Remember the good old days, when we giggled about doobies, pot-brownies, and the munchies and laughed out loud at the antics of Cheech and Chong in “Up in Smoke?” Talk of marijuana was a bit taboo, and while we all “knew people” who did a little weed now and then, it really wasn’t a big deal. For the most part, it wasn’t big business either, except perhaps, for that hippie down the street who sold it out of his van. And it certainly didn’t cause a political stir, quite simply, because everyone knew the facts: marijuana is a drug and it is (was) illegal.
Well, times, they are a’changin’. As of November 11, 2016, twenty-nine states have laws on the books legalizing the use of marijuana for medicinal purposes, with seven of those states and the District of Columbia adopting more expansive laws legalizing marijuana for recreational use. Four out of five states aiming to legalize marijuana for recreation succeeded this fall, and there is a strong push among lobbyists in several states to legalize and expand the industry.
The topic of medical marijuana comes up from time to time in my clinic, with patients asking my opinion and trying to sway me one way or the other. I’m guessing, depending on your location and patient population, it comes up in your clinic too. Proponents tout it as a safe alternative to opioids, and the media provides sensational stories of lives changed since the legalization of it. I have one patient who loves to bring me stories from newspapers and the internet proving pot is the end-all-be-all answer to pain. Maybe he is hoping to drum up some business, assuming Wisconsin turns green one of these days. Considering the substantial buzz on the topic, medical marijuana is something we now discuss in our advanced Therapeutic Neuroscience Education courses. And, it’s a topic we should all be prepared to discuss intelligently.
There is some compelling research advocating the medical use of cannibus. For instance, in a 2015 systematic review published in JAMA, KP Hill found “Use of marijuana for chronic pain, neuropathic pain, and spasticity due to multiple sclerosis is supported by high-quality evidence. Six trials that included 325 patients examined chronic pain, 6 trials that included 396 patients investigated neuropathic pain, and 12 trials that included 1600 patients focused on multiple sclerosis. Several of these trials had positive results, suggesting that marijuana or cannabinoids may be efficacious for these indications.”
In fact, there is a movement to re-schedule and re-brand marijuana, described by Carter et al. in a 2015 article . The authors’ state: “The field of pain medicine is at a crossroads given the epidemic of addiction and overdose deaths from prescription opioids. Cannabis and its active ingredients, cannabinoids, are a much safer therapeutic option. Despite being slowed by legal restrictions and stigma, research continues to show that when used appropriately, cannabis is safe and effective for many forms of chronic pain and other conditions, and has no overdose levels. Current literature indicates many chronic pain patients could be treated with cannabis alone or with lower doses of opioids. To make progress, cannabis needs to be re-branded as a legitimate medicine and rescheduled to a more pharmacologically justifiable class of compounds.”
However, before we get too excited and order green prescription pads for our offices, we need to look a little closer at what the literature has to say about the diagnoses for which cannabis is effective, and compare that to the types of patients we see in the clinic. Belenduik et al. provides a review of the safety and efficacy of marijuana for the treatment of common state-approved medical and psychiatric disorders in this free article.( According to the authors, common medical conditions for which marijuana is allowed (i.e., those conditions shared by at least 80 percent of medical marijuana states) were identified as: Alzheimer’s disease, amyotrophic lateral sclerosis, cachexia/wasting syndrome, cancer, Crohn’s disease, epilepsy and seizures, glaucoma, hepatitis C virus, human immunodeficiency virus/acquired immunodeficiency syndrome, multiple sclerosis and muscle spasticity, severe and chronic pain, severe nausea…and post-traumatic stress disorder.
As it turns out, research on musculoskeletal pain and marijuana is quite limited. Rather, according to Belenduik et al., pain-specific clinical trials have examined smoked and oral administration of cannabinoids on different types of pain (e.g., neuropathic, post-operative, experimentally induced) in multiple patient populations (e.g., HIV, cancer, and fibromyalgia). Areas of concern arose concerning dosage, as some studies have found that higher doses of smoked marijuana are associated with improved analgesia, whereas other studies show that higher doses of smoked marijuana increase pain response. In addition, one meta-analysis showed that marijuana increased the odds of altered perception, motor function, and cognition by 4 to 5 times. After reviewing the two meta-analyses that explore the association between marijuana and pain, the authors conclude that “Although there is preliminary support to suggest that marijuana may have analgesic effects, there is insufficient research on dosing and side effect profile, which precludes recommending marijuana for the management of severe and chronic pain.”
The Down-Right Scary:
As the push to legalize marijuana for medical purposes gains momentum and acceptance in the mainstream, we need to look at what we know about the side effects of the drug on individuals and ask ourselves: Would marijuana be helpful for our patients already struggling with the effects of a brain on pain? Remember the Pain Neuromatrix? A brain that is enslaved to pain commonly already has difficulty with focus, problem solving, fear, memory, body maps, motor control, stress responses, and motivation. Consider some of these facts about marijuana, which are outlined in the Surgeon General’s Report on Alcohol, Drugs, and Health:
- Long-term health consequences of marijuana use: mental health problems, chronic cough, frequent respiratory infections, increased risk for cancer, and suppression of the immune system.
- Other serious health-related issues stemming from marijuana use: breathing problems; increased risk of cancer of the head, neck, lungs, and respiratory tract; possible loss of IQ points when repeated use begins in adolescence; babies born with problems with attention, memory, and problem solving (when used by the mother during pregnancy).
- Increased risk for traffic accidents: Marijuana use is linked to a roughly two-fold increase in accident risk.
- Increased risk of schizophrenia: The use of marijuana, particularly marijuana with a high THC content, might contribute to schizophrenia in those who have specific genetic vulnerabilities.
- Increased risk of addiction from high-potency marijuana available in legalized states: Concern is growing that increasing use of marijuana extracts with extremely high amounts of THC could lead to higher rates of addiction among marijuana users.
- Permanent Loss of IQ: One study followed people from age 13 to 38 and found that those who began marijuana use in their teens and developed a persistent cannabis use disorder had up to an eight point drop in IQ, even if they stopped using in adulthood.
The report notes that, “While laws are changing, so too is the drug itself with average potency more than doubling over the past decade (1998 to 2008). The ways marijuana is used are also changing – in addition to smoking, consuming edible forms like baked goods and candies, using vaporizing devices, and using high-potency extracts and oils (e.g., “dabbing”) are becoming increasingly common. Because these products and methods are unregulated even in states that have legalized marijuana use, users may not have accurate information about dosage or potency, which can lead and has led to serious consequences such as hospitalizations for psychosis and other overdose-related symptoms.”
Smart Approaches to Marijuana, SAM, is an alliance of organizations and individuals dedicated to a health-first approach to marijuana policy. They refer to the marijuana industry as Tobacco 2.0, and they make a strong case against the commercialization and normalization of marijuana. Their concern is not only for the effect on individuals, but on general public health and society as well. Their fact list on the consequences of marijuana use and legalization is sobering (sources for all facts and stats cited below available on SAM’s website.
- One in every six 16 year-olds (and one in every eleven adults) who try marijuana will become addicted to it.
- Today’s marijuana is not your “Woodstock weed” – it can be 5-10 times stronger than marijuana of the past. The psychoactive ingredient in marijuana, THC, has increased almost 6-fold in the past 30 years.
- Adolescents who smoke marijuana once a week over a two-year period are almost six times more likely than nonsmokers to drop out of school and over three times less likely to enter college.
- Emergency room admissions for marijuana use now exceed those for heroin and are continuing to rise.
- The link between suicide and marijuana is strong, as are car accidents – many of which result in death.
- Regular marijuana use is associated with lower satisfaction with intimate romantic relationships, work, family, friends, leisure pursuits, and life in general.
- In most states that permit the use of medical marijuana, less than 2-3% of users report having cancer, HIV/AIDS, glaucoma, MS, or other life-threatening disease.
- We know that most people who use pot won’t go onto other drugs; but 99% of people who are addicted to other drugs started with alcohol and marijuana. So, indeed, marijuana use makes addiction to other drugs more likely.
- Beginning in the 1980s, scientists have uncovered a direct link between marijuana use and mental illness. According to a study published in the British Medical Journal, daily use among adolescent girls is associated with a fivefold increase in the risk of depression and anxiety. Youth who begin smoking marijuana at an earlier age are more likely to have an impaired ability to experience normal emotional responses. The link between marijuana use and mental health extends beyond anxiety and depression. Marijuana users have a six times higher risk of schizophrenia, are significantly more likely to develop other psychotic illnesses.
- Residents of states with medical marijuana laws have higher odds of marijuana use and marijuana abuse/dependence than residents of states without such laws.
- Cannabis food and candy is being marketed to children and are already responsible for a growing number of marijuana-related ER visits. Edibles with names such as “Ring Pots” and “Pot Tarts” are inspired by favorite candies of children and dessert products such as “Ring Pops” and “Pop Tarts.” Moreover, a large vaporization industry is now emerging and targeting youth, allowing young people and minors to use marijuana more easily in public places without being detected.
SAM asserts that the marijuana industry consistently puts corporate profit and addiction ahead of public health. Amazingly, Colorado has more marijuana businesses than McDonalds and Starbucks combined! In one of the most disturbing trends they are tracking, our youth seem particularly vulnerable. Consider the brain of a teen, ripe for neuroplastic change, becoming exposed to what young people commonly believe is “safe marijuana”…after all, it’s medicine! The Monitoring the Future Study found that over one third of 12th graders who use marijuana use someone else’s medical marijuana, and 60% view it as not harmful. The MTF report also found that 6.5% of current high school seniors are using marijuana daily, compared to just 2.3% in 1993. That is a 300% increase in 20 years.
SAM articulates the following stance on medicinal marijuana: Medical marijuana should really only be about bringing relief to the sick and dying, and it should be done in a responsible manner that formulates the active components of the drug in a non-smoked form that delivers a defined dose. However, in most states with medical marijuana laws, it has primarily become a license for the state-sanctioned use of a drug by most anyone who desires it. Developing marijuana-based medications through the FDA process is more likely to ensure that seriously ill patients, who are being supervised by their actual treating physicians, have access to safe and reliable products.
At ISPI, we see smoking marijuana as a behavioral issue, similar to smoking, illicit or prescription drug abuse, alcohol abuse and surgery: medical marijuana is yet another passive way to treat pain. The normalization of passive approaches to pain (meds, modalities, injections, surgeries) has done us no favors in helping people get their lives back. In addition, we know there is a proliferation of canniboid receptors, and that tolerances, like opioids, can increase over time, leaving us with many long-term questions.
We know it’s the active approaches that work best in the treatment of chronic pain: understanding how pain works, getting regular cardiovascular exercise, practicing good sleep hygiene, setting goals, cognitive behavioral therapy, establishing a plan, etc. Trying to foster these practices through the haze of marijuana seems challenging at best, non-sensical at worst. Physical therapy is active, safe, and to the best of my knowledge, has no risk of inciting a schizophrenic episode in someone genetically predisposed.
As we look at the whole patient, remembering it’s always about the patient, we need to ask, is marijuana, medical or recreational, legal or illegal…is marijuana in this person’s best interest? Will it help them get their lives back? And as we look at our society, we need to slow down and ask ourselves, is this really where we want to go as a country. SAM will make no bones about it, and after my initial study on the topic, neither will I. The new face of marijuana is not Cheech and Chong. It is executives in three-piece suits looking to make a fortune at the expense of the brain cells of our youth, people in pain, and an unsuspecting nation.
What do you think? This is a juicy topic, and I’d especially love to hear from any of my colleagues in Colorado or Washington who have experience working in areas where marijuana has been legal medicinally for some time and is now legal across the board!