felony drug offenses unaffected by Prop 47 did not alter, such as sale. Whether this reflects racial differences in offending, or racial biases and practices in drug law enforcement, cannot be determined from our data, but other studies point to the latter . Prop 47 targeted drug possession, with the aim of decriminalizing substance use disorder. However, distinctions between sale and possession can be murky and influenced by prosecutorial discretion concerning which charges to file. Further study of racial inequalities in drug charges could help to address this unintended effect in California and states considering similar policies. Given substantial evidence of the role of social and economic factors in health outcomes , reducing incarceration and felony convictions through policy reform may be a critical component to addressing racial disparities in health. Our findings suggest that reclassifying drug offenses to misdemeanors is an effective approach to decreasing felony arrests across racial/ethnic groups, and absolute differences between Blacks and Whites.

However, a full assessment of how reducing criminal penalties affected racial/ethnic disparities in criminal justice involvement must go beyond the stage of arrest, particularly since groups may differ in the prevalence of prior convictions, which affect the likelihood of prosecution. Still, there is clear evidence that on a population level, there were declines in incarceration resulting from Prop 47,vertical grow system providing an opportunity to evaluate how reducing exposure affects health and associated racial/ethnic disparities, including the health of families and communities most affected by high rates of incarceration. Regarding more direct health impacts, a core component of Prop 47 was to reinvest savings from reduced incarceration to buttress substance use disorder and mental health treatment, with grants totaling $103 million awarded to 23 city and county agencies in mid-2017 . Prop 47 generated debate about whether arrestees would lose the incentive to enroll in treatment without a felony threat, which remains to be evaluated . Alternatively, populations accessing treatment or the proportions entering through voluntary vs. court-referred admissions may change . Racial disparities in substance treatment access could be impacted by Prop 47 as well. Blacks and Latinos arrested for drug offenses are more likely than Whites to receive incarceration, rather than drug treatment diversion . Sentence standardization initiated by Prop 36 in 2001 reduced disparities, but had a greater impact on Latinos than Blacks, perhaps because Blacks had more prior drug and violent offenses that precluded eligibility for diversion. Treatment resources generated by Prop 47 may have more promise for reducing disparities, given broader participant eligibility criteria stipulated in grant requirements . Critical questions remain regarding how shifting funds from a criminal justice to a public health approach to substance use disorders will influence treatment enrollment and outcomes for health, well-being, productivity, and public safety.

New programs funded by Prop 47 offer opportunities to evaluate these questions, and identify the most effective models for improving public health. In arrests with multiple offenses, only the most severe is included in the dataset. Since Prop 47 reduced the severity of drug possession offenses, one concern is whether some reduction in arrests could be attributed to co-occurring offenses that became comparatively more severe than drug possession postProp 47. This could occur only in measures incorporating offenses classified as felonies pre-Prop 47 and misdemeanors post-Prop 47. These would include drug arrests reclassified by Prop 47 and total drug arrests, but would exclude felony drug arrests, misdemeanor drug arrests, and felony drug arrests unaffected by Prop 47. We used data on juvenile arrests, which contain up to five co-occurring offenses, to estimate possible bias. We found that potential masking was minimal and would not alter findings. Approximately five percent of “drug arrests reclassified by Prop 47” may have been masked post-policy – far less than the 46-51% declines in this category 12 months post-policy. Masking in the “total drug arrests” measure was estimated at three percent, compared to declines of 17-22% at 12-months post policy. Data are also event-, rather than person-level. Some arrests may represent the same person, though we minimized this possibility by using monthly rates. We assessed the extent of possible bias by linking individuals on name, date of birth, and jurisdiction for July 2013; just 1.2% were arrested more than once and 0.1% more than twice. We also lacked data on prior convictions; Prop 47 offenses retain felony classification for individuals with serious and/or violent convictions such as homicide and sexually violent offenses, or convictions requiring registration as a sex offender. The history of more frequent arrests and severe charges among Blacks arrested for drug offenses , may have minimized the effects of Prop 47 on reducing Black-White disparities in felony convictions. Given that other states are pursuing similar policy changes to reduce racial disparities , this effect should be further explored, and limiting prior record exclusion criterion considered. Race/ethnicity in arrests data may be based on officers’ observations, rather than self-report, in population denominators. This could lead to misclassification of the numerator in arrest rates, though sensitivity analyses indicated findings were robust. We also only analyzed three racial/ethnic groups; though these groups make up 95% of arrests in California, further research could assess disparities and impacts among other populations.State-level criminal justice reforms often leave a great deal of room for interpretation and discretion. There can be a tension between the goals of state legislators enacting criminal justice laws and county level officials who administer them, leading to highly county-specific implementation . As an example, mandatory minimum sentencing laws were seen as tough on crime and therefore historically supported by state legislators as a symbolic statement. They were opposed by courts, however, because they increased trial rates and case processing times, and penalties were considered disproportionately severe . In his review of two centuries of mandatory minimum sentencing laws, Tonry found a long history of courts using devices to circumvent them: prosecutors refused to file charges, plea bargaining was used to reduce charges, and judges refused to convict or ignored the statute and imposed a different sentence . When severe mandatory minimums for drug sale were in place in Michigan, for example, nearly every charge was reduced to possession , while harsh minimums for felony possession during the Rockefeller drug law era in New York were circumvented by reducing charges to misdemeanors or referring defendants to drug courts . Scholars have proposed that differences in local contexts determine how discretionary options are used within locales, producing geographic variation in case dispositions. Specifically, cases are prosecuted in accordance with personal and local principles of proportionality , local political leanings, resources for prosecution, and community priorities .

In practice, GMO labeling has not given EU consumers greater choice, because food processors in Europe have recombined ingredients away from GMOs to avoid labeling. As suggested by comments from meat packers, the same pattern may develop with COOL. Just as intended, COOL is a non-tariff barrier to trade; this does not necessarily mean that it will be challenged at the WTO, but it could be vulnerable to such a challenge, or subject to negotiation. At the WTO, country-of-origin labeling is covered as a technical regulation subject to the WTO Agreement on Technical Barriers to Trade which states that countries are allowed to take measures to protect human health or prevent deception of consumers, subject to the requirement that countries are not unjustifiably discriminated against, and that measures do not constitute a disguised restriction on trade.In NAFTA, country of origin labeling is allowed, but requirements must be minimally difficult and costly. Concerns about meeting this requirement may have been what initially prompted Secretary of Agriculture Ann Venneman to speak positively about the suggestion that a “North American” label could be appropriate . COOL compliance may be most costly for developing country suppliers to the U.S. market who lack record keeping infrastructure to maintain audit trails. To this extent, COOL directly conflicts with the spirit of trade liberalization in the Doha Development Agenda, which aims to give preference to the trade agendas of developing countries. To justify the continued existence of the Export Enhancement Program, which purports to offset subsidies and other trade-distorting practices used by other countries, Congress expanded its list of unfair trade practices to include “unjustified trade restrictions or commercial requirements, such as labeling, that affect new technologies, including biotechnology” .

The irony of this new requirement in the same bill mandating country-of-origin labeling will not be lost on U.S. trading partners where consumer distrust of biotechnology, whatever its scientific merits,vertical grow system is an important phenomenon. Challenging labeling of GMOs at the WTO may be more difficult after the passage and implementation of the 2002 COOL regulation.The 2002 Farm Bill roughly doubles annual federal expenditure on environmental programs, including the Environmental Quality Incentive Program , the Conservation Reserve Program and the new Conservation Security Program , from $2 billion to $4 billion, over 1996 levels.Each of these programs benefits producers in California.EQIP provides technical assistance, cost sharing, and incentive payments for producers that undertake qualifying practices that provide environmental benefits. The new CSP provides incentive payments of about $300 million per year for the maintenance or implementation of soil, water, and air quality conservation activities. By paying producers to maintain practices they have previously found to be profitable to undertake, CSP payments are not necessarily intended to internalize environmental externalities but are certainly intended to support agricultural incomes. The continued exemption of environmental payments from support ceilings makes payments for environmental benefits an attractive program for policy makers wishing to subsidize agriculture while meeting WTO obligations. International trading rules have only recently become potential constraints on the form and content of U.S. domestic support to agriculture. The Uruguay Round Agreement on Agriculture introduced a major reform that the U.S. must take into account when setting domestic agriculture policy: a ceiling on so-called trade distorting domestic support for agriculture.

All support for agriculture must be classified as trade distorting, minimally trade distorting, or non-trade distorting, and, while total support levels are unconstrained, trade-distorting support must fall at or below a negotiated cap that declines over time. “Amber box” support is trade-distorting and counts towards countries’ negotiated cap, and “green box” support is deemed not trade-distorting and may be allowed without limits.14 Since supposedly non-distorting “green box” spending is not subject to a cap on support expenditure, identifying support measures that can qualify as “green box” is valuable from the perspective of policymakers wishing to both subsidize agriculture and meet WTO obligations. Green box support includes income support not related to production decisions , environmental and land retirement program payments, domestic food aid, research and extension services, and export promotion programs like the MAP. Over 80 percent of U.S. domestic support for agriculture in 1998 was defined as “green box” by the USDA in 1998 .From 1995 to 1998, U.S. aggregate measure of support to agriculture declined while Green box support grew slightly.While the rules for some of the environmental programs, in particular the CSP, are still being developed, in general, environmental payment programs can be designed for inclusion in the WTO green box, making increased funding for these programs attractive. Domestic support qualifies for the WTO green box if the measure, is paid for by federal government revenues , does not provide price supports, and does not distort trade or has minimal effects on trade. Environmental payments in particular must be limited to the extra cost or loss of income incurred as a result of participation in the program. Some authors have argued that, whatever its merits as a negotiating position, subsidies for agriculture as a means of generating desirable joint outputs or environmental benefits is poor public policy . This is principally because subsidies for agriculture or payments to agricultural producers for environmental services do not directly target the production of the desired nonfood outputs but do so indirectly.

In general, less transparent programs lacking clear environmental goals are unlikely to be cost-effective means of achieving desired environmental outcomes. Bohman et al. give the example of beautiful meadows to illustrate this claim. Meadows are desirable, and one way of creating them is to provide support to dairy farmers; in this case, meadow existence is indirectly supported. A more transparent policy, more closely targeted to meadow creation, would be to compensate people for maintaining meadows. Dairy farmers may or may not be the most efficient providers of the desired good. More generally, other social objectives can be accomplished by broader development initiatives , and environmental externalities can be internalized through targeted and transparent regulations and taxes. The key empirical question, on which further research is needed, is which desirable nonfood outputs are genuinely joint outputs of food production, and which of these would be supplied at a socially inefficient level if food production were not subsidized . Too often, proponents of multi-functionality may overstate the extent to which positive environmental or social externalities are truly joint outputs of food production as an excuse to avoid the politically difficult task of reducing subsidies to agriculture. Environmental goals might be more cost-effectively achieved with policies not intended to subsidize agriculture.California agricultural producers cannot all win from increased trade liberalization. Ending government support for agriculture and lowering tariff barriers will inevitably benefit some more than others. On the whole however, California producers sell high value competitive products, and their major markets, especially Japan and the EU,cannabis plant growing remain protected and difficult to penetrate. Coordinated liberalization that affords California increased access to these markets, even if at the expense of increased competition from China and Mexico, could be an important opportunity. This is all the more true because most of California’s agricultural producers have few subsidies to give up. Even the loss of the export promotion programs would not be very costly; these programs provide little benefit to the industries they support. Because California agricultural producers as a whole stand to gain from global trade liberalization, if the 2002 Farm Bill jeopardizes the possibility of wide ranging reform at the WTO, it may be correct to conclude that the Farm Bill was costly to California farmers. Negotiations are currently stalled; largely over disputes about government support to agriculture in the U.S. and EU. The international response to the 2002 Farm Bill has generally been negative; the Bill has been characterized as politically motivated, and a violation of the spirit, if not the law, of the U.S. commitment to reduce domestic subsidies for agriculture undertaken in the URAA and at the commencement of the Doha round of negotiations.

It does appear that the U.S. will not violate its support cap of $19 billion as a result of the 2002 Farm Bill , although this depends on whether the U.S. commits explicitly to reducing support outlays in the event that a violation appears likely. Yet there is some suggestion that the moral authority of the U.S. as a proponent of liberalization at negotiations has been compromised. Others argue that new provisions of the Farm Bill may represent bargaining chips that can be used in negotiations to encourage other developed countries to reduce their own support for agriculture . The current U.S. negotiating position, announced in July 2002, proposes further tariff reductions, an end to export subsidies and a somewhat tighter cap on amber box domestic support . Despite the negative international reaction to the Farm Bill, there remains a relative consensus, at least in the popular press, that the EU’s CAP is possibly more damaging to developing country agriculture than U.S. farm policy. In addition, as recently as January 2003, the French government reaffirmed its commitment to protect French farms from international competition. It is difficult to predict how this unapologetic stance, in contrast to the continuing claims by U.S. representatives at the WTO that their country is committed to reform, will impact WTO negotiations. The U.S. balancing act between a stated commitment to trade liberalization at the WTO and the 2002 Farm Bill also contrasts with the position of the Cairns Group of countries at the WTO.17 The Cairns Group countries , provide little domestic support for agriculture and are relatively competitive producers expected to benefit from trade liberalization. The Cairns group has called not only for substantial reductions in distorting domestic support and an end to export subsidies, but also a stricter interpretation of the rules for including support measures as green box support. The group’s negotiating proposal states that “since the conclusion of the Uruguay Round the green box has been abused” .18 Certainly, it is plausible that, even if individual programs in a country’s green box claim do not distort trade, the total level of green box support may do so. Given the wide differences between the visions of the EU and the Cairns Group, with the U.S. somewhere in between, trade negotiations will continue to be difficult. 19Government influences agriculture everywhere. This chapter reviews some of the most significant governmental programs that influence California agriculture and highlights similarities with and differences from agricultural policy elsewhere. The chapter describes government programs that support California commodities and attempts to quantify that description. We present new producer support estimates building on the work of Sumner and Hart. Federal government programs and some California state programs support California agriculture. The central legislative basis for federal farm programs is now the Farm Security and Rural Investment Act of 2002 . The law affects program crops and provides a framework for government support of some conservation programs that affect a wider array of commodities. We also discuss the implication of implementation of the Uruguay Round Agreement on Agriculture , which became effective in 1995. Federal budget outlays that support California agriculture are also covered. The most important of the California state policies that we cover is the milk marketing order. However, we also discuss other state marketing orders and state outlays for agricultural support.Other chapters in this book have dealt with environmental and resource policies that are particularly important in California. Labor market policy is also important and the subject of a separate chapter. Here we focus the discussion mainly on farm commodity programs, but other governmental policies that provide support to agriculture are also included in the review. As noted throughout this book, one of the most striking aspects of California agriculture is the breadth of commodities produced. This breadth makes it nearly impossible to deal with each of the policies or programs that may be important for government support for agriculture. We highlight major programs that affect the most important handful of the commodities grown commercially in the state. Government’s overall effect on agriculture includes the impacts of a variety of policies that affect business in general. These policies include taxes on sales, income, excise, and real estate property, as well as provisions of infrastructure, education, and other government services. In addition, regulation of certain other businesses may affect agriculture indirectly. While these general policies pertaining to business may be important, they will be dealt with here only to the extent that agriculture is treated differently from other industries.

The lower endorsement of the two trauma items and one schizoid personality item may be the result of the stigma that is associated with abuse, specifically sexual abuse, and severe mental illness, e.g., being afraid of being crazy. For social support, participants indicated that a majority felt they had family members who they could talk to and rely on. Similarly high was the frequency for having peers to hang out with and not talk about work or family issues. Overall, nearly all participants indicated at least one form of social support. That is, they said yes to at least one or more items on the survey. Affirmative responses for substance problems were calculated for answers that indicated some lifetime use. For example, positive answers to using substances one year ago or more recently were coded yes. The majority of participants said that alcohol and other drug use never made them feel depressed or experience any other kind of psychological problem. Half of the participants indicated that they used AOD weekly or more often in the past 2-12 months compared to a third saying they were trying to hide AOD use, and parents or others complained about their AOD use for the same time frame. Irrespective of a time frame, a majority of participants reported using AOD weekly, and indicated that others were complaining about their AOD use at some point in their lives. Therefore, it appears that a large proportion of the sample showed problematic substance use behaviors or substance problems. Table 1 represents the percentages of affirmative responses to the study items.In order to address hypothesis 2.1, a CFA determined whether the measurement model for trauma,growing cannabis outdoors schizoid personality, social support, and substance problems was valid for the youth offender sample. A CFA was performed on the entire sample using the factor structure indicated by previous research.

The aim of the CFA was to validate the four-factor structure for the sample; that is, it served to reveal whether the four latent constructs can be measured by the observed variables or survey items. The trauma factor was specified by eight indicators, all of which comprised a sub-scale of past traumatic experiences on the GAIN General Victimization Scale. Schizoid personality consisted of six indicators, all of which reflect criteria of the DSM-IV-TR and relevant case studies . Substance problems were measured by five indicators of the recency of problematic drug-using behaviors. Social support was measured by nine indicators capturing different sources of support at school, work, home, or outside of school. Each indicator had an error term indicated by the small error pointing to it as depicted in Figure 1. The error on the indicator reflects variance that is not explained by the latent factor. Factor loadings were considered adequate for values greater than 0.30 . The unstandardized factor loading of the reference variable for each factor was set to 1.0, while the remaining variables were allowed to be freely estimated. The following goodness-of-fit statistics helped to determine adequate model fit: the comparative fit index , the Tucker-Lewis Index , and the root-mean-square error of approximation were consulted. CFI and TLI values close to .95 , and RMSEA values below .08 were considered adequate . The chi-square fit statistic was examined but given less weight in determining fit because of its sensitivity to sample size and the increased likelihood for committing a type I error . Modification indices were requested in order to assess whether correlating any indicator error terms would improve overall fit. Decisions for modifications were based on the value of the modification index, the standardized expected parameter change, parsimony, and general fit. Good model fit demonstrated how well the estimated variance-covariance matrix resembled the observed variance-covariance matrix.

Good model fit indicates that the model is appropriate to detect observed relationships and that it is able to explain a large percentage of the endogenous variables. Moreover, parsimony is a critical component of a good model since highly complex models have less free parameters and tend to have more constraints. Finally, the weighted root-mean-square residual , which is a relatively new fit index, was not considered to determine the viability of the model because of a lack of established research on it. A SEM model was specified in which psychological trauma was hypothesized to have an indirect effect onto substance problems and a direct effect on schizoid personality. Another path was modeled from schizoid personality to social support and to substance problems. Social support had a direct regression path onto substance problems. Together, trauma, schizoid personality, and support, were modeled to predict substance problems. All modeled relations are depicted in Figure 2. Factor loadings specified for each factor were allowed to be freely estimated, except for the reference indicator for each factor that was constrained to be 1.0 as part of unit-loading identification. Akin to the CFA, WLSMV was used as an estimation method, which was selected in the presence of dichotomous indicators in Mplus. Since model fit was good, no modifications were made. Results for research hypotheses 3.1-3.5 show that the following path coefficients were significant in the hypothesized direction: trauma significantly and positively predicted schizoid traits when controlling for social support and substance problems. In other words, an increase in one standard deviation in trauma yielded a .53 standard deviation increase in schizoid personality characteristics. This supported hypothesis 3.1. The effect size suggested that trauma explains 28% of the variance of the schizoid personality factor.Another set of findings is related to the viability of the constructs of trauma, support, personality, and substance problems when applied to the youth offender population.

Many of those constructs have been primarily employed with non-offending youths or adults, so that it was important to test whether they would work equally well with this sample before moving into the structural model analysis. Results show that these constructs worked well for assessing personality and risk constructs among youths on probation, and that these constructs are interrelated in meaningful ways. This suggested that the subsequent analysis of direction and significance of the paths between them could be conducted. The relations among the four constructs were examined. It was hypothesized that trauma would have a direct, positive, and significant effect on the development of schizoid personality traits. This hypothesis was confirmed. It was hypothesized that schizoid personality would negatively impact social support due to interpersonal difficulties that result in social withdrawal. This was confirmed by the significant, negative association schizoid personality had on social support. In other words, the more schizoid traits an adolescent endorsed, the less likely he was to have different types of support at school or home. It was also hypothesized that social support would decrease substance problems. This hypothesis was not confirmed. That is, for this sample having access to more and different types of support ranging from school counselor to parents did not decrease AOD use. It was hypothesized that schizoid personality would have a positive, direct,growing cannabis indoors and significant effect on substance problems. This was confirmed because higher levels of schizoid traits predicted higher AOD use. Similarly, the hypothesis of trauma having an indirect, positive relationship with substance problems was confirmed. Trauma had an indirect, significant, positive association with substance problems providing evidence for the role of childhood abuse adversely affecting AOD use behaviors in adolescence. This effect was found for the traumaschizoid pathway only but not for the trauma-schizoid-social support pathway. This implies that substance problems share a pathway with trauma and personality. As a consequence, the epidemiology of substance problems should encompass traumatic experiences as well as personality traits. The conceptualization of problematic underage AOD behaviors requires a multifaceted model that accounts for the association between intrapsychic factors and extrapsychic outcomes. This study explored whether social support decreases the association of schizoid personality with substance problems.

In the literature social support in the form of parental support was found to decrease adolescent substance use by instilling healthier coping mechanisms and better self-control . The measure of social support used in this study did not focus on only one type of support but included a variety of sources to which youths have access; i.e., teachers, parents, friends at school, and friends at home as well as hobbies. Assessing different forms of support including instrumental and emotional support, the hypothesis was not confirmed. For individuals with schizoid traits having different sources of social support did not ameliorate the negative trajectories of childhood trauma to substance problems. Particularly, social support did not act as a resilience factor in the trauma-schizoid-substance problems pathway. Over one third of the participants responded to items on the schizoid personality scale indicating that they did not care to be around people, and they did not feel emotional about people. Besides, twice as many reported not trusting most people, wanting to get even, and space out the world. These findings carry implications for counselors, as well as for probation officers, courts, and school personnel. The endorsement of several schizoid items clearly indicates a differentiated personality profile from the antisocial type. This overlooked type presents with a complex affective, cognitive, and behavioral profile that is shaped by past trauma and personality traits that require a special set of interventions. High levels of introversion, mistrust, and emotional detachment are qualitatively different from the emotional coldness of the so-called psychopath . A person with such a profile is likely to have a rich inner life created in an attempt to compensate for failed relationships with caregivers that is not accessed via conventional AOD treatment. Even though early traumatic experiences do not inevitably lead to personality disorders, they impact the way individuals see the world and others. Hence, assessing for personality traits should not be minimized to diagnostics, but serve the need for a greater understanding of the individual client. Research finds that relational trauma between child and caregiver has long-lasting effects on development . Childhood abuse is a risk factor for psychiatric disorders as it impacts the way individuals relate to others and the self . This is because the experience of abuse becomes internalized psychologically and physiologically in the form of brain function . Research on childhood trauma indicates that physical, sexual, and emotional abuse are associated with interpersonal hostility, low self-esteem, inadequate social functioning, and lower use of social coping strategies . From an object relations perspective, schizoid traits are the result of post-natal failures of loving relationships in which a strong sense of self was prevented from unfolding . Copious research has studied the relations trauma has with mental health and antisocial behaviors, such as substance abuse . Giaconia et al. found that as a result of affective, cognitive, and behavioral vulnerabilities trauma survivors are more likely to experience substance problems as well. This pathway was supported by the results of this study. This study also contributed an additional element, i.e., schizoid personality, into the conceptualization of the pathway between trauma and substance use. While schizoid traits in themselves are not pathological, having more of those traits in the context of trauma predicted substance problems. Hence, moving toward the higher end of the schizoid dimension poses a risk factor for problematic AOD use among youths who committed a crime, including trying to hide one’s use, using substances more frequently, and annoying others with their use. Psychoanalytic accounts of schizoid personality state that underneath the expressions of indifference and emotional coldness is a hunger for love and intimacy, a hyper-reflectiveness about the self, and a curiosity about others . This may help to conceptualize the relationship between schizoid traits and substance problems when thinking of AOD use as a way to numb the potentially distressing, unmet needs for interpersonal connectedness. Generally, results suggest that having experienced trauma in childhood is related to emotional detachment and psychological distress. This study was able to demonstrate that the effects of childhood trauma on personality can entail schizoid traits. Moreover, the alternative model demonstrated that when including personality in the model the direct effect between trauma and substance problems became non-significant, therefore providing empirical evidence for subsequent intrapsychic effects of trauma that led to maladjustment and not the occurrence of trauma per se. This corresponds to a resilience framework whereby maladjustment is not an irrevocable result but instead springs from the presence of additional risk factors that may have emerged from the original trauma. This work contributed to the resilience literature by examining the role of social support for different populations and personality types.

Object relations are interpersonal relationships that are part of a person’s most fundamental desire or libido because they strengthen the self . Objects can be thought of as actual persons that carry a maternal or caregiving role in a child’s life . Babies form a relationship to the world and subsequently to themselves by relating to an external object, i.e., the mother . In other words, relating to others is a behavior external to the individual that has an intrapsychic function. Object relations theory directs attention to disturbances in early parent-child interactions that negatively affect the child’s personality development and interpersonal functioning. Social relationships from a psychoanalytic account are far more than having someone to talk to; they are essential for developing self-regulatory mechanisms. Object relations are critical for developing an inner sense of self that can be distinguished from, yet that is related to, an outside reality . According to Winnicott children need to be reared in a “good enough” home with a mother or caretaker who adapts to the child’s needs and facilitates development. He notes that the mother’s preoccupation with the child’s needs is critical, so that the child experiences an omnipotent object that is strongly attuned to his needs until he is able to tolerate some frustrations without being traumatized by mother’s shortcomings . Recognizing the child’s needs and responding to the child’s internal processes by reflecting them back are essential caretaking roles that communicate emotional availability and interest . Adequate object relations in infancy are established by a variety of activities by the caretaker,cannabis grow table such as looking at the child, smiling, appropriate touching, and joining the child in his gaze or activity. Object relations theorists state that a child requires love, recognition, and attention from an object to develop a sense of self and reality of self.

If the caregiver fails to provide attunement to the child, he will experience this as a rejection regardless of the reasons for the lack of love . As a result the child internalizes the parent as a bad object who failed to meet his most basic needs. This leads to feelings of deprivation and inner emptiness . According to the British object relations school internal and external objects fulfill qualitatively different relationships; that is, the child who experienced frustrating external object relations is turning to internally generated fantasies of mergers and identification with the desired object . Hence, the libido for connection is turned inward toward objects of fantasy. It is this process that has great significance for the development of antisocial behaviors such as substance problems. Object relations theory adds to the biological model of addiction by claiming that impulses have to be met by a self-state. In the case of the schizoid personality type the self has become dissociated, so that drug addiction is a reflection of a dissociated self-state that once was yearning for love . Psychoanalytic self-psychology theorists have proposed that the parents’ or self-objects’ lack of mirroring and love can have long-lasting negative consequences for the development of the child, and it contributes to the development of schizoid personality disorder . The term self-object stems from Kohut’s self psychology theory that is related to object relations and emphasizes the “internal psychological experience of an object” . Mirroring is an important self-object function that serves to satisfy the child’s needs for recognition and praise . It helps the child develop a sense of reality of self that is worthy. Guntrip describes schizoid tendencies as a reaction to negative self-object relations.

Failures by the mother as the mirroring self-object put the child at risk for being traumatized due to experiencing a discontinuity of existence . Hence, from a psychoanalytic point of view the absence or inconsistency of parental adaptation to the child is a risk factor for the child’s self-fragmentation enhancing the vulnerability for maladaptive personality types. Fairbairn , one of the pioneers of the object relations school, studied schizoid personality intensely. He asserts that schizoid states stem from failed object relations that leave the child feeling unloved and rejected. The early rejection translates into a fear of closeness and true intimacy, and behaviors of withdrawal and chosen isolation . Individuals who experience schizoid states fear that their love will destroy the object because it is too consuming . They therefore prefer relying on internalized object relations and inner fantasies. They are able to role-play sociable interactions when necessary and can therefore easily be overlooked and underestimated in terms of their psychopathology and suffering. Similarly, self-psychology theory is helpful for understanding the emergence of personality and personality disturbances because it is concerned with “the self’s structural defects and shortcomings [in an interpersonal context]” . From that perspective a personality disorder results from insufficient self object responding to the child’s needs for “affirmation, merger, and idealization” . Affirmation is related to empathic attunement discussed earlier. Merger describes the experience of fusion of the self with a self object whereby the internal experience is temporarily fused with the external experience. Idealization, from Kohut’s perspective, refers to the three main areas of self, which are the “two polar areas” of the grandiose self, the “idealized parent imago” , and the “executive functions [that are] talents and skills” . The grandiose self is related to feelings of omnipotence and perfection, which can lead to narcissistic disturbances if they are not mirrored by the mother.

For example, a child who stands up for the first time needs to see pride in his mother’s eyes, a smile, and encouragement in order to satisfy an experience of self and of his potential. The child also maintains a feeling of omnipotence by projecting it onto his caregivers, which is called the “idealized parental imago” . The child’s idealizing expectations of the parent will unavoidably be frustrated, which will transform the child’s internalization to accept strengths and weaknesses in himself and others. For example, mother may not look at him every time he takes a new step or makes a discovery. Experiencing such frustrations within an overall caring, consistent care giving relationship helps the child de-intensify his grandiose self to enable more mature self object relations . Finally, the child needs the executive functions to achieve the ambitions represented by the grandiose self and the idealized parent. Ultimately,hydroponic cannabis system this will lead to productivity and meaning creation. Fair bairn notes that schizoid characteristics are an outcome of unsatisfying emotional bonds with parents and particularly with mother . This includes possessive and indifferent mothers who leave their children emotionally deprived, which causes regression to more primitive states for basic love need satisfaction. This more basic state may lead to depersonalization and “de-emotionalization” of object relations. As a result children may develop low distress tolerance and dependence in adult life. The traumatic experience that underlies schizoid characteristics stems from an emotional frustration because the mother does not love the child for himself and because she does not accept and value his love for her . This coins the child’s interpersonal style to adopt a distanced stance toward others since they are unable to fulfill his love needs. Intrapsychically, the child shifts object relations inside of himself where he relates to internalized others by incorporating or taking as opposed to giving and sharing. According to Fair bairn individuals with schizoid traits fear to give themselves emotionally to others because it feels to them like losing parts of their personality. They do not receive the same intrinsically motivating emotions from giving, such as creating values and self-respect . Another resulting feature from the relational trauma is the experience of inferiority due to not feeling loved in their own right . This sense of low self-worth may lead to a fixation on mother and narcissism as a defense against it . The schizoid character, albeit rare in the general population, appears to be relevant for the offender population. That is because it relates to antisocial behaviors in several ways: First, it is known that the prison population has elevated rates of trauma and dysfunctional family relationships that may foster schizoid traits; second, the process of identification with a bad object, i.e., the perpetrator of abuse, can lead to criminal behavior. Because the libido relates to parental objects, forms of abuse create inner conflict that can leave the child feeling ashamed.

By means of identification with a parent who abuses, the child develops a sense of badness . For Fair bairn whether a child becomes delinquent or not depends on several factors; the extent of internalization of the bad object in the unconscious, the degree of dysfunction of the object, the extent of identification with the bad object, and the ego defenses available to protect against acting out the bad object. Fair bairn makes an interesting and important point that a child may be motivated to engage in antisocial behaviors in order to release the repressed badness, and to protect the ideal image of his parents that appear good opposite to his badness. As a result, some of the character traits of schizoid personality may be considered defenses against a repressed, internalized bad object. In sum, parenting is critical in the child’s personality development because by serving as self objects parents help the child develop the affective and self-affirming structures it relies on for development and later functioning. Mirroring and idealization serve the narcissistic development and experience of omnipotence, which precede self-esteem and adaptation . When considering the experience of abuse by the hands of the caregiver or self object, it becomes apparent how devastating relational trauma can be for a child’s development. Surprisingly, differences in personality factors are rarely addressed in treatment allocation and intervention. This is astonishing provided that personality characteristics have significant influence on interpersonal and intrapersonal functioning that are central for recovery and rehabilitation. It is helpful to think of personality in dimensions to represent developmental levels and typologies . The dimensions can have substantial overlap, and people tend to oscillate along the dimensions because their functioning is impacted by stressors.The typology dimension captures the specific kind of defenses used, and helps classify them along the developmental dimension. For example, personality types using denial would be classified at the lower end of maturity and at the higher, more severe end of the typology. It is important to note that this study refers to personality types rather than personality disorders as listed in the DSM-IV-TR because it takes the participants’ developmental stage into consideration. Adolescence is a developmental phase in which personality is still emerging and traits are flexible. It is important to note that personality is conceptualized as a fluid construct consisting of propensities that undergo developmental changes and that are directly affected by stressors in the environment, such as poverty and poor family relations . Therefore, it is helpful to think of personality type as propensity or tendency, rather than a permanent set of thought and feeling patterns. Personality disturbances comprise of patterns of cognition, affect, impulse control, and interpersonal relationships. Individuals who suffer from personality disorders have inner experiences and perceptions that are often not mirrored by the outside world and do not meet society’s expectations and norms . Personality disturbances can therefore result in high levels of distress for the individual. Personality disorders like many other disorders occur on a spectrum of high and low intensities that include overlaps with other, related disorders. For example, schizoid personality shares symptoms of a lack of interest in personal relationships and emotional detachment with autism spectrum disorders. Furthermore, it is critical to diagnostically differentiate schizoid symptoms from contextual factors that affect an individual’s emotional style and behaviors. Growing up in disadvantaged neighborhoods and experiencing ethnic discrimination can cause individuals to display detachment and emotional indifference as a form of self-protection that should not be classified as a personality disturbance. Many individuals with schizoid personalities are highly functioning, hold jobs, and lead productive lives . A schizoid personality style describes individuals who tend to be introverted and solitary . Individuals high on this trait tend to be shy, avoid competitive relationships, and are described as eccentric . Individuals with schizoid traits display autistic thinking that entails daydreaming without a loss of a sense of reality . When confronted with an unpleasant stimulus, such as a disagreement, individuals with schizoid traits rather withdraw than express hostility .

ABAG-MTC provides support for achieving PDA visions through the PDA Planning Grant and Technical Assistance Program, Place making Initiative, One Bay Area Grant , East Bay Corridors Initiative, Resilience Program, and Entitlement Efficiency working group. PCAs are open spaces identified as lands in need of protection from urban development and other uses. Such spaces provide agricultural, natural resource, scenic, recreational, and/or ecological values and ecosystem functions. PCA identified lands are eligible for funding through the OBAG program. The PPA program would create a third land use designation in Plan Bay Area. Planning for non office businesses is often left out of the PDA framework. ABAG-MTC’s staff describes PDAs as places that bring housing, transit and economic services together. Thus, PDAs often are not specifically job oriented. Even when jobs are included in PDAs, the mixed-use environment and implied level of density is not compatible with most industrial jobs. The PPA program would provide an opportunity for regional planning to consider land use needs of a broader range of employment types and for cities to receive regional support for areas of importance to employment that do not have the housing and transit location characteristics of PDAs. The PPA program would also build off of the partnerships and knowledge pool that the Bay Area Urban Manufacturing Initiative has developed over the past three years.Through this ongoing effort, BAUM has developed tool kits to provide city staff, policy makers, and partner organizations with strategies to support manufacturing. While this effort is focused on manufacturing,planting table the PPA program provides an opportunity to continue and expand regional coordination around a broader set of industrial land uses. This report summarizes findings from an initial PPA program development phase that initiated outreach and engagement with local jurisdictions.

Interviews with eleven cities and four economic development experts in the region and secondary data analysis provided insight into how a PPA might work in different cities, the degree to which a PPA could benefit different jurisdictions, potential criteria cities could use to designate PPAs, and how transportation challenges around industrial land could be addressed through the PPA program. The findings discovered during this process will serve as a launching point for ABAG-MTC as they begin to shape the PPA program. Conversations with local jurisdictions revealed that city staff are interested in a PPA program that could address a number of challenges that cities experience with industrial land, including market pressures and competition with other uses, limited space, mixed-use districts, outdated zoning codes and policies, outdated infrastructure, environmental concerns, talent attraction, internal city government resources and structure, political barriers, and a lack of constituency. Staff expressed that the PPA program would be useful in addressing these challenges by elevating the profile of industrial land through a regional framework, focusing on employment issues, providing funding, and establishing a toolbox of regional best practices. Transportation challenges to, from and within industrial sites for both goods and people were identified as a primary concern across jurisdictions. Given ABAG-MTC’s role in transportation planning and financing, creating a transportation plan could be a key element of the PPA program. The following sections will discuss each of these issues identified by city staff in more detail and how they could shape the ultimate form of the PPA program. It is no secret that space in the core Bay Area is limited for all uses, and the housing crisis is rightfully receiving the spotlight. The ABAG Executive Board action on the PPA program acknowledges the need for both housing and industrial uses and the importance of a program that will not divert resources from addressing the under supply of housing.

The PPA program will seek to complement the existing development strategies for housing and office jobs in an effort to retain industrial spaces that provide operating space and support services for driving sectors or important local clusters in the Bay Area. The Industrial Land and Jobs Study for the San Francisco Bay Area , conducted by Professor Karen Chapple at the Center for Community Innovation , inventoried the region’s industrial land and examined its capacity for future growth, occupancy, and expected demand. Study analysis reveals that, although the supply of industrial land exceeds projected demand at a regional scale, there is a mismatch between available land supply and expected growth in demand in the urban core, where industrial lands are at risk of pressure to convert to other uses. Chapple defines industrial land uses to include production, distribution, and repair businesses – a definition adopted from San Francisco’s PDR industrial land preservation program. PDR uses go beyond what one may typically envision as industrial and the classic assumption that industrial means manufacturing. Chapple predicts the following industries, in rank order, as those that will contribute an additional 1,000 new jobs or more by 2040: Merchant Wholesalers of Durable Goods and Non-durable Goods , Repair and Maintenance , Transit and Ground Passenger Transportation , Waste Management and Remediation , Machinery Manufacturing , Truck Transportation , Support Activities for Transportation , and Warehousing and Storage . Furthermore, the types of businesses that constitute each of the PDR categories often varies by city and is somewhat in flux given evolving industries, especially tech and R&D uses that could be considered office or industrial. Chapple finds that industrial lands contain a high share, relative to the region, of jobs that provide middle-wage opportunities for workers without a college degree. Overall, middle-wage jobs were found to be sixty percent more concentrated on industrial land as in the region. Furthermore, in 2011, middle-wage jobs accounted for almost half of jobs on exclusive industrial land, while low-wages jobs accounted for 28%, and high-wage jobs for 28%; the study predicts that this distribution of employment is expected to remain similar through 2040 . This finding suggests that a loss of industrial land in the urban core could push out these middle-wage jobs in the PDR sector, exacerbating sprawl and equity issues.

Industrial land has been converted in areas where the market values non-industrial uses over industrial uses and the city has permissive zoning codes. When land is in short supply, PDR businesses react in a variety of ways: some businesses will leave; others will increase productivity to compensate for increased land prices; and others may adapt their land consumption altogether, transforming their business model to relocate to high density sites downtown while outsourcing or moving their production facilities . However, while land availability will not drive industrial job growth single handedly, preserving space for industrial uses is key to maintaining the PDR sector’s role in the region . Once industrial land is converted to another use, it is highly unlikely that it will ever be converted back to industrial. Although the PDR sector may not stimulate regional job growth on its own, providing space for industrial uses is key to stabilizing the PDR sector that plays a critical role in two driving sectors in the Bay Area: high-tech and consumption needs for the creative workers. The interrelationships between these sectors enables agglomeration economies that support the regional economy and often provide value to city governments in the form of revenues. Additional clusters are supported through the PDR sector,cannabis indoor grow system such as the agricultural and food sector, as well as logistics. Industrial land preservation is expected to have several advantages . In 1986, Heikkila and Hutton suggested that an industrial land preservation policy offers the advantages of keeping rents low for businesses and providing certainty to developers about city intentions, particularly when the industrial district is economically viable, there is a high level of structural employment, and the industry generates negative externalities. Furthermore, Howland finds that industrial districts support the regional economy as job generators, providers of supplies and services, including back-office functions or automobile repair for businesses and households, and low-cost space. Chapple establishes a causal link between industrial land designation and job creation or retention that further supports the importance of industrial land preservation. Her analysis reveals that firm size plays the most important role in business dynamics, and the availability of industrial zones and large buildings also support firm expansion. Thus, retaining a reserve of flexible industrial zones that can accommodate a range of industrial businesses is critical to sustaining industrial agglomeration economies. Policy makers use industrial land’s role in regional agglomeration economies to justify public intervention in the market based on industrial land’s roles in regional agglomeration economies. However, there are also costs, or potential inefficiencies, of industrial land preservation.

Heikkila and Hutton suggest that preserving industrial land has a number of potential costs, including inefficient use of resources, inhibition of industrial transition, and impacts on the local tax base. Opponents also contend that the costs of the city subsidizing the land outweigh the benefits of the policy and dispute the regional growth claim by arguing that this policy slows relocation of industrial businesses to perhaps more economically efficient areas . Furthermore, zoning for industrial land has been accused of interfering with the market that may on its own generate more economically and socially optimal outcomes. However, zoning also is a means of correcting market failures, such as negative externalities generated by industrial uses. The fact that zoning and land use controls operate under local control calls for conversations with local jurisdictions to better understand industrial land across the region. A number of cities across the U.S. are often cited for their industrial land preservation policies or strategies. Chapple’s study highlights three cities that have established programs to preserve their industrial spaces through local land use controls: Chicago’s Planned Manufacturing Districts and Industrial Corridors, New York’s Industrial Business Zones , and San Francisco’s Production, Distribution, and Repair zones . In addition, Portland, Philadelphia, Boston and Vancouver, BC also have notable industrial land preservation regulations. The Puget Sound Regional Council provide tax incentives, assistance with workforce development, services for business retention and attraction, and assistance with site selection for businesses looking to expand or relocate . Regions that have taken a regional approach to industrial land use planning, namely Los Angeles and Seattle, are more relevant to the concept of the PPA program. The City of Los Angeles’ Industrial Development Policy Initiative frames its industrial land strategy withina regional and global context, recognizing that private and public policy forces at all scales influence industrial businesses and development. One of the primary categories within the city’s initial industrial land policy framework was “regional cooperation for economic development.” The Puget Regional Council , the MPO for the Puget Sound region, created a regional industrial designation in 2003, Manufacturing/Industrial Centers . Given PSRC’s role as a Metropolitan Planning Organization the recent legalization of cannabis in California. Additionally, in the current market, city officials suggested that developers prefer to outprice industrial users and turn industrial land into R&D office space, versus trying to intensify a higher-value site that is designated for office uses.Addressing the need for employment lands in the context of the current housing crisis is often not so easy in practice. For instance, San Jose city officials stated that they believe current real estate values for industrial spaces in their city include a premium within the cost of land, with the underlying assumption that at some point the city will allow residential on the industrial sites. Staff at the City of San Jose highlighted the challenges they face in preserving industrial land in this market, stating that “We’ve been consistent on holding the line on preserving industrial. But at the same time, we don’t really have anything that has enough teeth to […] put our foot down and really make it 100 percent clear to the market that these areas are going to stay for production.” They have found this to be particularly true in industrial areas near residential, as developers could eventually generate significant profit on housing at some point. The housing crisis in the Bay Area is a regional issue, yet the pressures are felt most strongly in the inner core areas. A conversation with the East Bay Economic Development Alliance emphasized that the political climate around housing will pose challenges in the inner core for the implementation of the PPA program: “[The PDR sector] is not going to succeed just because you set up some rules. It’s going to succeed if you have housing, if you have proper training for the workforce, all of those things.

Outcomes of such practices and variations between trauma registries leads to a lack of confidence regarding data accuracy and resulting analyses. Motor impairment and/or execution of complex behavioral sequences often accompany psychotic symptoms, as in the case of obsessive-compulsive disorders. Such an occurrence likely reflects the anatomical overlapping of brain areas serving both motor and cognitive functions.Cannabimimetic drugs represent an interesting tool to investigate psychomotor behaviors, because of their documented ability to influence both motor and cognitive performances . Indeed, cannabinoid administration is accompanied by profound effects on motor behaviors, as well as by attenuation of d-amphetamine-induced hyperactivity and stereotypy. In addition, cannabinoid substances produce a large spectrum of psychotropic effects in humans, ranging from euphoria, short-term memory impairment, altered perception of space and time, and dream states. Similarities between certain cognitive impairments occurring in psychoses and the pharmacological effects of D 9 -tetrahydrocannabinol, the active principle in marijuana and hashish, have also been documented. The discovery of the brain cannabinoid receptor, CB1, and the mapping of its neuroanatomical distribution, have greatly improved our understanding of the effects of cannabimimetic drugs on psychomotor functions. CB1 receptors are most concentrated in areas of the central nervous system that are critical for the regulation and processing of motor functions, cognition,stacking pots and motivation. In keeping with this distribution, disruption of the CB1 receptor gene has been shown to severely impair movement control and to result in a functional reorganization of the basal ganglia.

The pharmacological properties of cannabis-derived drugs have prompted clinical evaluations of marijuana use in motor disturbances, such as spasticity, tremor, and dystonias . At the same time, the discovery of naturally occurring ligands of cannabinoid receptors, and the identification of their pathways of biosynthesis and inactivation, have opened a new research field aimed at investigating the physiological role of these molecules in health and disease, as well as their possible use as a new target for therapeutic interventions. The purpose of this mini-review is to draw together these studies, pointing out to the potential involvement of the endogenous cannabinoid system in psychomotor disorders.The cloning of the CB1 cannabinoid receptor and the mapping of its distribution in the brain has impelled the search for the corresponding naturally occurring ligands within the brain. Two endogenous cannabimimetic substances have been identified so far, arachidonylethanolamide and 2-arachidonylglycerol. Unlike neurotransmitters that are released from synaptic terminals via vesicle secretion, both anandamide and 2-AG are thought to be produced upon demand through stimulus-dependent cleavage of two distinct phospholipid precursors present in neuronal membranes . Anandamide, but not 2-AG, is released extracellularly by neural activity evoked by localized pulses of high K1, and it is thought to act near its sites of production as a local neuromodulator. Whether 2-AG is produced in vivo under physiological circumstances and/or it exits neurons in other regions of the CNS, has not been determined yet. The biological actions of anandamide are terminated by two subsequent reactions consisting of high-affinity transport into cell, followed by hydrolysis catalyzed by an amidohydrolase enzyme. 2-AG is thought to be inactivated by cleavage into glyceroland arachidonic acid. The enzyme activity involved in this reaction has not been clearly identified, though anandamide amidohydrolase and monoacylglycerol lipase have been suggested to play a role. Other saturated and monounsaturated fatty acylethanolamides are produced by activated neurons together with anandamide.

Although these lipids share a common biosynthetic mechanism with anandamide, they do not bind to cannabinoid receptors and they are not released extracellularly in vivo. The possible physiological roles of these compounds are still largely unexplored. One exception is represented by palmitylethanolamide which was shown to exert peripheral anti-inflammatory and antinociceptive effects, mediated through a putative CB2-like cannabinoid receptor .The basal ganglia are a forebrain region playing a key role in sensorimotor and motivational aspects of behavior. The high density of CB1 receptors in this area indicates that cannabinoid substances may modulate essential aspects of basal ganglia physiology. The existence of an endogenous cannabinergic tone in the basal ganglia has been suggested by the finding that the CB1 receptor antagonist SR141716 was able to produce increased locomotion in mice and stereotypies in rats. These findings have been recently confirmed by in vivo microdialysis studies, showing that membrane depolarization stimulates the outflow of anandamide from striatal neurons. Functional interactions between endogenous cannabinoids and distinct neurotransmitter systems modulating basal ganglia functions have been also postulated. Neuroanatomical studies have shown that CB1 receptors are mainly located in the terminals of GABA-ergic medium-spiny neurons projecting from the striatum to the globus pallidum and substantia nigra. Although direct evidence for an interaction between endogenous cannabinoids and GABA-ergic system is still lacking, it is known that exogenously administered cannabinoids can modulate GABA transmission, as suggested by their ability to inhibit GABA release from striatal and hippocampal nerve terminals and potentiate GABA-induced catalepsy. Coexpression of m -opioid and CB1 receptors in striatal cells indicates that opioids and endocannabinoids can also interact within the striatum. In keeping with this, chronic cannabinoid exposure regulates proenkephalin mRNA levels in the rat striatum. Finally, a role for the cannabinoid system as a modulator of dopaminergic activity in basal ganglia is emerging.

Activation of cannabinoid receptors was shown to cause significant reductions of the electrically evoked dopamine release from rat striatal slices, and to potentiate neuroleptic-induced catalepsy. Moreover, injection of cannabinoid receptor agonists into the basal ganglia counteracts the motor responses of locally administered D2-receptor agonists. Conversely, cannabinoid-mediated motor behaviors can be affected by dopamine manipulations. For example, chronic administration of dopamine D1 and D2 receptor agonists results in differential modulation of the locomotor effects of the cannabinoid agonist HU-210, suggesting a possible cross-talk between dopaminergic and cannabinergic systems within the striatum. In this regard, the observation that anandamiderelease can be induced by pharmacological activation of the D2 class of dopamine receptors in freely moving animals suggests that endogenous cannabinoids may represent a primary component of the network of neurochemicals modulating striatal function. Further support to this hypothesis is provided by behavioral studies showing that the hyperactivity associated with post-synaptic D2 receptor activation is markedly potentiated by the CB1 antagonist SR141716A. Taken together, these data suggest that pharmacological blockade of cannabinoid receptors enhances quinpirole-induced motor activation by removing the inhibitory control exerted by the endogenously released anandamide. Furthermore, the lack of effect of SR141716A when given alone at the same dose used to potentiate quinpirole-induced motor activation, indicate that anandamide can reach a sufficient concentration to induce its behavioral effects only after stimulation of D2 receptors. Thus, the released anandamide may offset dopamine D2-induced facilitation of psychomotor activity . Functional interactions between endogenous cannabinoids and dopaminergic system may have important therapeutic implications in pathologies that involve disregulated dopamine neurotransmission, such as Parkinson’s disease, Tourette syndrome,grow lights and schizophrenia. On a speculative basis, the blockade of anandamide inactivation and the consequent increase of endogenous levels of this lipid, may be beneficial in reducing hyperactivity and hyperkinesia associated with Huntington’s disease, a pathology where a massive loss of CB1 receptor binding has been reported in the basal ganglia of postmortem patients. However, the potential therapeutic use of cannabinoids for the treatment of psychomotor disorders is not only matter of speculation. It has been shown that blockade of CB1 receptors may potentiate or prolong the effects of dopamine-based therapies currently used in Parkinson’s disease and use of D 9 -THC for the treatment of Tourette syndrome has been reported. Increasing evidence suggests that schizophrenia may be associated with abnormalities in the function of the endogenous cannabinoid system. Clinical evidence indicates that cannabis consumption is significantly higher in schizophrenic patients than normal individuals and chronic use of high doses of cannabinergic substances may precipitate schizophrenic symptoms in vulnerable patients. Additional support for a role of cannabinoid signaling in schizophrenia comes from the observation that anandamide is markedly elevated in the cerebrospinal fluid of schizophrenic individuals. The non-cannabinoid acylethanolamide PEA is also increased in these patients. Although PEA is produced in the CNS through a biosynthetic mechanism similar to anandamide’s, this lipid is not released in vivo as a consequence of D2-receptor stimulation. Therefore, further investigations are needed to clarify the physiological role of PEA in the CNS as well as its possible link to schizophrenia. Drugs that block D2-like dopamine receptors have been extensively used to mitigate symptoms of psychoses and motor disorders.

Given the linkage between D2-receptor activation and anandamide release, it is likely that the high CSF levels of this lipid may reflect homeostatic adaptations of the endogenous cannabinoid system to disturbances in dopamine neurotransmission occurring in schizophrenia. Additional support for this possibility comes from the observation that chronic treatment with D2-family antagonists results in upregulated expression of CB1 receptor mRNA in striatum. On the other hand, alterations in cannabinoid signaling may directly contribute to the manifestation of subgroups of symptoms in schizophrenic syndromes. Further investigations in larger populations of patients and studies aimed at determining the neuronal origin of the AEs in CSF may help elucidate the possible participation of these lipids in the pathogenesis of schizophrenia.Successful viral suppression from combination antiretroviral therapy has led to an increase in life expectancy among persons living with HIV . While severe HIVassociated neurocognitive disorder is less prevalent in the cART era, mild to moderate HAND persists despite virologic suppression. HAND affects up to 50% of HIV-positive persons, with older HIV-positive adults at greater risk for neurocognitive impairment than their younger counterparts.Among neurocognitive domains affected by HAND, complex motor skills are consistently compromised across time. Complex motor skills refer to a combination of cognitive and perceptual-motor abilities, including perception, planning, continuous tracking, and sequential movements.Although the prevalence of complex motor impairment has receded in comparison to the pre-cART era, deficits in complex motor functioning are still observed in approximately 30% of those with HAND. Complex motor impairment is related to everyday functioning impairment, including driving ability, highlighting the clinical relevance in understanding mechanistic pathways underlying HIV-associated motor dysfunction. A recent longitudinal study found that complex motor function is particularly vulnerable to the effects of age and stage of HIV infection, and implicated the basal ganglia as a neural correlate of interest.The effects of acute HIV infection on the basal ganglia are well documented, with greater atrophy associated with psychomotor slowing.Inflammatory processes are one putative factor that may contribute to central nervous system injury, including deficits in complex motor skills. Biomarkers of inflammation, such as cytokines and monocytes, are elevated in the context of HIV infection. HIV, viral products, and activated immune cells are able to cross the blood brain barrier and contribute to inflammation in the CNS. Neuroimaging studies have shown that peripheral inflammatory biomarkers are able to alter neural activity in the basal ganglia, including dopaminergic activity, which is reflected by psychomotor slowing in HIV-negative adults. Among HIV-positivepersons, global neurocognitive impairment is associated with elevation of various peripheral biomarkers of inflammation and coagulation . Taken together, deficits in complex motor performance are commonly observed among HIV-positive persons, and elevation in peripheral biomarkers of inflammation may be a contributing factor. Thus, we hypothesize that HIV will have negative direct and indirect effects via inflammation on complex motor performance.Participants were 90 HIV-positive and 94 HIV-negative persons, with balanced recruiting in each age decade , from the five-year Multi-Dimensional Successful Aging among HIV-Infected Adults study conducted at the University of California, San Diego .Only baseline data were included in this analysis. The study received approval from the UCSD Institutional Review Board. Participants provided written, informed consent. Exclusion criteria for the parent study were diagnosis of a psychotic disorder and presence of a neurological condition known to impact cognitive functioning . Additional exclusion criteria for current analyses included being off ART, having detectable HIV viral load , and meeting criteria for a current substance use disorder. HIV infection was screened via a finger stick test and confirmed with an Abbott Real Time HIV-1 test or by submitting specimens to a Clinical Laboratory Improvement Amendments -certified laboratory for HIV-1 viral load quantitation. Although neurologic findings commonly associated with HIV infection have been suggested to largely remit with initiation of cART, our cross-sectional study observed worse complex motor skills across the adult age continuum of HIV-positive, relative to HIV-negative, adults. Inflammation burden was higher among HIV-positive adults, compared to the HIV negative comparison group.

Study methods employed by each of the eight included studies varied with some studies utilizing medical chart reviews, while others utilized validated surveys and questionnaires to gather their data. The studies by Andelic et al., Barker et al., and Bombardier et al. all utilized the participants’ medical charts for retrospective review for presence of substances. The studies by Andelic et al., Nguyen et al., and O’Phelan et al. used trauma registry databases to collect data on TBI patients and the presence of substance abuse. Pakula et al. collected data on the presence of substance abuse in post-mortem patients with traumatic cranial injuries by evaluating autopsy reports. Finally, the studies by Bombardier et al., Kolakowsky-Hayner et al., and Kreutzer, Witol and Marwitz utilized questionnaires to interview participants. The variance in study methods, ranging from retrospective review of charts to the use of self-report methodology subjects the included studies to recall bias and unreliable data. A factor negatively contributing to the quality of the included studies is the variance in defining a TBI. Three of the studies did not provide a definition for what constitutes a TBI, nor did they describe the severity of TBI. The study by Andelic et al. defined TBI using the TBI Modified Marshall Classification. The study by Barker et al. defined TBI using the TBI Model Systems Data Base definition. Nguyen et al. used the International Classification of Diseases-Ninth Revision codes and the Abbreviated Injury Severity codes to define TBI. These codes are widely used in trauma data registries for entering and recording the injury type and severity,garden racks wholesale for performance improvement and billing purposes. However, reliability can be an issue as coding may be subjective. The information is extracted from the chart by registrars who read and enter notes written by physicians.

Often, coding depends on physician documentation, attention by trauma registrars to the various sources of documentation and communicating with physicians when necessary. If not subject to continuous data validation, a data gap may ensue. The study by Pakula et al. defined a central nervous system injury by the presence of any of the following written diagnosis as found in the autopsy reports: 1) TBI, 2) skull base fracture, 3) spinal cord injury, and 4) cervical spine injury. Only one study, the study by O’Phelan utilized a Glasgow Coma Score to define a severe TBI. Risk of bias in terms of selection and information was determined for each study. The majority of the articles were subject to selection bias in terms of their participant population and methods of data collection: See table 2 for specifics. The included studies varied in their definition of TBI. One study used the Modified Marshall Classification of TBI which is a Computed Tomography scan derived metric used to grade acute TBI on the basis of CT findings. Another study defined TBI using the TBI Model Systems National Database definition. The TBIMS-NDB has been funded by the National Institute on Disability and Rehabilitation Research in the U.S. Department of Education to study the course of recovery and outcomes following a TBI. They describe the TBIMS-NDB TBI as: Damage to brain tissue caused by an external mechanical force as evidence by medically documented loss of consciousness or post-traumatic amnesia , or by objective neurological findings on physical or mental examination that can be reasonably attributed to TBI. Three of the eight studies did not specify how TBI was defined. The procedures by which the presence of marijuana exposure was detected varied across the selected studies. In some of the studies, marijuana was detected via a positive urine drug screen or via blood alcohol levels. In addition to utilizing toxicology screening results to identify the presence of marijuana, the studies by Andelic et al., Kolakowsky-Hayner et al., and Kreutzer et al. also utilized the General Health and History Questionnaire to gather self-reported patient incidence or marijuana exposure. As described earlier, the GHHQ questionnaire aims at assessing the psychosocial, neuro behavioral and vocational status of patients with traumatic injuries. Although all eight studies investigated marijuana exposure in TBI patients, only one study specifically investigated the use of marijuana alone on outcomes in TBI.

All other remaining studies investigated the presence of all possible substances and/or drugs, meaning investigators were not specifically examining marijuana exposure by itself. In Nguyen et al. all patients who had sustained a TBI and had a urine toxicology screen were included. The actual noted presence of marijuana was obtained from the urine toxicology screen and not through any other modes of measurement. The authors classified study patients according to marijuana screen results which they defined as greater than 50 ng/ml. Though marijuana was noted to have been detected across all eight studies, the actual numerical or absolute value measured was never reported by any of the studies. Additionally, it is important to note that excluding the study by Nguyen et al., the presence of marijuana was not reported in a quantifiable manner, making any potential statistical inference impossible. Lastly, six of the included studies investigated the presence of marijuana at the time of injury, while the remaining two studies measured the presence of marijuana use during the past year and post-mortem respectively. The study by O’Phelan et al. did not investigate any other time frame for which marijuana may have been used, rather, the authors only collected data on the presence of drugs at the time of injury. An important finding from the systematic literature review showed that marijuana was the most favored drug reported. However, only one study of the eight studies included explicitly searched for and found a connection between the presence of a positive toxicology screen for marijuana and mortality outcomes in TBI patients. Nguyen et al. three-year retrospective review of trauma registry data found that 18.4 percent of all cases meeting inclusion criteria had a positive marijuana screen and overall mortality was 9.9 percent . Nguyen et al. found that mortality in the marijuana positive group was significantly lower when compared to the marijuana negative group . Authors adjusted for the following differences between study participants: age, gender, ethnicity, alcohol, abbreviated injury scores, injury severity scores, and mechanism of injury. After adjusting for differences, Nguyen et al. found that a positive marijuana screen was an independent predictor of survival in TBI patients .This review sought to determine the use of marijuana and its role in TBI prevalence and outcomes.

A key finding from this review is that there are few studies available that examine the specific role of marijuana exposure on TBI severity, leaving many questions unanswered. Furthermore, this review found that there is a significant variation in how substance abuse has been defined, conceptualized, and operationalized in TBI research. Another important finding was that the reviewed studies operationalized substance abuse inconsistently, often combining alcohol and drugs in one category titled ‘substance abuse,’ making it difficult to ascertain if there was an association between specific drugs, particularly marijuana,hydroponic racks and TBI severity and outcomes. The difference in how substance abuse was operationalized in these reviewed studies has important implications for how findings are interpreted as well as provide recommendations for future research. Although there was no restriction made to the countries in which these studies were conducted, those meeting inclusion criteria were all studies conducted in the US except one from Norway. Therefore, the applicability of findings from that one non American study is limited. Additionally, it is difficult to draw valid and reliable conclusions when the studies reviewed utilized a wide variety of study objectives, sample size, study methods, and varying definitions for substance abuse classification. The review showed a great variation existed across the studies in types of data collected and methods used, thus severely minimizing comparability. For example, the disparity in measurement of blood alcohol levels considerably reduce the reliability of data related to pre-injury intoxication. In the reviewed studies, information on alcohol and substance use was obtained from a range of different sources, including self-reports and patient records, as well as a variety of different measures rendering results unreliable across studies. This review set out to answer a specific question: what influence, if any, does marijuana exposure at time of injury have on TBI severity and outcomes? Only one study about marijuana’s effect on TBI outcomes was available. Nguyen et al. reported that a positive marijuana screen is an independent predictor of survival, suggesting a potential neuroprotective effect of cannabinoids in TBI. The rest of the studies yielded a variety of findings, with the most common finding being that marijuana and other drug use, including alcohol, are common before TBI. To clearly understand what marijuana’s influence on TBI is, potential confounding variables must be identified and controlled for.

The literature review identified no consensus on relevant confounding variables aside from age and gender. The variability in all other demographic variables highlights the lack of certainty of the full range of relevant demographic variables. Another potentially important confounding variable is mechanism of injury. Historically, the most frequent cause of TBI related deaths in civilians was considered motor vehicle crashes. However, recent data show that falls are actually the leading cause of TBI related hospitalizations, with the second leading cause is being struck by another object. Importantly, only six of the studies included mechanism of injury as a variable in their analysis of findings. Five of the eight included studies did not address TBI severity as a variable.Andelic et al. used the Marshall classification to classify neurological anatomical abnormalities as seen on CT scans. Nguyen et al. utilized the Abbreviated Injury Scale score for the head and neck region to classify TBI severity. The use of the AIS score is common in general research studies as often times the GCS score is not always recorded for each individual participant. Hence the only study showing a link between marijuana exposure and TBI severity did not use the gold standard of GCS to measure TBI specific severity. Finally, severity as a variable in the TBI population is an important characteristic and is a parameter of interest when answering the research question of whether or not marijuana influences TBI severity; available studies are not able to answer that question mostly because the majority of them did not measure severity in the first place. Severity is important because it provides a level of specificity about the injury which determines management of care. Additionally, TBI severity can yield valuable insight about proximal and distal outcomes. It seems reasonable that it would be an important measure to include when examining the relationship between TBI and all included variables. Additional tools, such as the AIS scores and imaging studies, may be necessary in accurately capturing TBI severity in study participants; these studies, in addition to GCS, should be considered an essential variable that must be accounted for. All of the studies measured presence of marijuana, yet the methods by which marijuana was measured varied. For example, urine was the most common way to measure marijuana concentration in patients in reviewed studies, but urine tests results are not specific to time of injury: The detectable level of marijuana can be present in urine for approximately 4.6 to 15.4 days after last use for infrequent and chronic users respectively. The presence of marijuana on a urine toxicology screen may not accurately reflect or correlate marijuana levels in an individual’s system at time of injury, rather, it reflects recent use. Therefore, when considered as a variable, a marijuana level should be considered as reflective of recent use at time of injury, not directly at time of injury. Finally, this review and other systemic reviews consistently identify blood alcohol concentration as an important potential confounder in TBI studies. All reviewed studies except included alcohol as one of the examined substances. Much has been studied about the relationship between alcohol and TBI. As a prominent pre-disposing factor in TBI, the implications alcohol intoxication has on TBI is important and must be accounted for when examining the effects of marijuana on TBI. The current systematic literature review has several limitations, the first of which was the inability to perform a meta-analysis with the studies acquired. There was heterogeneity across the studies addressing marijuana exposure and TBI; from different criteria used to classify TBI, to diverse populations of interest, to varied outcomes of measures, the studies varied widely preventing a meta-analysis of the 8 included studies.