A prescription for trouble?
by Doris C. Gundersen, MD
Editor’s note: This article was originally published as “critical thinking on issues of medical licensure and discipline” in the Journal of Medical Regulation, Volume 101, Number 1, 2015. This excerpt has been reprinted with permission.
The United States is clearly divided over the legalization of marijuana. Those in favor argue that legalization of marijuana protects individual rights and eliminates criminal convictions and incarceration for minor offenses. They also maintain that it would do away with the black market and provide significant tax revenue to each state. Those opposed to its legalization express concern about a possible escalation in use with concomitant adverse mental and physical health effects, increased medical costs and negative societal consequences.3 Many of these concerns appear to be unfolding today in Colorado.
In August 2014, the Rocky Mountain High Intensity Drug Trafficking Area Investigative Support Center released a report summarizing the impact of the recent easing of federal marijuana arrests and the eventual legalization of marijuana in Colorado.1 According to the report, the ramifications of these developments in the state are widening.
Public health and safety impacts, for example, include an increase in traffic fatalities involving drivers testing positive for marijuana. The majority of driving-under-the-influence-of-drugs arrests in Colorado involve marijuana. In 2013, 48 percent of Denver adult arrestees tested positive for marijuana, a 16 percent increase from 2008. From 2011 through 2013 there was a 57 percent increase in marijuana-related emergency room visits. Hospitalizations related to marijuana have also increased.
In the state’s schools, marijuana use is higher than national averages. In 2012, Colorado ranked fourth in the nation for marijuana use among 12 to 17 year olds and 39 percent higher than the national average. Drug-related school suspensions/expulsions increased by 32 percent between 2009 and 2013; the vast majority were for marijuana violations.
The use of marijuana among adults in Colorado is also much higher than national norms, with the state ranking third in the nation in 2012 – 42 percent higher than the national average.
Other concerning trends have been observed since the de facto and actual legalization of marijuana. Butane hashish oil (aka BHO) labs are emerging. Infusing hashish oil with butane and smoking or vaporizing the concoction produces an intense mind-altering experience. Whereas an average-size marijuana “joint” contains 10 to 15 percent THC, BHO can contain up to 90 percent THC. The emergence of these THC-extraction labs has posed unique challenges to law enforcement officials and physicians alike. Flash fire explosions have originated from the butane used in the extraction process. In 2013, there were 12 THC extraction lab explosions. In the first half of 2014, the number of explosions more than doubled. In 2013 there were 18 documented injuries from THC extraction labs and in the first half of 2014 there were 27 documented injuries. While “dabbing” (e.g., smoking BHO) has gained popularity in recent years, others consider it the “crack of pot” and fear it could jeopardize the marijuana legalization movement.1
“Black market” marijuana was expected to disappear once the substance was legalized in Colorado. However, marijuana illegally cultivated on federal land in Colorado is a thriving business. There is no evidence to suggest that the legalization of recreational marijuana has diminished the illegal production of marijuana on national forest system lands.1 Given the high taxation on legal marijuana and demand for the drug in neighboring states, it is unlikely that this underground business will disappear.
Similarly, the applications for medical marijuana cards were expected to diminish with the passage of Amendment 64. Instead, Colorado’s Medical Marijuana Registry reveals that the CDPHE’s issuance of medical marijuana cards almost tripled between December 2009 and April 2014. A possible cause is the fact that marijuana dispensed for medicinal purposes is taxed at a lower rate than that purchased for recreational use.1
Proponents theorized that legalizing marijuana would reduce alcohol consumption in the state of Colorado. However, the data does not support that this is occurring. Alcohol consumption in Colorado is consistently above the U.S. average of gallons of alcohol consumed per year.1
When recreational marijuana became legal on Jan. 1, 2014, a flood of consumers began to visit dispensaries. The proliferation of marijuana “edibles” surprised state officials and industry alike. Cookies, candies and drinks (e.g., “soda pot”) infused with THC became quickly popular, accounting for 45 percent of the legal marijuana marketplace.
Unfortunately, of those new consumers, many were not aware of the potent THC content in edibles. Three deaths resulted. A 19-year-old college student, after consuming a marijuana-infused cookie, became agitated and jumped off a hotel balcony. An adult male Denverite shot and killed his wife after eating a THC-containing piece of candy. A 23-year-old skier visiting from out of state shot and killed himself after ingesting edibles. Hospital emergency rooms continue to treat children, adolescents and adults who develop paranoia, anxiety and/or psychosis following intentional or accidental exposure to these edibles. In addition to unpleasant psychiatric effects, more hospitals are treating chronic marijuana users for Cyclic Vomiting Syndrome, a cannabinoid-induced hyperemesis that has created a burden to the health-care system as it often leads to costly gastrointestinal workups and hospitalizations.1
The promise of large state tax revenues from the sale of marijuana may have served as an enticement for the legalization of marijuana. However, tax revenue from marijuana sales has fallen short of what was anticipated. In December 2014, state tax revenues received from marijuana sales were predicted to top $100 million but in reality were on pace for a little more than half that amount.24
Limitations in marijuana research
Clearly, the legalization of marijuana has increased the acceptability, accessibility and use of this drug, and it should be noted that some results from medicinal marijuana use appear to show promise. A few families, for example, have traveled to Colorado to legally obtain cannabidiol tinctures for their children who suffer from intractable epilepsy and, more specifically, Dravet Syndrome – and for some, the results have been encouraging. In a recent study of 19 children with epilepsy, two children experienced complete remission from seizures. Another eight children experienced a significant reduction in seizures and six experienced a reduction of 25 to 60 percent in their symptoms.8
While promising, however, this small sample size does not provide the kind of efficacy and safety data the FDA would demand before introducing a new drug to the public. What is more common, and more troubling, is a general murkiness that can cloud scientific discovery when the availability of medicinal marijuana is exploited by recreational users and financial opportunists – as in the spike in diagnosis of “severe pain” among young men in Colorado between 2009 and 2014. Effective public health policy depends on accurate health reporting and scientific analysis – neither of which is possible when bad actors, whether they are patients or the physicians who treat them, are distorting health care decision-making for personal benefit.
It is ironic that at a time when we are emphasizing evidence-based medicine and conducting vigorous smoking cessation campaigns, marijuana is being promoted – despite the known health hazards, such as pulmonary disease, vascular complications, neurotoxicity to the developing brain, cognitive deficits in adults, addiction and other psychiatric problems, including psychosis.8
While the Institute of Medicine’s 2003 authoritative report identifies potential benefits of marijuana related to its anti-inflammatory, antiemetic, antispasmodic and analgesic properties, in addition to its ability to lower intraocular pressure, studies conducted in the past had several limitations. Research on the use of marijuana for medical purposes is lacking, partly because it is currently classified as a Schedule I drug, making it virtually impossible to conduct the randomized, double-blind, placebo-controlled prospective studies that are normally employed to assess efficacy and safety. Studies thus far have been retrospective in nature with small subject numbers. Differing cannabinoid concentrations, differing exclusion criteria and confounding variables limit the reliability of earlier study outcomes.8, 11, 14, 25
Complicating matters, the THC potency, as measured in marijuana obtained through interdiction seizures, has steadily increased from approximately 3 percent in the 1980s to 12 percent or higher in 2014. Thus, the marijuana available today may be associated with more hazards than previous studies reflect.
In short, for medical professionals and public health officials, we are clearly putting the cart before the horse in terms of public policy and our ability to provide the most accurate scientific information about any associated health risks or benefits related to marijuana use.
What path forward for regulators?
All of this creates great challenges for state medical boards. If public health and safety is potentially impacted by marijuana use, how can regulators ensure that the actions of licensees are not contributing to public harm? How do regulators ensure the safety of patients when much-needed, large-scale research is lacking, and when, at the same time, public opinion seems to be colliding with the medical evidence? How do regulators navigate the conflict between state and federal laws? As more states move in the direction of legalizing marijuana for medicinal purposes, we can anticipate more patients inquiring about its risks and benefits – and in the current atmosphere it is likely they will receive conflicting advice. This will create difficulty in making judgments about medical competence.
We can also anticipate more patients requesting marijuana for treatment, and regulators in medical marijuana states should consider identifying a core set of practices to guide physicians as prescribing continues to increase. For physicians choosing to recommend marijuana for medicinal purposes, it should only be done in the context of a patient- physician relationship that includes regular follow up and reassessment.
Physicians should also:
- Obtain a thorough clinical history and any needed laboratory evaluation before making a recommendation for marijuana.
- Provide informed consent based on the most current literature available about the benefits, risks and alternative treatments to marijuana.
- Maintain a chart on every patient and have regular follow up to monitor progress and identify any unintended consequences or side effects from the marijuana treatment.
- Recommend patients not drive or operate machinery when under the influence of the drug to avoid accidents.
- Caution patients to keep their marijuana in a secure place to reduce the risk of child and adolescent exposures.
- Screen for contraindications. Any physician recommending marijuana for medicinal purposes should be able to diagnose substance use disorders and recognize mental illnesses that have the potential to be aggravated by the use of marijuana.
- Stay abreast of advancing science and adjust practice accordingly.
- Check with their malpractice carrier to make sure they are covered adequately for this practice.
The CDPHE has established a Medical Marijuana Scientific Advisory Council in an effort to gather new scientific evidence about marijuana. Grants will be awarded to seasoned researchers in Colorado and other states with the hope of delineating the benefits and risks associated with its use. Until then, other states facing legislative efforts to legalize marijuana should consider Colorado’s experience as a cautionary tale. Approving medical treatments by ballot initiatives sets a dangerous precedent for public health. This will be one of the great social experiments of the century. n
About the Author
Doris C. Gundersen, MD, is an assistant clinical professor in the Department of Psychiatry, University of Colorado Health Sciences Center. She also serves as the president of the Federation of State Physician Health Programs.
Note: References follow the numbering of the original article.
1. Rocky Mountain High Intensity Drug Trafficking Area (RMHIDTA) Investigative Support Center, “The Legalization of Marijuana in Colorado: The Impact,” Volume 2, August 2014.
3. Richter KP, Levy S. Big Marijuana – Lessons from Big Tobacco New England Journal of Medicine 371;5, July 31, 2014.
8. Volkow ND, Baler RD, Compton WM, Weiss SRB. Adverse Health Effects of Marijuana Use, New England Journal of Medicine 370;23 June 5, 2014.
11. Wallace M, Schulteis G, Atkinson JH, et al. Dose-dependent effects of smoked cannabis on capsaicin-induced pain and hyperalgesia in healthy volunteers. Anesthesiology 2007;107:785-96.
14. Nussbaum AM, Boyer JA, Kondrad EC, “But my Doctor Recommended Pot”: Medical Marijuana and the Patient- Physician Relationship, J Gen Intern Med, August 24, 2011 [Online]. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3208453/.
24. Marijuana Policy Group. Market Size and Demand for Marijuana in Colorado. A study for the Colorado Department of Revenue, National Survey on Drug Use and Health, marillow.com, Colorado Department of Revenue.
25. Institute of Medicine. Marijuana and Medicine: Assessing the Science Bases. [Online]. Available at: www.com.edu/REPORTS/2003/Marijuana-and-Medicine.
Posted in: Colorado Medicine | Practice Management | Legal and Ethics