Marijuana legalization is creating a raft of opportunities and challenges for healthcare providers, panelists said Thursday morning at an Oregon Health Forum discussion of the consequences of legal cannabis use. But with data on the federally controlled substance still sparse, and high-quality studies difficult to conduct, anecdotes and experience – rather than research – seemed to drive the views of presenters as they spoke.
Dr. Libby Stuyt, medical director of the a Colorado inpatient treatment program for people with mental illness and substance abuse who have failed at other treatments, portrayed legal marijuana as dangerous, addictive, and riddled with negative health consequences that she said are being overlooked by many professionals – though she also advocated for continuing to allow legal recreational sales.
Stuyt was joined on the panel by Oregon State Epidemiologist Dr. Katrina Hedberg and Oregon Health and Science University faculty member Dr. Esther Choo, who both offered more nuanced takes on marijuana – and who each focused on the limits of current research and called for additional study.
“This drug is not the drug most people thought it was, when people voted on this – especially in Colorado,” Stuyt said in her opening remarks. “We’ve taken a tobacco epidemic and an alcohol epidemic, and we’ve merged them. It’s not just additive, it’s logarithmic, in terms of the consequences.”
Stuyt bemoaned the influence of pro-cannabis industry groups in the exploration of marijuana’s intersection of healthcare, noting that at conferences she has attended she has seen industry groups promoting cannabis as a tax source, healthy, beneficial, and environmentally friendly.
“We need to be very careful, and we need to sort thing out and not take the industry’s word,” she said, noting that tobacco advocates would never be allowed to have such a prominent role at a conference on nicotine and health.
Stuyt cautioned the Oregon Health Forum audience that retail marijuana flower routinely now has THC, the active recreational chemical in pot, at levels of 30 percent or more – while 10 percent or less was more typical in the 1960s, ‘70s and ‘80s. Concentrated products have even higher THC amounts, she said. “This is not marijuana anymore. This is a drug that causes problems.”
Some of Stuyt’s claims were demonstrably untrue, including that recreational dispensaries rarely carry cannabis products with low levels of THC and high levels of medically CBD, a chemical innate to the plant that has been shown to reduce pain and to have other potential medical uses. Despite Stuyt’s assertion, the pot review and listing website Leafly.com shows numerous high-CBD, low-THC strains available in the Portland area, and across Oregon.
Stuyt’s discussion of addiction also drew some consternation from the crowd, with one addiction specialist saying that Stuyt’s framing addictive drug use as a personal failing and a cognitive choice could be actively harmful.
Hedberg, who spoke second at the forum, did not actively dispute Stuyt’s remarks, but presented a more nuanced view, which she said grew out of the efforts Oregon has made since overs approved medical marijuana in 1998.
“Marijuana is interesting, because it has a long history – for thousands of years people have been using marijuana for both medical and recreational,” she said. “But because it is a schedule 1 substance, we lack a lot of the data that we have with other medicines.”
State data shows that since recreational pot has been legalized, teenage use of the drug has held steady – with about 22 percent of 11th grade students reporting regular use. That’s higher than the national average, but not changed from pre-recreational days. At the same time, alcohol use has fallen, with 30 percent of 11th grade students reporting regular drinking in 2016, compared to 34 percent of 11th graders in 2014.
Hedberg also noted that about 60,000 Oregonians now hold medical marijuana cards, down from the pre-full-legalization peak of about 80,000 as some medical users now buy from recreational stores. And she affirmed the role that CBD can play in treating pain, while cautioning that some legally authorized medical uses of pot – such as to treat post traumatic stress disorder – are not backed up by evidence.
“There are good aspects to this, but we are here to look at the unintended consequences,” she said.
Among those: calls to poison control and visits to the emergency department are up – though early fears that children would get into edible marijuana candies have not born out. Instead, adults are reporting the negative symptoms of high doses of marijuana, which can include drowsiness, anxiety, tachycardia, delusions, paranoia and vomiting, Hedberg said.
Acknowledging Stuyt’s concerns about high levels of THC in many recreational pot strains, Hedberg urged users to “start low, go slow,” as they learn about dosing.
She also noted that smoking the drug creates health effects beyond intoxication, because burning and then inhaling any particulate poses a risk to the respiratory system.
Speaking last at the breakfast, Choo detailed her experiences as an emergency room physician – and the ways that pot legalization has changed the conversations between doctors and patients.
“In the ER you usually come in with some kind of pain – we are here to treat whatever is hurting you. We often ask, ‘What did you do for the pain?’” she said. “Patients will say, I took ibuprofen, Tylenol, a Vicodin left over from a dental appointment – and I took some cannabis. Did cannabis just fall into the Tylenol category? It used to be, ‘I took these things, and then I took a shot of vodka to take the edge off,’ and there’s be a little bit of shame about it. But people use cannabis differently, and are more open about discussing it now.”
Ironically, before marijuana was legal, many ER doctors were more thorough about documenting pot use than after, Choo said she believes. “I don’t put ‘ibuprofen administration’ as part of a diagnosis. I feel that physicians are a little more blasé about it now.”
That creates a challenge when trying to use hospital data to understand the role cannabis has played in changing the health system – because the data does not always exist. Even when use is documented, it can be hard to know when cannabis was a cause of a medical situation, and when it was incidental.
Choo presented this hypothetical: Did a patient who came in with buttock pain smoke pot to make the pain less severe? Or did that patient sit on a burning joint and get injured as a result? Depending on how an ER visit is documented, it may not be possible to differentiate.
She also noted that in some cases, cannabis can be used as a tool for harm reduction.
A patient might say, “I have chronic pain, I was on opioids for many years, I overdosed, I almost died, and then I got onto cannabis,” Choo said. “That seems like a reasonable harm reduction maneuver. I’m not going to stand in the way of you using cannabis. In fact, it’s one of the evidence-based uses of cannabis – chronic pain.”
And now that cannabis is legal, many patients are more willing to ask questions and discuss their use with their medical providers – which is beneficial overall, but can leave doctors confused because of the lack of available evidence to guide their responses, she said.
When asked for advice on strains and formulations, “We are all like deer in the headlights. A 20-something budtender is more equipped for these conversations, even though he has no medical background,” Choo said.
