The Skinny on Cannabis

photorandy2023

1 year ago

I have written several articles healthcare issues. A series of links have been provided at the bottom of this article for your convenience.

We Need to Ensure Legal Cannabis Is Safe

Today’s cannabis plant is highly cultivated and incredibly potent. Treating it like a commodity, and not a testable, regulated medicine, is hurting people.

Fruit-flavored gummies. Tinctures. Creams.

Today’s cannabis is not simply dried flowers in plastic baggies or the special ingredient in dorm-room brownies. These days, it comes in candy form, suppositories and even vaporizable dab and wax concentrates. This new cannabis is heavily engineered, cultivated and manufactured to reach THC concentrations of up to 90 percent (delta-9-tetrahydrocannabinol), whereas earlier plants had only 2 to 4 percent. And while the cannabis of yore was something that required more under-the-radar action, today’s cannabis, blended into a cornucopia of products, is readily available at a neighborhood store, depending on where you live.

The ubiquity of cannabis creates the impression that it is akin to an evening glass of wine or a nice IPA. That is misleading. The reality is that scientists, policy makers and public knowledge have not kept pace with the rapid expansion of the cannabis market; we do not even know if the products on shelves of dispensaries are truly safe or alleviate the specific symptoms retail cannabis sellers claim they will.

I study both the beneficial and harmful health effects of cannabis, and in a recent report released by the National Academy of Science, Engineering and Medicine (NASEM), my co-authors and I broke down the public health concerns we saw with the commoditization and high-THC cultivation of cannabis in this country. The bottom line is that our state patchwork of laws leaves many users in legal limbo. Our knowledge of what high-potency cannabis does to the body is evolving. To treat it simply like a food, cosmetic or over-the-counter medication as it’s now sold is misleading, if not dangerous. We have to do more to make sure what people consume is uniform and safe.

The push to legalize cannabis in the U.S. has created an unprecedented situation. The Food and Drug Administration by law mandates thorough safety and efficacy testing to determine whether new plant, medicine or food products can be marketed to the public. For cannabis, voters and ballot measures have decided that cannabis is “medicine” and “safe” for public use.

Thus cannabis and derived cannabinoid products, which are marketed as treatments for sleep, anxiety and pain, and as ways to augment creativity, have largely bypassed this federal regulation. That legislative leapfrog has resulted in a state-by-state patchwork of laws in the U.S., allowing new cannabis products to enter the market with minimal oversight. While those gummies and tinctures may tell consumers how much THC is in them, or in what form, consumers don’t know if the product is safe. Nor do we know if it’s effective. We don’t even independently know if the “dosage” on the label is actually correct.

This includes hemp-derived products, sold on the unsubstantiated assertions that they are “THC-light.” While these are intoxicating, consumers are told they are safer than traditional cannabis (hemp has less than 0.3 percent THC). Until rigorous research is conducted on the various forms of cannabis, classifying it uniformly as a safe drug is wrong.

In my work as director of the Addiction Institute at the Icahn School of Medicine, Mount Sinai, I know that we still lack sufficient understanding of how these modern, highly potent and concentrated forms of cannabis affect our health. Highly potent and concentrated cannabis and cannabinoid products are associated with significant mental and physical health risks, including the development of schizophrenia or psychosis, respiratory symptoms including chronic bronchitis, and lower birth weight from prenatal exposure. This is not adequately or equitably reflected in our legislation or public understanding.

What this means is that states that fully legalize cannabis use fail to consider the hazards of high potency and concentrated THC. Hemp-derived semi-synthetic products, including delta-8-THC, are far removed from the original plant, and on top of intoxicating users, they can contain harmful chemicals that are a byproduct of processing. Marketing these products as safe is dishonest and not supported by data.

If we want the public use of cannabis to be not only safe, but effective and nondiscriminatory, laws on cannabis must be standardized nationally, based on data. In many states, using the products of cannabis plants still arbitrarily carries criminal charges. In others, while hemp products are being sold legally from stylized brick-and-mortar dispensaries, using other forms of cannabis is illegal.

The federal government must be proactive; rather than waiting to address further harms, which is how we developed our alcohol and tobacco policy, it can use that established policy to set the groundwork on safe cannabis use.

In many ways, cannabis legalization has made it easier to conduct research on its use. What we know now is that cannabis use disorder is a growing concern likely because of the availability of extremely potent products, as well as daily or near-daily use. Cannabis use in people ages 12 and older currently exceeds that of alcohol consumption. My research, along with that of many other investigators, demonstrates that developmental THC exposure has long-term effects on both brains and behavior that are relevant to psychiatric risk into adulthood.

Framing cannabis as a general wellness product or a benign recreational drug is an overcorrection from the fear-mongering days of it being a “gateway drug.” While those fear-based campaigns caused real harm to our communities, the current promotion of cannabis as completely harmless is equally misleading. An evidence-based, public education campaign, especially one targeting people most at risk—such as children, teens, pregnant individuals and those over 65 — would significantly improve knowledge and encourage safer health choices regarding its use.

Providing accurate information about reducing the risks associated with cannabis can empower individuals to make informed decisions about their health. Health equity must also address the impact of the high density of cannabis retailers now placed in low-income communities and communities of color, which have already suffered from the previous harsh cannabis laws. Moreover, while cannabis arrests did decrease in states that legalized it, the NASEM report indicates that this decline primarily benefited white people. Our current landscape of state laws continues to promote racial inequities in both justice and health.

In addition to standardizing legalization policies, I strongly urge policy makers to remove barriers to effective research on the health impacts of cannabis legalization. As noted in our report, enhanced population-level data collection from the CDC, and elimination of the restrictions against studying the legalization of cannabis by the White House Office of National Drug Control Policy, would enable health researchers to keep better pace with the evolving cannabis landscape. This would ensure that cannabis products are safe and that there are data to inform consumers about their effectiveness.

The cannabis plant itself is not inherently good or bad, but its modern iterations are more varied and less understood. This knowledge gap should be a real cause for concern; a historic 42 percent of adults in 2023 ages 19 to 30, and 29 percent of those ages 35 to 50, used cannabis during the prior year. Without more nuanced and updated data on cannabis, policies will unfortunately continue to be driven by public perception rather than public health. We owe it to the public to investigate this complex and evolving cannabis landscape and to develop evidence-based policies that prioritize people’s health.

Is The Cannaboid Hyperemesis Syndrome Real?

This strange syndrome is linked to regular cannabis use—and cases have doubled

Nausea. Severe abdominal pain. Compulsive bathing. These are some of the hallmarks of cannabinoid hyperemesis syndrome, a medical condition that’s on the rise.

Recurring episodes of nausea, vomiting, and severe abdominal pain. Compulsive bathing.You might not think of these as potential consequences of regularly using cannabis—especially given that it’s known to have anti-nausea effects in people undergoing chemotherapy.

But they are in fact classic signs of cannabinoid hyperemesis syndrome (CHS), a puzzling gastrointestinal condition that’s associated with frequent, long-term use of marijuana.

First described in 2004 by doctors in Australia, CHS affects an estimated 2.75 million people in the U.S. each year, and cases are rising: According to research in an October 2024 issue of JAMA, emergency department visits related to CHS doubled in the U.S. and Canada from 2017 to 2021.

What’s behind the rise?It may be partly because marijuana is now easier to access, thanks to the broadening legalization of cannabis for recreational use. Research supports this notion. In a 2024 study published in the Journal of Clinical Gastroenterology, researchers compared hospitalizations for CHS at a large hospital in Massachusetts in 2012 and 2021, before and after cannabis was legalized in the state: They found a significant increase in hospitalizations.

Another factor: “The cannabis that’s available now is much more potent than what was available 30 years ago,” says Deepak Cyril D’Souza, a professor of psychiatry at the Yale University School of Medicine and director of the Yale Center for the Science of Cannabis and Cannabinoids. In the 1960s, the potency of delta-9-tetrahydrocannabinol (THC), the psychotropic component in marijuana, was typically 2 to 4 percent, D’Souza notes, whereas these days the concentration of THC can be 18 to 35 percent or higher.

Still “why some people seem to be vulnerable to this and not others really seems to be a mystery,” says D’Souza. Here’s what researchers are unraveling about this curious condition.

Who’s at risk and why

The biggest risk factor for CHS is heavy cannabis use, as in almost daily or multiple times per day over several years. People can develop the syndrome at any time, even after decades of prolonged use of cannabis.

That said, “most people who smoke cannabis daily don’t get this,” says Christopher N. Andrews, a clinical professor of gastroenterology at the University of Calgary. Among those who do, it isn’t a constant affliction. “It comes and goes and it happens in cycles,” says D’Souza. “If it continued indefinitely, that would force a person to stop” using cannabis.

In a 2019 review of 271 cases, researchers found that the mean age for having CHS was 30 and that 69 percent of people were male. They also found that daily use occurred in 68 percent of people with the syndrome, and the mean duration of cannabis use before the onset of CHS was 6.6 years.

So what might make some people more susceptible? D’Souza speculates that it may have to do with some people’s endocannabinoid systems.

The human body has an endogenous (internal) cannabinoid system that regulates many critical bodily functions, including learning and memory, pain perception, and immune function. It’s comprised of cannabinoid receptors (mainly in the brain and throughout the gut) that respond to signals from the body, as well as compounds known as endogenous cannabinoids that are similar to those found in the cannabis plant.

CHS may be related to an imbalance in the body’s communication system—the hypothalamic-pituitary-adrenal (HPA) axis—which regulates stress responses,” says Andrews. “The [brain’s] endocannabinoid system modulates the stress response, and cannabis makes that pendulum swing further one way than the other,” which can trigger symptoms.

There also may be a genetic susceptibility to CHS, and depression and anxiety are common in people with the syndrome. “The paradox of this is we don’t understand what’s triggering this in a particular moment,” says David Levinthal, director of the Neurogastroenterology and Motility Center at the University of Pittsburgh Medical Center. Among the leading suspects, he says, are lack of sleep and intense stress.

The symptom patterns associated with CHS are similar to cyclic vomiting syndrome (CVS), a chronic disorder related to gut-brain interaction that’s characterized by recurrent episodes of nausea, vomiting, and dry heaving, separated by symptom-free periods in between.

The biggest difference between the two syndromes: It’s chronic cannabis use that triggers flareups of CHS. “There’s a debate about whether cannabinoid hyperemesis syndrome is a subset of cyclic vomiting syndrome with a different trigger,” says Levinthal.

Regardless of how it’s classified, “this can be a severe condition that can cause complications if it’s not treated,” says Maria Isabel Angulo, an assistant professor of internal medicine and pediatrics at the University of Illinois in Chicago. Complications can include severe dehydration and electrolyte imbalances, which can lead to kidney injury, heart rhythm abnormalities, and seizures. In addition, frequent vomiting from any cause can lead to erosion of tooth enamel and potentially tooth loss, she adds.

Diagnosis and treatment

The criteria for diagnosing CHS includes having three or more episodes of nausea, vomiting, and abdominal pain in a year, with each episode lasting less than a week; using cannabis more than four days per week for more than a year; and having symptoms resolve after quitting cannabis for at least six months, according to the AGA.

“The way to make the diagnosis is to come off cannabis, proving retrospectively that it’s the cannabis [that was causing the symptoms],” Andrews explains. Because it requires many months of abstinence to diagnose CHS, some chronic cannabis users are reluctant to go down that path, experts say.

When CHS flare-ups occur and the vomiting is profuse, people can become dehydrated, which is why they should seek urgent medical care. That way, they can receive intravenous fluids (with electrolytes) and anti-emetics drugs (anti-nausea medications such as ondansetron, promethazine, or prochlorperazine) to stop the vomiting. In other instances, they may be given a benzodiazepine (such as alprazolam) or an antipsychotic medication (such as haloperidol) to try to stop an episode in its tracks.

During a flare-up, people with CHS also often take hot baths or showers, sometimes multiple times per day, to try to relieve their discomfort. “People with CHS often report temporary relief of symptoms from bathing in hot water, which may lead to compulsive bathing,” Angulo says. This suggests that the area of the brain that’s involved in regulating body temperature—the hypothalamus—might be involved in CHS, D’Souza says.

A lesser known intervention: Application of topical capsaicin (0.1%) cream to the upper abdomen can reduce nausea and vomiting associated with CHS. A study in the journal Academic Emergency Medicinefound that when people with nausea and vomiting due to CHS were treated with capsaicin cream, they experienced a significant reduction in nausea within an hour.

So far, giving up cannabis has been shown to be the only long-term solution. But quitting cold turkey can lead to cannabis withdrawal symptoms such as anxiety, irritability, anger, sleep disturbances, depressed mood, and loss of appetite. Working with a counselor and taking a tricyclic antidepressant (such as amitriptyline) “can help with marijuana cessation,” Angulo says. Another option is to slowly taper off use of THC.

For people who can’t contemplate quitting, “other ways to improve symptoms [of CHS] are to reduce cannabis use and to stop using concentrates,” says Andrews. He adds that people might also switch to a more balanced formulation of THC and other cannabinoids such as cannabidiol (CBD), which does not cause a “high” sensation; these hybrid formulations are less potent.

Meanwhile, scientists are continuing to explore the mechanisms behind this mysterious condition and how it can be better treated. “Clearly, we need to study this more,” D’Souza says.

Do you smoke weed recreationally? Here’s what experts want you to know.

Today’s cannabis strains are not your grandma’s weed—and they may be impacting your mental health, heart health, and more.

Some 23 states and the District of Columbia have legalized recreational cannabis in recent years, and others, including Florida, will vote to do so in November. This changing landscape has led to a dramatic rise in consumption, with some 62 million Americans using cannabis in 2023. But legalization of cannabis doesn’t mean that regular consumption is completely safe.

A growing body of evidence has documented an array of health concerns beyond just dry mouth and fatigue and includes both mental and physical illnesses. One recent study even links cannabis consumption to heart disease.

“People think about Bob Marley when they think about cannabis. They think it’s natural, it’s Mother Nature, that it’s not going to do any harm,” says Marco Solmi, a psychiatrist at the University of Ottawa. Yet his review of the substance published in the BMJ found numerous potential problems.

Cannabis isn’t dangerous in the same way opioids are, says Deborah Hasin, an epidemiologist at Columbia University who has researched cannabis use and abuse. “People don’t die from cannabis overdose,” she says. “But it can have a lot of other consequences to both physical and psychological health.”

Stronger strains abound

Some of the problems can be attributed to the stronger strains now available. As Maria Rahmandar, medical director of the substance use and prevention program at Chicago’s Lurie Children’s Hospital, put it at a recent discussion of cannabis at the National Academies of Sciences, Engineering, and Medicine, today’s products are “not your grandmother’s weed.”

“These products are much more potent and come in so many different formulations, that it’s very different from those in the sixties and even the nineties,” Rahmandar says.

The way people consume cannabis today increases the amount of the active ingredient, tetrahydrocannabinol (THC), they ingest. Vaping and edibles generally deliver higher quantities than rolling and smoking joints does, Rahmandar says.

Psychological distress a significant problem

One of the lesser-known but troublesome risks of regular cannabis use is substance-abuse psychosis, where a person has delusions or paranoia, hears voices, and otherwise temporarily loses touch with reality. The psychosis generally resolves within a few days, but in some cases requires hospitalization.

This condition can occur with any psychologically altering substances, but the risk from cannabis is higher even than from cocaine, Solmi says.

“You’re more likely to develop substance-abuse psychosis if you use cannabis daily, but I cannot tell you there’s a safe amount that would prevent this,” he says. Young adults and males are the most prone.

Especially worrisome, up to a third of people who experience substance-abuse psychosis go on to develop the more permanent condition of schizophrenia, Solmi says.

Observational studies also connect other mental-health conditions to frequent cannabis use. Solmi’s review found that depression increases, as does violence among dating couples. And since cannabis causes cognitive impairment—as well as visual impairment—car accidents have risen among users who drive while under the influence.

Experts especially worry about the mental health impacts for teenagers. Some 17 percent of tenth graders report using cannabis, even though no state has legalized the drug for anyone under 21.

Adolescents are 37 percent more likely to develop depression by young adulthood if they regularly use cannabis compared to non-users. Rates of suicide are also higher.

“Teenage brains are going through a time of maturity and pruning, so when substances are put in there, they have more of an influence than they do on adult brains,” Rahmandar says.

Cannabis harms the heart

Regular use of cannabis can also lead to significant physical problems.

People who use the drug regularly have a higher risk for heart attack, stroke, and other heart disease, according to a large population-based study published in the Journal of the American Heart Association in February. Heart attack rates rose 25 percent while stroke increased 42 percent in this group, the researchers found.

This likely occurs because THC affects blood flow in the arteries and because receptors for cannabinoids exist throughout the cardiovascular system, the authors state. People who smoke their weed also boost their heart disease risk from the particulate matter they inhale alongside the THC.

Other studies have linked cannabis with improving nausea and vomiting after chemotherapy, but the BMJ review found regular users can actually suffer from an extended vomiting condition known as hyperemesis. “This is rare, but it’s increasing as more people use the drug,” Hasin says.

Pregnant women who use cannabis regularly are more likely to have preterm births and dangerously small babies. More research is needed to determine whether this results from the drug itself or from other lifestyle factors among those who choose to use cannabis while they are pregnant, Solmi says.

Cannabis addiction is a concern

Many people perceive cannabis to be safer than alcohol, but one in five cannabis users develop an addiction to the drug. Symptoms of cannabis use disorder are like those for other substances.

“If people experience cravings, feel they need more and more to get the same effects, they’ve had unsuccessful attempts to quit or cut down,” or have any of several other symptoms “that’s a warning,” Hasin says.

As with alcohol, cannabis addiction can lead to personal, financial, legal, and health problems.

Certain groups are at particularly heightened risk for this addiction. Rates in veterans have increased substantially since 2005, Hasin found in her research. She attributes this to a combination of increased potency and greater acceptance of the drug from its legal status, as well as the likely use of cannabis to self-medicate chronic pain and psychiatric disorders. “The VA has done a good job of reducing unnecessary prescribing of opioids in veterans, so some of them might be turning to cannabis,” she says.

Young people are also at risk for developing this disorder. Youth who begin using the drug at earlier ages or who have a family history of addiction especially heighten their odds for trouble.

“People younger than 25 should avoid cannabis altogether,” Solmi says. “They have no idea how they will react to cannabis. You’re gambling with your brain and your health.”

For everyone else, moderation is key.

“This isn’t a benign substance that has no risk,” Rahmandar says. “Most users will be fine, but we can’t predict who will develop problems.”

Resources

scientificamerican.com, “We Need to Ensure Legal Cannabis Is Safe.” by Yasmin Hurd; nationalgeographic.com, “This strange syndrome is linked to regular cannabis use—and cases have doubled.” By Stacey Colino; nationalgeographic.com, “Do you smoke weed recreationally? Here’s what experts want you to know.” By Meryl Davids Landau;