Update on marijuana 2016

I attended the Swedish Hospital Update on Chronic Pain in Seattle two weeks ago on the stormy Friday. The power went out and we were without slides from about noon on.

The first two hours and three lectures were about marijuana. Including medical marijuana and one speaker for and one against. So here are some of my notes.

In 1960 and 1970, the marijuana had about 4% THC. Now some strains have 30% THC, so long term there is no data about what 30% THC will do to a person rather than 4%. THC in strains ranges from 0% to 30% and CBD from 0 to 3.5%. However, those two are not the only active ingredients, so to speak. 537 constituents have been identified that work at the cannabinoid receptor…. that is impressive. I think it might take a while to sort out what they do.

At any rate, we don’t know what smoking 30% THC will do, because it’s new. 4% had pretty minimal psychotropic effects. 30% has a lot more. The average now is 12%. Hashish is closer to 66% and hash oil 81% THC. A patient recently told me that she fainted within the last year. She got butter from the fridge at a friend’s and buttered her toast. Turned out it was THC infused butter and she was taken by surprise on a walk 30-60 minutes later. Luckily someone was with her and she was not hurt.

Recent data is showing that there is not much tolerance smoking 12% THC regularly. However, higher doses show tolerance in about 2 weeks in a study of HIV patients with dronabinol, which is 40% THC. Another study of multiple sclerosis patients with 15/15% CBD:THC reduced pain, reduced spasticity and did not show tolerance.

There is anecdotal evidence about seizures, but no study yet. There is some evidence that CBD reduces THC induced paranoia and/or hallucinations. THC side effects from dronabinol include drowsiness, unsteady gait, delusions, hallucinations, mood change and confusion.

The growers are being very creative in names and marketing. This is re recreational pot.
There are hundreds of names and hundreds of varieties and they make interesting claims as to effects. For example:

AK47 with 36.6% THC and 0.3% CBD ….. creative, euphoric and hungry
sage with 27.5% THC and 0.7% CBD ….. attentive
flow with 23.2 % THC and 0.6% CBD ….. happy, relaxed, alert
Super Sour Diesel 22.7 % THC and 0.8% CBD ….. attentive, giggly, hungry
707 Headband with 22.1% THC and 0.7% CBD ….. euphoric, lazy, inspired

How amazing the difference less than a percent of THC makes… oh, wait. There aren’t clinical trials on this, hon, this is MARKETING.

Onset for oral is 30-90 minutes
peak in 2-4 hours
half life 8-12 hours but sometimes 20 hours

sublingual tincture
onset 30-45 minutes
peak 60 minutes
half life 3-5 hours

Smoked onset quicker and I did not get those numbers.

The emergency rooms in Colorado saw lots of people who were “trying it” but if they had only tried smoking marijuana in the 1970s, a strain with a much higher percentage made many people sick or hallucinate or frightened. The gummi bears look just like the ones for kids, so kids got sick. More sick people with edibles, as some eat too much.

People using THC before age 25 who have risk factors for schizophrenia are more likely to develop it. Family history, other hallucinatory drugs, mental health problems. The age 21 limit should be taken very seriously.

In Arizona re medical marijuana, 90% of the prescriptions were from only 24 physicians. In Colorado, 94% of the patients applying for medical marijuana did so for “severe pain”. Two of my friends in their early 20s  got medical marijuana permits in California for “back pain”, um, ok, hooey. Some people DO have severe chronic pain….

The history of medical marijuana is that Eli Lilly produced a medical version from 1850-1940 for pain. It was removed in 1942. In 1970 it became a schedule one, that is, illegal, drug. There are a few randomized clinical trials for pain, the best ones with high CBD/low THC treatments. Marijuana smoke alone has not been proven to cause lung cancer, but combined with tobacco or other smoke, the evidence is that it is synergistic and makes things worse faster. Dependence can occur, an increase in antisocial personality disorders and there is a withdrawal syndrome for dependent folks. For the small number of people I have had working hard to stop, sleep is the most difficult issue. Anxiety as well.

If people state that they use pot a small amount a couple of times a week, their urine sample should clear after a week. If it’s not clear they 1. couldn’t stop and/or 2. were using quite a bit more.

As far as Washington state law, it was described as a mess. Physicians can’t prescribe, they can only “attest” that the person has a problem treatable by medical marijuana. To attest, the physician has to sign a document saying that they are sure that not only has the patient READ the law chapter 69.51A RCW but also “understands the requirements of being a patient”. There are 24 sections. The physician doing this part of the talk said that he would only prescribe to non-driving MS patients in wheelchairs. Because he finds it hard to read the law himself, so the signing that the patient has read and understood it…. well, the driving legality issue is huge. And the provider, including NDs (naturopaths) and ODs (Doctor of Optometry) in Washington can attest. They are then immune in Washington but not at the federal level.

Every marijuana store is legally obliged to have a medical marijuana consultant present at all times that they are open. The medical marijuana consultant has 20 hours of training to get certified. Patients that are certified with an attestation can grow 6 to 15 plants but ONLY after they have been entered into a database which includes the person who signed the attestation and a photo of the patient. If they grow without being entered, they are breaking the law.

Use of THC long term, the risk of addiction is 25-50%. 17% of the addicted folks started during adolescence. Addiction is currently estimated at 9% of people who have tried it overall. About 30% of users have “problem use” and starting before age 18 increases the problem use 4-7 times. The DSM-V has diagnostic criteria for “marijuana overuse syndrome”, including not being able to stop even though the person wants to. Risk factors for addiction and problem use include early use, family history, PTSD (especially sexual abuse), bipolar diagnosis, ADHD, conduct disorder, oppositional defiant disorder. Mediating factors include parental disapproval, parental supervision, academic competence, higher perceived risk and availability.

And am I attesting? No. My MS patients get the attestation from the neurologist if they want it….

Medical marijuana consultant training: http://www.doh.wa.gov/YouandYourFamily/Marijuana/MedicalMarijuana/RulesinProgress/MedicalMarijuanaConsultantCertification
Washington State Medical Marijuana attestation form: http://www.doh.wa.gov/Portals/1/Documents/Pubs/630123.pdf
WA law: http://app.leg.wa.gov/RCW/default.aspx?cite=69.51A
And pain clinics getting closed down: http://www.seattletimes.com/seattle-news/health/pain-patients-scramble-for-care-after-clinic-crackdown/

The tree trunk is a bonsai from the Lan Su Chinese Garden in Portland. I like the thorns…..