A Toxic Weed

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It was 1978 and I was a third year medical student when my friend was slowly dying of metastatic breast cancer.  Her deteriorating cervical spine, riddled with tumor, was stabilized by a metal halo drilled into her skull and attached to a scaffolding-like contraption resting on her shoulders.  Vomiting while immobilized in a halo became a form of medieval torture.  During her third round of chemotherapy, her nausea was so unrelenting that none of the conventional medications available at the time would give her relief.  She was in and out of the hospital multiple times for rehydration with intravenous fluids, but her desire was to be home with her husband and children for the days left to her on this earth.

Her family doctor, at his wit’s end, finally recommended she try marijuana for her nausea.  My friend was willing to try anything at that point, so one of her college age children located a using friend, bought some bud and brought it home.

Smoking, because of its relatively rapid effects, didn’t do much other than make her feel “out of it” so that she was less aware of her family,  and she hated that the entire house reeked of weed, especially as she still had two teenage children still at home.  Her nausea prevented her from eating marijuana mixed into food.

Desperate times called for desperate measures.  I simmered the marijuana in a small amount of water to soften it, then combined it with melted butter.  That mixture was chilled until it was solid and I molded multiple bullet size suppositories, which were kept in the freezer until needed for rectal administration.  Although we never could warm up the suppositories to a temperature that was comfortable for her without them melting into unusable marijuana mush, she found that she could get relief from the nausea within twenty minutes of inserting the frozen marijuana butter rectally.  It worked, without her feeling as stoned as the smoked marijuana.

My actions, though compassionate, were also illegal and if my medical school had found out I was acting as an apothecary, preparing an illicit drug for use for a non-FDA approved indication, I could have lost my student standing and future profession.   I don’t regret that I did what I could to help my friend when she needed it. Subsequent studies have confirmed the efficacy of marijuana, in various forms, for nausea from HIV and chemo, muscle spasm from multiple sclerosis and quadra- and paraplegia, some types of chronic pain, and glaucoma, yet it has never been seen by the medical community a first line drug for any of those conditions.  During my professional career, I have prescribed Marinol, the FDA approved pill form of cannabis in a few cases where it was warranted because of the refractory nature of the patient’s symptoms, for indications that are supported by controlled clinical studies.    This made sense and like most medications, it worked for some, not for all with varying degrees of side effects.

And now, nearly 40 years later, marijuana is readily available everywhere in every imaginable form — smokeable, vapeable, edible, drinkable — in states like ours with legalized recreational use, the shops are on nearly every corner as ubiquitous as the coffee stands.  Our society is split into the users and the abstainers and those who can’t stand the stuff as they know what it has done to their lives.

If you believe the growing number of vocal marijuana promoters, marketers and profiteers, cannabis can ease almost any condition under the sun and make life liveable again.  It is a fine example of not so modern snake oil, as it has been around for thousands of years, except now we have state legislative bodies and through initiatives, the voters, putting their stamp of approval on it for recreational purposes, and as a medical therapy without the regulations or scrutiny we require of any other substance.  For a mere $5 gram, relief is as close as the corner store thanks to the collective wisdom of our citizenry.

As a physician working daily with adolescents and young adults in a college health center, there is no question retail marijuana is now the cannabis equivalent to the  growing market for artisan beers and local microbreweries.  There are distinct brands and strengths to attract users of all types and needs.  Yet one thing hasn’t changed with legalization: marijuana is not for everyone,  particularly not for young developing brains, particularly not for the mentally ill nor the pregnant.

Patients who have enormous antipathy for the pharmaceutical industry or for government agencies responsible for studies of drug safety and effectiveness seem to lose their skepticism when confronting the for-profit motivation of marijuana growers, brokers and storefront sellers. After all, isn’t this a free market system now happily unconstrained by the need for proof for safety or efficacy?  The most attractive product at the best price to the consumer wins.  We are now revisiting the devastation to our societal health and well being thrust upon us decades ago by the tobacco industry.  And we thought we were winning that battle of making cigarettes socially unacceptable and unwelcome.

Cannabis use has become as normalized as tobacco or alcohol to the point of some parents smoking or ingesting THC with their adolescent and adult children as part of holiday gatherings, special family events (Super – Bowl, anyone?) and evenings-at-home  “wind-down” routines.  It is a challenge for a clinician to question the judgment of a parent who sees no problem in their 18 year old using marijuana to help sleep or reduce their stress level or ease the pain of their knee injury, especially since that is exactly what the parent is doing themselves.

Although I see marijuana as the “least” of the problem recreational drugs, not as physically devastating nor fatal in overdose as nicotine, alcohol, benzodiazepines, methamphetamines, or opiates, I’ve still seen it ruin lives and minds. In its twenty first century ultra high concentrated version,  far more powerful than the weed of the sixties and seventies, it just makes people so much less alive and engaged with the world.   They are anesthetized to all the opportunities and challenges of life.  You can see it in their eyes and hear it in their voices.  In a young person who uses regularly, which a significant percentage choose to do in their fervent belief in its touted “safety”, it can mean more than temporary anesthesia to the unpleasantness of every day hassles.  They never really experience life in its full emotional range from joy to sadness, learning the sensitivity of becoming vulnerable, the lessons of experiencing discomfort and coping, and the healing balm of a resilient spirit.  Instead, it is all about avoidance and getting high.

Marijuana often exhibits paradoxical effects and is unpredictable even in experienced users.  It is a common factor in the history of adolescents and young adults with persistent depressive and anxiety disorders, paranoia, recurring dissociative episodes and psychosis.  Beyond the mental health impacts,  there is frequent morning anxiety, irritability, nausea and abdominal discomfort in some regular users, sometimes to the point of vomiting, which prompts the user ingest even more marijuana to “help improve appetite”.  This is part of the symptom spectrum of cannabinoid hyperemesis syndrome as GI workups, antiemetics and other meds fail to help until marijuana use is discontinued completely.

So, as in most things, buyer beware.  Don’t be snowed by the marketing and promotion designed to sell the most product to the most people.  The profit motive is still alive and well in this country, no matter the cost to the individual.

Even when — especially when– selling a potentially toxic weed.  After all, what’s the matter with a little paranoia among friends?

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Of Marijuana and Moss

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Washington state grows marijuana crops almost as prolific as it grows moss, particularly since legalization of recreational weed last year.  Retail marijuana outlets now are a common sight on our commute to work, complete with their warm glowing lighting, inviting interiors, plush furniture and fancy display cases.  These are not fringy scruffy deadhead establishments but surprisingly upscale.

It has become a brave new retail world for a drug with side effects as varied as the bodies and brains ingesting it.

As a physician working daily with adolescents and young adults in a college health center, there is no question in the last few months retail marijuana is now the cannabis equivalent to the  growing market for artisan beers and local microbreweries.  There are distinct brands and strengths to attract users of all types and needs.  Yet one thing hasn’t changed with legalization: marijuana is not for everyone, and particularly not for young developing brains.  That caution is given lip service in state laws, though little attention has been paid to the effects on underage users until now.

The American Academy of Pediatrics has developed a statement about the health effects of changes in marijuana legality and made recommendations about enforcement policies here.  Seattle pediatrician Dr. Wendy Sue Swanson offers an excellent summary of the concerns over marijuana safety in youth here.

My daily clinical work in a university health center confirms my belief that marijuana is a far more complicated drug than a society desiring legalization chooses to believe.

Cannabis use has become normalized (thanks to NORML) to the point of some parents smoking or ingesting THC with their adolescent and adult children as part of holiday gatherings, special family events (Super – Bowl, anyone?) and evenings-at-home  “wind-down” routines.  It is a challenge for a clinician to question the judgment of a parent who sees no problem in their 18 year old using marijuana to help sleep or reduce their stress level, especially since that is exactly what the parent is doing themselves.  After all, some parents reason, it is safer than alcohol and has never “killed” anyone in an overdose, right?

I guess it depends on the definition of “safer” when comparing two very different mood-altering drugs, both of which have been shown in studies to cause significant potentially long-lasting damaging effects in developing brains.  True, alcohol poisoning carries imminent risk of death and injury while heavy marijuana use may simply cause acute and chronic physical and mental health disorders.

Marijuana often exhibits paradoxical effects and is unpredictable even in experienced users.  It is a common factor in the history of adolescents and young adults with anxiety disorders, paranoia, recurring dissociative episodes and increasingly persistent depressive symptoms.  Beyond the mental health impacts,  I’m seeing puzzling morning nausea and abdominal discomfort in some regular users, sometimes to the point of vomiting, which prompts the user ingest even more marijuana to “help improve appetite”.  This appears to me to be a mild version of cannabinoid hyperemesis syndrome as GI workups, antiemetics and other meds fail to help until marijuana use is discontinued completely.  Many regular users remain unconvinced about the connection —  anecdotally I’m convinced we are seeing a pseudo-withdrawal syndrome from routine use of high THC concentration marijuana.

Other states considering legalization of recreational marijuana will learn a great deal from the Colorado and Washington experiment of growing, regulating, and taxing retail recreational marijuana.  I hope they will look carefully at the effects such laws have on the attitude and habits of youth who are now adopting life-long use patterns and are too often harmed by regular use of powerful chemicals that “older and wiser”  society members have deemed “safe” without sufficient data to back those claims.

Maybe we in Washington state should simply stick to growing moss.

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