Cannabis is medicine — don’t make it taste good

Most of the clinical fiascos I’ve seen and heard about associated with cannabis consumption have involved the use of cannabis edibles, going back to the days when two bohemian college roommates visited Amsterdam, took two “space cakes,” waited 30 minutes, took two more, and spent the next 20 hours clinging to each other and hiding in the closet. I asked, “How was Amsterdam?” In unison, they replied, “We don’t know.”

I was surprised recently to be accused of “reefer madness” when I suggested, on Twitter, that cannabis shouldn’t be formulated into gummy bears or other succulent treats that a young child or a pet could gleefully over-consume. According to my logic, if cannabis is, or can be used as, a medicine, one should make it look and taste like a medicine. If we wouldn’t put ibuprofen into a candy, why would we put a psychoactive substance like THC into a chocolate bar? To me this is a no-brainer, but some people appear to take any limitation on their inherent right to consume medicine (or get stoned) by eating a gummy bear quite seriously.

Edibles have fueled the debate about cannabis safety

The topic of cannabis edibles is a flashpoint in the debate over how cannabis should be legalized and regulated, with arguments of personal freedom and responsibility clashing with concerns for public health. As with many things cannabis-related, the issue is highly politicized, and usually, when a new study comes out about some cannabis-related benefit or harm, such as levels of teenage usage, crime rates, medical uses, or driving statistics, there isn’t consensus on either the validity of the data or the implications of the data. It can be difficult to get a clear picture of the true benefits and dangers of cannabis.

Availability of edibles and emergency room visits

A recent study in the Annals of Internal Medicine discussed ED visits that were “deemed at least partially attributable to cannabis,” meaning that other conditions and factors could have been contributing to the admission. The study authors suggest that visits for cannabis edibles in the ED have been steadily rising in Colorado as a consequence of legalization of cannabis. Another explanation for the perceived increase in cannabis-related ED visits is that with legalization, patients are finally able to state the true reason they are in the ED without fear of getting in trouble with law enforcement or social services for using an illegal drug.

Personally, I believe the premise that ED visits are up for cannabis, in part because of the availability of edibles, and because of the many anecdotal stories I have heard through lifelong involvement with this issue. For example, an acquaintance, who is trying to be open-minded about a family member who uses medical cannabis, consumed that family member’s THC-infused medicinal chocolate bar which he found, unmarked, in the fridge, and ended up in the emergency department with a panic attack. This should never happen. By leaving a medicated but unmarked edible lying around, you put someone else’s well-being at risk. What if that person tried to drive? Then even someone else could have been harmed. The same goes for cannabis-infused barbecue sauce, pizza, honey, etc. I would suggest that these items are intrinsically too dangerous, in terms of accidental or incidental risk to others, to market and sell.

On social media, some people defend this type of risk, or the risk of exposure of a small child or a pet to some cannabis-infused treat, by saying, most commonly, “People should be responsible,” “A few irresponsible people shouldn’t ruin it for the rest of us,” or “Parents should just not leave it out around their kids.” Not to be cynical, but after practicing as a primary care doctor for 25 years, I can say with confidence: not all adults act like responsible adults. Also, even responsible adults can make mistakes. Any unmarked “spiked” consumable risks the well-being of anyone who is not aware of that fact.

Edibles are not for novice cannabis users

The main benefit of cannabis edibles is that they are long-acting — up to 12 hours — which can be helpful for chronic pain or chemotherapy patients. But the long-acting nature of edibles can also explain some of their menace: if you have consumed too high a dosage, you are stuck with it for a long time, and, if this is causing a panic attack, it can be extremely uncomfortable. It also can be difficult to gauge one’s dose correctly, as edibles can take from 30 to 200 minutes to kick in, and people often make the mistake of re-dosing too early, leading to an over-dosage and a miserable experience.

Edibles don’t always have the same effect every time

Edibles take effect more rapidly on an empty stomach, and their absorption depends on the amount of fat in your last meal. They aren’t always labeled accurately in dispensaries and, when cooked at home, the cannabis isn’t always evenly spread throughout the brownie batter. The effects of edibles are chemically different from that of smoked cannabis, because orally consumed cannabis passes more directly through the liver (versus the lungs) and the THC, which causes the high, is chemically converted to a different cannabinoid, called 11-hydroxy-THC, which has a different, and potentially stronger, psychoactive effect.

What if you’ve unknowingly consumed too much?

In clinic, with medical cannabis patients, I try to steer clear of problems with edibles altogether by advising all but the most experienced cannabis users to flat-out avoid them, and by reminding all patients to “start low and go slow.” If a medical or recreational cannabis user finds oneself in the unenviable situation of having consumed too large a dosage of a cannabis-containing edible, the best practice is to sit in a calm, quiet place, practice some mindfulness, hold the hand of a friend, drink plenty of water, try some CBD if you have it (which may antagonize the effect of the cannabis). Many people believe that consuming CBD helps negate the effects of THC, but this has not been definitively proven. Remind yourself that this will wear off, and you will be fine. This method almost always works. However, if you start to develop a full-blown panic attack, difficulty breathing, chest pain, or start having any unusual psychiatric symptoms, you must at that point consider having a friend take you to the emergency department.

If it can be used as a medicine, make it look like a pill

I believe there are a few sensible regulations that would reduce the problems caused by cannabis edibles: make them look and taste like medicine, in pill form, in pill bottles, with specific labeling that specifies exact dosages and with childproof packaging. This could go a long way toward helping us protect our pets and our kids, as well as those who find a benefit from cannabis and those around them. Sensible regulation of edibles may move us toward finding a larger patch of common ground on which to construct future cannabis policies.

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Is Coca-Cola really putting pot in its beverages?

A flurry of recent news reports would make you think so — here are a few examples:

Coke plans to brew weed drink
Coca-Cola In Talks To Make Marijuana-Infused Drink
Coca-Cola eyes cannabis market

The truth turns out to be a bit less dramatic. Here’s how the company’s statement put it:

“We have no interest in marijuana or cannabis. Along with many others in the beverage industry, we are closely watching the growth of non-psychoactive CBD as an ingredient in functional wellness beverages around the world…. No decisions have been made at this time.”

A few clarifications are in order here:

“CBD” is short for cannabidiol; it’s found in marijuana but also in hemp, and there are claims that it can provide a number of health benefits (see below).

“Non-psychoactive” means that it does not cause a person to feel intoxicated or “high.” As such, CBD is not considered to be addictive or prone to abuse; that’s why it is legal in all 50 states (though with some restrictions).

“Functional wellness beverages” are those that provide some health benefit above and beyond nutrition or hydration. Gatorade is one example, as it is ‘fortified’ with electrolytes lost during intense exercise. There are many others, such as Pom Wonderful, which describes its products as “the Antioxidant Superpower” and “the perfect fuel to get you to CrazyHealthy;” or Red Bull, which “Vitalizes Body and Mind.” It’s worth emphasizing that in the US, functional beverages do not have to prove that their health claims are true; as with conventional foods, they only have to have ingredients that are “generally recognized as safe.”

There was no mention in this statement of actually putting CBD or other marijuana-related substance in Coca-Cola.

Why would the Coca-Cola Company put CBD in its beverages?

Soda sales are down, while functional wellness beverage consumption and the respectability of CBD are on the rise; industry experts see this as a financial opportunity.

And what is CBD good for? The list of supposed health benefits of CBD is long and includes the treatment of:

  • anxiety and depression
  • insomnia
  • chronic pain
  • symptoms related to cancer and its treatment, such as nausea
  • symptoms related to neurologic disease, such as multiple sclerosis and Parkinson’s disease.

Most of these claims are considered unproven, based on preliminary evidence such as animal research, or human studies involving a very small number of people. The only approved use of CBD is for certain childhood seizure disorders (called Lennox-Gastaut syndrome and Dravet syndrome); the FDA approved the first-ever medication containing CBD for these conditions in June of 2018, and then in September the FDA reclassified CBD from Schedule I (“drugs with no currently accepted medical use and a high potential for abuse,” such as heroin) to Schedule V (drugs with a low potential for abuse)

Side effects of CBD are generally minor and include diarrhea, fatigue, and anxiety. It can also interact with medications you take, so it’s important for your doctor to know if you’re taking it.

Is pot going mainstream?

The news about the Coca-Cola Company follows recent announcements by Coors and Constellation Brands (makers of Corona beer) about developing marijuana-containing products. And a few CBD-containing beverages are already on the market.

So, it seems like this is only the beginning. In fact, the time could soon come when CBD (and, perhaps, marijuana) make it into widely available foods and beverages, including those sold in supermarkets. With the legalization of marijuana spreading like a weed (sorry, couldn’t resist!), it may be just a matter of time before it’s viewed a bit like alcohol. And that means it could soon be in the food supply. I just hope that by the time that happens, we have a better understanding of its risks and benefits.

As for CBD, you can expect claims of health benefits to multiply as it morphs from a component of an illicit drug to a financial opportunity in the growing “wellness” food and beverage industry. But I’ll still be looking for more studies confirming its safety and health benefits before I’ll buy anything containing CBD.

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Why pregnant and nursing mothers shouldn’t smoke marijuana

As more states legalize marijuana, the number of pregnant women who smoke marijuana is rising — and this could be really bad for babies.

In 2002, 2.3% of pregnant women used marijuana. In 2014, that number was up to 3.84%, a rise of two-thirds. To make matters worse, the amount of tetrahydrocannabinol (THC) in marijuana has quadrupled. THC is the active ingredient in marijuana, the chemical that gives the “high.”

We don’t know all the effects of THC on infants, but we know enough that the American Academy of Pediatrics (AAP) has issued a statement warning parents.

THC can pass easily through the placenta and into the bloodstream of a developing baby. Studies suggest that when it does, it can affect the brain. Because babies are still developing, anything that affects that development can lead to permanent changes. THC can affect something called executive function. These are skills such as concentration, attention, impulse control, and problem solving; they are crucial skills for learning and life success. Studies also suggest that children who have prenatal exposure to marijuana may have a higher risk of substance use disorder or mental illness.

THC also passes into breast milk. That means that it’s still not okay to smoke marijuana after birth, because the brains of infants are actively developing — actually they are actively developing for the first three or so years of life. The effects of secondhand marijuana smoke on kids appear to last even longer, with possibly permanent effects on executive function continuing even through the teenage years.

As with alcohol, it’s impossible to say for sure what a safe amount is during pregnancy. The safest thing is not to use it at all, and to not take any form of it while breastfeeding or to smoke it around children. Some women use it to manage the nausea of pregnancy, but there are many other ways of managing nausea.

When you are pregnant and parenting, it’s no longer just about you. The choices you make could have a lifelong effect on your child — so make good choices.

Follow me on Twitter @drClaire

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Cannabidiol (CBD) — what we know and what we don’t

Cannabidiol (CBD) has been recently covered in the media, and you may have even seen it as an add-in booster to your post-workout smoothie or morning coffee. What exactly is CBD? Why is it suddenly so popular?

How is cannabidiol different from marijuana?

CBD stands for cannabidiol. It is the second most prevalent of the active ingredients of cannabis (marijuana). While CBD is an essential component of medical marijuana, it is derived directly from the hemp plant, which is a cousin of the marijuana plant. While CBD is a component of marijuana (one of hundreds), by itself it does not cause a “high.” According to a report from the World Health Organization, “In humans, CBD exhibits no effects indicative of any abuse or dependence potential…. To date, there is no evidence of public health related problems associated with the use of pure CBD.”

Is cannabidiol legal?

CBD is readily obtainable in most parts of the United States, though its exact legal status is in flux. All 50 states have laws legalizing CBD with varying degrees of restriction, and while the federal government still considers CBD in the same class as marijuana, it doesn’t habitually enforce against it. In December 2015, the FDA eased the regulatory requirements to allow researchers to conduct CBD trials. Currently, many people obtain CBD online without a medical cannabis license. The government’s position on CBD is confusing, and depends in part on whether the CBD comes from hemp or marijuana. The legality of CBD is expected to change, as there is currently bipartisan consensus in Congress to make the hemp crop legal which would, for all intents and purposes, make CBD difficult to prohibit.

The evidence for cannabidiol health benefits

CBD has been touted for a wide variety of health issues, but the strongest scientific evidence is for its effectiveness in treating some of the cruelest childhood epilepsy syndromes, such as Dravet syndrome and Lennox-Gastaut syndrome (LGS), which typically don’t respond to antiseizure medications. In numerous studies, CBD was able to reduce the number of seizures, and in some cases it was able to stop them altogether. Videos of the effects of CBD on these children and their seizures are readily available on the Internet for viewing, and they are quite striking. Recently the FDA approved the first ever cannabis-derived medicine for these conditions, Epidiolex, which contains CBD.

CBD is commonly used to address anxiety, and for patients who suffer through the misery of insomnia, studies suggest that CBD may help with both falling asleep and staying asleep.

CBD may offer an option for treating different types of chronic pain. A study from the European Journal of Pain showed, using an animal model, CBD applied on the skin could help lower pain and inflammation due to arthritis. Another study demonstrated the mechanism by which CBD inhibits inflammatory and neuropathic pain, two of the most difficult types of chronic pain to treat. More study in humans is needed in this area to substantiate the claims of CBD proponents about pain control.

Is cannabidiol safe?

Side effects of CBD include nausea, fatigue and irritability. CBD can increase the level in your blood of the blood thinner coumadin, and it can raise levels of certain other medications in your blood by the exact same mechanism that grapefruit juice does. A significant safety concern with CBD is that it is primarily marketed and sold as a supplement, not a medication. Currently, the FDA does not regulate the safety and purity of dietary supplements. So you cannot know for sure that the product you buy has active ingredients at the dose listed on the label. In addition, the product may contain other (unknown) elements. We also don’t know the most effective therapeutic dose of CBD for any particular medical condition.

The bottom line on cannabidiol

Some CBD manufacturers have come under government scrutiny for wild, indefensible claims, such that CBD is a cure-all for cancer, which it is not. We need more research but CBD may be prove to be an option for managing anxiety, insomnia, and chronic pain. Without sufficient high-quality evidence in human studies we can’t pinpoint effective doses, and because CBD is currently is mostly available as an unregulated supplement, it’s difficult to know exactly what you are getting. If you decide to try CBD, talk with your doctor — if for no other reason than to make sure it won’t affect other medications you are taking.

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