The Case for Cannabis

FigureFigureA couple of great articles have been published in the past few months about the negative consequences and side effects of Cannabis, one on cannabinoid hyperemesis syndrome (CHS) (REBEL EM. Jan. 7, 2021; https://bit.ly/3tZYHUe) and an opinion article about concerns over high-potency THC. (MedPage Today. Feb. 1, 2021; https://bit.ly/3cBfpmT; free subscription required.) The HaVOC Trial The legalization of recreational Cannabis has become more popular, and more states have passed similar laws in recent years. And the ED, of course, has seen an increase in the number of CHS cases. Is this a surprise to anyone? A new substance is introduced with no rules, without any further education or guidance to the public or physicians, who typically are educated on these things, and we start seeing increased negative consequences from its use. The number of actual ED visits reported due to this diagnosis varies based on how the data were captured. But this article details the first good trial I have seen in years on CHS. It was done at two hospitals in Canada (where Cannabis is legal), with 313 individuals identified but only 30 enrolled. The results found that haloperidol (Haldol) was associated with a shorter time to discharge, less use of rescue antiemetics, and a shorter ED stay for patients diagnosed with CHS. I was thrilled to read a good article on how to get patients home quickly and effectively after a CHS diagnosis. Why is it that patients who return to the ED repeatedly for the same preventable diagnosis do not have outpatient follow-up with a Cannabis physician? Applying the same principles to a patient with hyperglycemia who has been treated and sent home with recommendations, education, and medication would be expected to follow up with an endocrinologist, not a gastroenterologist who would be treating the symptomatic manifestation of hyperglycemia (vomiting). Why not send patients to see a Cannabis physician to assist them in taking their Cannabis medication if that is the cause of their vomiting? Yes, the only research-confirmed treatment is to stop THC products all together, but clearly that advice is not working seeing that patients make multiple visits for the same presentation and diagnosis. I have treated CHS in the ED, and I take a few more steps, like asking how much, how often, how long, and in what form the patient uses THC. The answer commonly is “a lot,” frequently throughout the day and for years, in smokable and edible forms. One first step in preventing patients from returning to the ED for CHS is to have them stop using edibles because they usually contain large quantities of THC that are detrimental to the frequent Cannabis user. A second step is to have patients stop vaping or smoking dab, wax, shatter, or highly concentrated oil. The last step is to refer patients to a Cannabis specialist (someone with a degree) to discuss their use, habits, and poor outcomes in more detail. This is a preventable diagnosis, so let's start working on preventing patients from becoming frequent users of the ED for CHS. Education is key. Too Much of a Good Thing The next article partly addresses the missing piece of the CHS article: When you treat a patient who is using THC that is clearly causing him harm, how much THC is too much? Can we look at this from the legal or public health perspective when the medication is so readily available with no rules or regulations on production and sales? The author of this article, Libby Stuyt, MD, an addiction psychiatrist in Colorado, provides an excellent discussion on the legal Cannabis options available in that state. She walks a fine line, avoiding the typical demonization of Cannabis at all levels and dosages. The article astutely identifies the current problem with legal, recreational Cannabis use: Anything goes. Manufacturers and Cannabis dispensaries, akin to any for-profit company, have been given the green light to make anything with little to no restrictions. They have taken a plant that comes from the earth, on which laws, lobbyists, and naïve individuals have based their approval of recreational legalization, and abused it. Cannabis products are now available in concentrations of 70 to 90 percent THC in oil form, with no labeling, caution, or budtender education about these excessively strong concentrations. Research and medical studies, which supported legalization, did not even get close to these concentrations. Robust research from the University of California San Diego on neuropathic pain and THC studied flowers with two to eight percent THC. Again, this is in stark contrast to oil and concentrates of up to 90 percent THC. When will we as physicians learn that we need to step in quickly in cases of medical responsibility? Physicians did not act when we recognized the harms of nicotine and cigarette smoking decades ago until late into the harm and addiction of patients. What about the current nicotine and e-vaping epidemic? Will we start discussing this in a decade? We will not win the respect of our patients simply by demonizing Cannabis. If I have taught readers anything over the past year, it is that Cannabis use has medical benefit in many situations. Where does that leave us? In much the same place as all medicine. Cannabis has benefit on multiple levels when used appropriately under the care of a physician, and clear harm can occur when used in excess. We are in a position to demand better regulations for Cannabis. The production, sales, and distribution of Cannabis and hemp products with appropriate quantities, labeling, education, and potentially limitations require independent input from physicians who are responsible only to patients and their care, not to the industries that are financially invested. I am calling out every state governmental organization responsible for the rules and regulations of recreational Cannabis: “How many physicians who work in Cannabis medicine do you have helping make rules for the public?” You are putting money ahead of the public's well-being if you have just one physician for every 10 Cannabis companies. Calling anything “medical” without a physician running the organization is false advertising. We must draw a line in the sand.

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