There’s no doubt that parents are the most powerful force in protecting and preparing children for the future. But these days, that job has become exponentially more confusing with the legalization of marijuana in many states and the subsequent arrival of a much more allusive, potent and dangerous variety that’s already flooding across state boarders. One thing has become clear: there’s no such thing as a harmless habit.
Marijuana is no stranger to most parents, but many are unaware of the way it’s being ingested these days and that it has 5x more THC than it did in the ’70s, ’80s and ’90s. Recent studies have concluded that it can even cause a permanent lowering of I.Q. for adolescents, along with a host of other problems which decrease the chances of having and enjoying a prosperous future. Continue reading →
by Brad Roberts, MD: I recently finished my residency in emergency medicine and began to practice in Pueblo, Colorado. I grew up there, and I was excited to return home. However, when I returned home, the Pueblo I once knew had drastically changed. (Above photo is of people lining up at the opening of a pot dispensary in 2014.)
Where there were once hardware stores, animal feed shops, and homes along dotted farms, I now find marijuana shops—and lots of them. As of January 2016, there were 424 retail marijuana stores in Colorado compared with 202 McDonald’s restaurants.1 These stores are not selling the marijuana I had seen in high school.
Multiple different types of patients are coming into the emergency department with a variety of unexpected problems such as marijuana-induced psychosis, dependence, burn injuries, increased abuse of other drugs, increased homelessness and its associated problems, and self-medication with marijuana to treat their medical problems instead of seeking appropriate medical care.
I had expected to see more patients with cannabinoid hyperemesis syndrome (and I have), but they were the least of my concern. Our local homeless shelter reported seeing 5,486 (unique) people between January and July 2016, while for the entire year of 2013 (before recreational marijuana) that number had been 2,444 people.2
Most disturbing, we weren’t seeing just homeless adults but entire families. It is a relatively common occurrence to have patients who just moved here for the marijuana show up to the emergency department with multiple medical problems, without any of their medications, often with poor or nonexistent housing, and with no plan for medical care other than to use marijuana.
They have often left established medical care and support to move here for marijuana and show up to the emergency department, often with suitcase in hand.
Increasingly Potent & Dangerous Drug
This new commercialized marijuana is near 20 percent tetrahydrocannabinol (THC, the psychoactive component of cannabis), while the marijuana of the 1980s was less than 2 percent THC.
This tenfold increase in potency doesn’t include other formulations such as oils, “shatter” (highly concentrated solidified THC), or “dabbing” (heated shatter that is inhaled to get an even more potent form) that have up to 80 or 90 percent THC.3
The greatest concern that I have is the confusion between medical and recreational marijuana. Patients are being diagnosed and treated from the marijuana shops by those without any medical training. I have had patients bring in bottles with a recommended strain of cannabis and frequency of use for a stated medical problem given at the recommendation of a marijuana shop employee.
My colleagues report similar encounters, with one reporting seeing two separate patients with significantly altered sensorium and with bottles labeled 60 percent THC. They were taking this with opioids and benzodiazepines.
In some cases, places outside of medical clinics, like local marijuana shops, are being used to give screening examinations for medical marijuana cards.4 Reportedly, no records are available from these visits when requested by other medical providers. A large number of things treated with marijuana, often with no cited research at all or with severe misinterpretation of research, are advertised online.
These include statements that marijuana treats cancer (numerous types), cystic fibrosis, both diarrhea and constipation, hypoglycemia, nightmares, writer’s cramp, and numerous other conditions.5–7
Although there are likely some very effective ways to use the cannabinoid receptor (probably better termed the anandamide receptor), putting shops on every street corner and having nonmedical personnel giving medical advice is a very poor way to use this as a medicine.
Furthermore, to suggest that combustion (smoking) be the preferred route of medication delivery is harmful.3,8–10 I am also concerned that this is being widely distributed and utilized as a medicine prior to safety and efficacy studies having been completed; widely varying dosing regimens, concentrations, and formulations are being developed, sold, and utilized.
Patients are not being informed of the adverse effects associated with marijuana use, but instead, they are being told, “There are no adverse effects.” I am in favor of using the anandamide receptor for treatment purposes. However, we should do this safely and appropriately. What is occurring now is neither safe nor appropriate.
There are numerous adverse effects of marijuana that are significant. Marijuana use may lead to irreversible changes in the brain.3,9,11,12 Marijuana use correlates with adverse social outcomes.3
It is strongly associated with the development of schizophrenia.13–16 Dependence can lead to problem use.17,18 There are adverse effects on cardiovascular function, and smoking leads to poor respiratory outcomes.3,19,20 Traffic fatalities associated with marijuana have increased in Colorado.1
Pregnant women are using marijuana, which may lead to adverse effects on the fetus, and pediatric exposures are a much more common occurrence.21,22
Different Approach Is Needed
We should approach mass marijuana production and distribution as we would any other large-scale public health problem. We should do what we can to limit exposure, and we should provide clear, unbiased education.
In the case of prevention efforts being unsuccessful, we need to provide immediate treatment and assistance in stopping use. If we are going to use this as a medication, then we should use it as we use other medications. It should have to undergo the same scrutiny, Food and Drug Administration approval, and regulation that any other medication does. Why are we allowing a pass on a medication that very likely would carry with it a black-box warning?
As emergency physicians, we are on the front lines. We treat affected patients; we need to be at the forefront of public policy recommendations at both state and national levels.
Originally published by ACEPNow, a journal of Emergency Medicine. We also published the testimony of another emergency doctor in Pueblo, Dr. Karen Randall.
Dr. Karen Randall, an emergency physician of Pueblo, Colorado, sent a letter to the physicians of Vermont. Their state legislature narrowly passed a bill that would legalize marijuana, but it’s hoped that Governor Phil Scott will veto it. There was not enough time to read Dr. Randall’s at a Press Conference on May, 18, 2016. Here’s the contents of that letter:
Firstly, I’d like to thank you all for the opportunity to share some of my experiences as a physician in a region with heavy legal marijuana use.
In 2012, Coloradans voted to pass Colorado Amendment 64 which led to the state-wide legalization of recreational marijuana beginning in January of 2014. Since then, the number of medical and recreational dispensaries in Colorado has grown to more than double the number of McDonald’s and Starbucks combined. While individual counties could and did choose to abstain from allowing recreational marijuana sales, my county, Pueblo, was one of many that embraced Amendment 64 and the projected benefits of recreational legalization, even unofficially rebranding itself the “Napa Valley of Pot”.
This led to an influx of people looking to smoke without the risk of legal consequences and to cash in on the burgeoning “pot economy”. Unfortunately, many of these people arrived only to find that the supply of marijuana-related jobs was far outweighed by the demand, and few had backup plans. Since 2014, Pueblo’s homeless population has tripled, and our low-income housing have occupancy rates of 98% or more. We have seen a drastic increase in the number of homeless camps, and social services and outreach programs are buckling under the strain.
Our medical infrastructure is also reaching critical mass. Out of the 160,000 residents of our community, roughly 115,000 are on Medicaid. As a result, we have been losing primary care providers at an alarming and unsustainable rate. The largest local clinic has been looking to hire 15 new doctors, but has only been able to hire 1 in the past two and a half years. My emergency medical group has been able to fill less than half of our open positions. The average wait time to see a new primary care provider is months with the wait for a specialist even longer, and many primary care physicians in the area are no longer taking new Medicaid patients.
Additionally, the legalization of marijuana has led to normalization of behavior that in my professional opinion is strongly impacting our youth. Despite sales being legally restricted to those ages 21 and over, the Healthy Kids Survey of 2015 shows: 16% of Pueblo High School kids under the age of 13 have tried marijuana, 30% of high school kids had smoked within 30 days of the survey, 64% feel that it would be easy or very easy to get marijuana, and that 6.3 and 6.6% of respondents have used heroin and methamphetamines respectively, compared to 2% for the rest of Colorado. The number of ED visits for cannabis hyperemesis syndrome, accidental
pediatric ingestions, accidental adult ingestions and psychosis have sharply risen. There has been an increase in the number of babies testing positive for marijuana at birth (many internet and dispensaries are now recommending marijuana for nausea in pregnancy).
The potency of marijuana has risen tremendously since legalization, which is also a cause for significant concern. Almost all of what we do know about marijuana is based on studies where the marijuana was 1-3 mg of THC. Currently, dabbing provides 80-90 mg of THC; edibles provide 10 mg THC per bite and are frequently packaged in quantities to total 100 mg of THC. Fortunately, legislation has passed so that edibles must be packaged in safety packages and can no longer be sold as appealing candy gummies, suckers, etc. Currently, law requires that chocolate be labeled with a stamp and dose quantity but it still looks like a chocolate bar to a child.
Ads and claims to the health benefits of marijuana are rampant on the internet with reported cures for almost every ailment, yet there is very little research, if any to support those “health benefits” and frequently people come to the area with a disease process (for instance, Parkinson’s disease) and purchase marijuana. Many of those looking for cures are seniors who are not toleratant to the dosage/strength of the current marijuana being marked and they come to the ED with side effects.
I deeply appreciate having been given a platform to share my experiences with you today, and I strongly encourage the physicians of Vermont to consider the broader medical, economic, and social ramifications of the legalization of marijuana.
Thank you for your attention, Dr. Karen Randall, FAAEM Southern Colorado Emergency Medicine Associates Pueblo Colorado
Dr. Randall presented her experiences at a press conference in Pueblo on October 20, 2016.