In the past 10 years, California doctors have authorized cannabis use by at least 350,000 patients. What have they learned about its adverse effects?
According to a survey of 19 doctors associated with the Society of Cannabis Clinicians, side-effects are relatively rare, mild, and transient. There have been no deaths, no major adverse events attributed to cannabis -with one exception involving a claim by an establishment psychiatrist that cannabis induced and exacerbated psychosis in an 18-year old whom she had on a regimen of Lexapro and Zyprexa.
Comments by the SCC doctors follow.
Frank Lucido, MD: Reported adverse effects are rare, in part because the patient coming to a medical cannabis consultation has already found cannabis to be of benefit. (I have had perhaps 10 patients in 10 years who had never tried cannabis or who hadn’t used it in many years and were uncertain if it would effectively treat their current illness or symptoms.) Two patients have discontinued use in response to decreased productivity. The overwhelming majority report that they are MORE productive when their symptoms are controlled with cannabis.
Robert Sullivan, MD: None common (c. 1%), none “serious.” Weight gain, tolerance, anxiety (related to potential theft from an outdoor garden), dry mouth, short-term memory decrease, anxiety, red eyes. All described in response to my inquiry (not spontaneous). None resulted in stopping cannabis use.
Marian Fry, MD: The most significant negative reactions are due to fear of incarceration and the results of abuse by officers unwilling to honor California law.
William Toy, MD: The most important adverse effects are respiratory problems caused by smoking. Most patients who have respiratory problems use vaporizers or edible forms of cannabis. We go out of our way to get patients on vaporizers and we now have only a small percentage of smokers -mostly people who have been smoking marijuana for 30-40 years. Most in this group use very little, maybe one or two doses a day.
Philip A. Denney, MD: Virtually none reported by patients except contacts with the legal system. Patients are able to stop using easily in order to pass drug tests or when traveling. Overdose from edible cannabis -an unpleasant drowsiness lasting six to eight hours- is rare and transient.
David Bearman, MD: Occasional complaints of cough. Many more complaints about Marinol than cannabis -dysphoria, ineffective, costs too much.
Tom O’Connell, MD: The most common is the “paranoid” reaction, in which, characteristically, a user who is “high” develops the uncomfortable feeling that everyone he/she sees KNOWS they are high and is critical of them for it. It almost always occurs in a situation where the person may be forced to deal unexpectedly with the public. It certainly needs further study. In any event, patients deterred from using pot aren’t lining up for approvals to do so.
William Courtney, MD: A significant number of my middle-aged patients are no longer enamored of the psychoactive effects that previously were the highlight of their cannabis use. For them, what was euphoric has now become dysphoric. Such patients tolerate the anxiogenic properties in order to enjoy the anti-spasmodic or analgesic effects -much as a patient on chemotherapy reluctantly accepts the nausea in exchange for the anti-tumor effects. While a few patients have discovered that there are strains that provide relief without dysphoria, others are excited by the possibility of daytime CBD analgesia or autoimmune modulation without alteration of their sensorium.
Dr. A.: We’ve had several reports of hypotensive reaction -a sudden drop in blood pressure, which results in fainting. It’s very rare and, as reported by my patients, is a one-time thing. It typically happens after a big meal, when the GI tract is opened up and absorbing a lot of blood.
Jeffrey Hergenrather, MD: Is there a downside to the use of cannabis? The sense of intoxication rarely lasts longer than an hour and tends to be more troubling to the novice than to the experienced user. For some people cannabis can induce dry mouth, red eyes, unsteady gait, mild in-coordination, and short-term memory loss, all of which are transient. These effects are reportedly trivial compared to those brought on by pharmaceutical alternatives.
Cannabis use is steadily finding acceptance in society. Still, for many it remains awkward if not totally impractical in the workplace. People whose jobs require multi-tasking such as pilots, drivers, dispatchers, switchboard operators, and many professionals find the intoxicating effects of cannabis inappropriate in the workplace, and therefore reserve their use for after work.
The survey, conducted by your correspondent for the upcoming issue of O’Shaughnessy’s (and previewed exclusively on CounterPunch), does not pretend to be rigorous. It involves the patient population least likely to experience adverse events and a setting in which adverse events might be downplayed (examinations in which the patient is seeking the doctor’s approval to use). As Dr. Lucido and others point out, in the first 10 years of legality created by Prop 215, almost all the patients seeking physician approval to use cannabis had been self-medicating previously with positive results. Truly naïve patients have been rare -and those experiencing unwanted side-effects would be unlikely to return to the doctor for a renewal, i.e., their complaints would go unreported.
The charge that cannabis use caused and then increased the severity of a psychotic break in an 18-year-old was made by a Stanford University psychiatrist, Dr. P., who filed a complaint with the state medical board against the doctor who had approved it. “I believe THC caused his depression to worsen, interferes with antidepressant meds, and clearly caused his psychosis,” Dr. P advised the board. “He is also psychologically and physically dependent on the substance. He refuses to quit. He even admitted to seeking the medical marijuana justification in order to use regularly ‘legally.'”
The assumption that marijuana causes physical dependence is without scientific foundation. Dr. P.’s use of the term “even admitted” reveals a prosecutorial frame of mind. She seems appalled to learn what all cannabis consultants know and what should come as no surprise to any person with common sense: feeling legitimate relieves anxiety! Dr. P.’s treatment of the mutual patient involved anti-marijuana exhortations and the pushing of her preferred corporate drugs. Lexapro is an SSRI antidepressant made by Forest Pharmaceuticals. Like all SSRIs it is slowly but surely being linked to suicide in the medical literature (while the drug companies and their paid researchers in the psychiatric establishment challenge each piece of evidence).
Dr. P.’s allegation that marijuana use precipitated and aggravated the patient’s break with reality can’t be proved or disproved. Some published studies indicate an “association” between marijuana use and schizophrenia, but not necessarily a causal relationship. (A person seeing demons or hearing voices may use cannabis because he finds that it quiets them.) Schizophrenia occurs in about 1% of adult populations in all countries and cultures, regardless of the prevalence of cannabis use. The use of Marinol (synthetic THC) by teenage cancer patients has not resulted in an increased incidence of schizophrenia.
Ironically, the component of the cannabis plant thought to have sedative and anti-psychotic properties -Cannabidiol (CBD)- is present only in trace amounts in the strains available to California patients. As indicated by Dr. Courtney, the SCC doctors are frustrated that they don’t know the cannabinoid contents of the herbs their patients are using. They all wish a high-CBD strain was available. They would have learned a lot in 10 years about how it differs from high-THC cannabis. Prohibition sabotages research.