The Centers for Disease Control (CDC) is reporting that between 30,000 and 40,000 Americans are dying each year from opioid overdoses. Most of these are not suicides but, are the consequences of people using “stuff” which is profoundly more potent than they imagined. From our local communities, to the state, and federal government levels, we are alarmed and we should be.
Parallel to the “opioid epidemic” is the “cannabis epidemic” which is going unnoticed and unreported. We see weekly hype about so called “medical marijuana,” but, little about the tragic consequences of cannabis overdoses.
Why? One reason is that opioid overdoses kill and cannabis takes the lives of its victims in a less dramatic way. Cannabis-induced psychosis robs the victims of their meaningful life.
The proverb says, “There are many ways to lose one’s life and dying is just one of them.”
The parallel to opioids is that the “weed” of today has been hybridized (genetically engineered) to be 5 – 6 times more potent than the weed of 20 years ago (4% THC compared to 19% THC). In addition, the contemporary delivery systems (example- vaping) increase the amount of THC getting to the brain. These unexpectedly high “doses” of today may include manic psychosis and schizophrenia like symptoms. The victim didn’t understand what she/he was getting. What was expected to be a few hours of pleasure has become a life-changing psychosis.
I predict that our fascination with “medical marijuana” will only accelerate this tragic epidemic of THC-induced psychosis.
If there is to be a place for “medical marijuana,” give it to the FDA where it can be studied by legitimate scientists who are not funded by the producers, distributors and charlatan practitioners. Clearly, the profits are huge and the costs to human lives are huge.
There may be a few serious conditions in which a small amount of cannabis helps to relieve suffering. Example: End stage cancer. Responsible physicians will use it wisely and compassionately just as they do with opioids.
The tragic hidden problem is aided by a very small number of “charlatan physicians” who will sell their souls to the callous industry. For a fee and without being seen, cannabis users can receive a “certificate of need.” This document allows the user to go into a retail cannabis dispensary and purchase whatever he/she wants from a large inventory of cannabis products.
Said again, opioids kill by suppressing respiration. Cannabinoids ruin lives by inducing psychosis. Both are tragic.
Dr. Dossett is a pediatrician in Hershey, Pennsylvania
Foodies who admire Michael Pollan’s The Omnivore’s Dilemma include parents opposed to marijuana and its manipulation into an increasingly potent, dangerous drug.
Pollan is writing a book about possible medical applications for psychedelics, which would fit nicely into an agenda promoted by the Drug Policy Alliance, MAPS and Erowid. Surreptitiously, these pro-drug lobbyists and groups are trying to legalize all drugs. If they get popular writers on board, it will be so much easier.
MAPS pushes pot as treatment for PTSD, even though an important study from Yale suggests that pot worsens PTSD in veterans. Bad psychiatric treatments are nothing new. At one time, the public also believed in lobotomies as a treatment for mental illness.
Drug Policy Alliance uses “social justice” reasons to push for legalization of all drugs, first through decriminalization.* The social justice angle isn’t a good argument, because drug dealers, legal and illegal, target minorities and poor communities. Dig a little deeper and social justice appears to be the excuse, not the true reason the DPA argues for drug legalization.
Psychedelics, Alternative Reality and Psychosis
Drug advocates are promoting many psychedelics as medicine: psilocybin mushrooms, LSD, marijuana, MDMA (Ecstasy) and ketamine. Psychiatrists of the ’50s and ’60s experimented with these drugs as psychiatric treatments. The most famous one, Scottish Psychiatrist R.D. Laing, experimented with LSD to treat some patients. Although he had genuine empathy towards the patients, Laing’s methods and those of his followers are often considered worse than failure. (Psychiatrist Isidora Ranjit-Singh explains: Laing “didn’t understand the interaction between illicit substances such as LSD and cannabis and mental health: illicit drugs are a contributory factor in psychosis. LSD is an awful drug that can result in seemingly psychotic flashbacks which can continue after the patient has stopped using it.”)
As long as we do not know the cause of many psychological issues, using psychedelics is like playing with fire. Emil Kraepelin, father of modern Psychiatry, maintained that catatonia and schizophrenia wouldn’t be solved until we know their cause. It doesn’t always boil down to genetics. When the root cause of a mental issue is trauma, there are successful therapeutic models and we don’t need new experimental drugs.
As for schizophrenia, marijuana is the one known trigger which can lead to this condition of permanent psychosis.
Psychedelics Study is Chance to Learn from Past Mistakes
Movers and shakers behind “medical” marijuana use the term “compassion” as a marketing scheme. To avoid FDA scrutiny, they devised a scam, recorded on videotapes, to bring about full legalization. Perhaps they’re pushing new “medicinal” uses for hallucinogenic drugs for similar reasons.
Ethan Nadelmann, formerly executive director of Drug Policy Alliance, explained the underlying plan on Reddit. “Michael Pollan’s forthcoming book on psychedelics and medicine will take media interest to yet another level. The more people know about this, the faster psychedelics will be legally accepted as medicines.” Nadelmann engages his followers with wishful thinking. In a TED talk, he said: “Our desire to alter our consciousness may be as fundamental as our desire for food, companionship, and sex.”
When Pollan has spoken to the press, he mentions psychedelics as “palliative” care in people facing the end of life. It sounds familiar, because the pot lobbyists initially promoted medical marijuana for end-of-life care. In reality, it’s mostly young men with pain who use “medical” marijuana, not the cancer and AIDs patients for whom it was intended. More recently pot advocates promote it to treat psychiatric disorders.
If hallucinogens can be used help in controlled settings, would those who become “caregivers” practice snake oil medicine? Would they set up they type of shams that plague “medical” marijuana? Again the public could be tricked, since everyone has compassion for the terminally ill.
There are strong ethical reasons not to endorse psychedelics, or to give so much power to psychiatrists and gurus. It would entail knowingly utilizing drugs that can make certain people worse. Furthermore, it would put incredible power into the hands of “caregivers” and psychiatrists. If teens get the idea that a drug is “medicinal,” they will think it safe to use –by anyone on any occasion.
When the US Government Has been “Right”
Although the US government gave some bad dietary advice over the past decades, it has revised some of the mistakes. Diet dictocrats now recommend eating eggs, the right kind of fats and fewer grains. Americans are eating better because they listened to critics such as Michael Pollan and many others.
The US government’s historical evaluation of and classification of marijuana in 1970 was never wrong. Judges and the FDA have consistently rejected the reclassification of marijuana.
Drug advocates wish to normalize drug use in order to capitalize on it. By using drugs, they hope to bypass the hard work it takes to obtain true spiritual growth. Modern America is not comparable to the ancient, ritualistic and shamanistic cultures that traditionally used psychedelics. We need our food to keep us alive, but we don’t need intoxicating, hallucinogenic drugs to sustain us.
Is Marijuana Use for Pain Driving Negative Societal Effects?
by Kenneth Finn, MD
Pain is the most common diagnosis associated with marijuana being recommended for medical use 1. With more states moving towards accepting marijuana use for medical purposes, there is a call from the medical and scientific community for more research and
evidence that it actually works for common pain conditions.
Out of the top 20 medical diagnoses presenting to the primary care physician nationally, there are only 3 that are associated with a painful condition 2: spinal disorders (i.e., lower back pain), arthropathies and related disorders (i.e., knee arthritis), and abdominal pain.
There were no other pain diagnoses in the top 20 diagnoses which present to the primary care physician for treatment, including cancer pain or neuropathic pain.
What does the medical literature tell us about the use of marijuana for pain? In 2011, The British Journal of Pharmacology released a paper looking at the use for cannabinoids for the treatment of chronic non-cancer pain 3. They narrowed a broad literature review to only 18 trials with a total of 925 participants. Most of the trials reviewed studied neuropathic pain (72%), including HIV neuropathy, in multiple sclerosis (3 trials), and single studies looked at arthritis or chronic spinal pain. There were only 4 studies which looked at smoked cannabis and in neuropathic pain only. Six studies evaluated synthetic cannabinoids (Dronabinol, Nabilione) for pain (off-label use).
From these trials, the average number of patients was 49 with average duration of 22 days, some of which were one week long. Despite their conclusion that cannabinoids may be helpful for chronic non-cancer pain, they note there were limitations with small sample sizes, modest effects, and stressed the need for larger trials of longer duration to determine safety and efficacy.
In 2015, the Journal of the American Medical Association (JAMA) released an article on cannabinoids for medical use 4. Chronic pain was assessed in 28 studies, involving 63 reports and 2454 participants. 13 studies evaluated nabiximols (not available in the US), 4 for smoked THC, 6 evaluated synthetic THC, 3 for oromucosal spray, 1 for oral THC, 1 vaporized cannabis. The majority of studies looked at some form of neuropathic pain or cancer pain. Two studies were at low risk of bias, 9 at unclear risk, and 17 at high risk of bias. Studies generally suggested improvements in pain measures associated with cannabinoids but these did not reach statistical significance in most individual studies. Despite that, they concluded that there was moderate-quality evidence to suggest that cannabinoids may be beneficial for the treatment of chronic neuropathic or cancer pain (smoked THC and nabiximols). Note these are less common pain conditions that present to the physician for treatment nationally. The authors noted an increased risk of short-term adverse effects with cannabinoid use, including some serious adverse effects. Common adverse effects included asthenia, balance problems, confusion, dizziness, disorientation, diarrhea, euphoria, drowsiness, dry mouth, fatigue, hallucination, nausea, somnolence, and vomiting.
In 2017, The National Academies of Science, Engineering, and Medicine released a paper on the health effects of cannabis and cannabinoids 5. It may be important to note that none of the authors had a background in Anesthesia or Pain Medicine. The authors felt the above JAMA article was the most comprehensive and that the medical condition most often associated with chronic pain in that article was a neuropathy and a majority of studies evaluated treatment with nabiximols, which are not available in the United States.
The committee found that only a handful of studies evaluated the use of cannabis and that many of the cannabis products sold in state regulated markets bear little resemblance to the products available for research at the federal level in the United States. They also note that very little is known regarding efficacy, dose, routes of administration, or side effects of commonly used and commercially available products in the United States. Despite that, they still concluded that “cannabis is an effective treatment for chronic pain in adults”.
The above noted papers are all that is available to the public and medical community and are the only information available regarding treatment of pain with marijuana. Despite that, the public has embraced that marijuana can treat all pain conditions and state governments have followed suit, without scientific evidence, and have allowed an industry to prosper on the thin ice of what is currently and scientifically available.
It is important to understand that pain covers a broad spectrum of disorders and pain of different origins does not necessarily respond the same to different medications. It is also important to understand that dispensary cannabis is considered a generic substance without defined or accepted dosing guidelines and will vary in purity as well as potency. It may also contain hundreds of other compounds, some of which may have physiologic activity. Cannabinoids are purified components of the plant which have been isolated in a
laboratory and have more scientific foundation, but are currently not available for study or use in pain conditions in the United States.
Since de facto legalization in Colorado in 2009, there has been a significant increase in public health and safety concerns, which include utilization of the health care system, an increase in adolescent substance use treatment for cannabis, as well as an increase in marijuana related driving fatalities 6. The addiction rates are reportedly 9% in the adult and roughly 18% in the adolescent, which was based on the potency of marijuana nearly 20 years ago. The potency has significantly increased in the past 5 years alone, so we are now in uncharted waters and unable predict the long term effects or addiction rates of currently available, highly potent products, with variable delivery systems.
As the number of medical marijuana patients increased in Colorado, there appears to be a parallel increase in the number of adolescents needing substance use treatment, most often for cannabis. Colorado is now contending with a huge opioid and heroin epidemic and despite the widespread availability of Narcan, does not appear to have leveled off or curb the number of opioid or heroin deaths in the state which continue to rise 7.
Although the concept of using marijuana to decrease opioid use is attractive and there is little data to suggest that may be the case. According to the CDC, the number of drug overdose deaths in Colorado has continued to increase, ahead of the national average 8. The above problems are now landing in the laps of other groups such as law enforcement and mental health providers who are pushing back and are straining their respective resources.
In summary, the problem of increased marijuana use has origin in its purported use for pain, but the medical literature is completely void of evidence for the treatment of common pain conditions with cannabinoids or cannabis. Current medical literature suggests benefit in less common pain conditions, with products not commercially available in the United States, or with synthetic THC, not with dispensary cannabis. The variability of available products changes regularly and their use in medicine, particularly pain, is unproven. The end game is in the court of law enforcement, mental health providers, the medical community, and our educational systems, at unknown societal costs, which are only now
Kenneth Finn, MD
Board Certified, Physical Medicine and Rehabilitation
Board Certified, Pain Management
Board Certified, Pain Medicine
American Board of Pain Medicine
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.