I was disappointed by the one-sided argument published in ACEP Now’s May 2017 article “Experiencing the Dangers of Marijuana Firsthand” by Brad Roberts, MD. Most of what the author points to as his evidence comes from dated reports and the anecdotal personal experience of a physician who describes himself as just out of residency. Most disturbing are instances in which Dr. Roberts conflates correlation with causation, such as his conclusion that legal cannabis is responsible for increased homelessness in Pueblo, Colorado. While I agree with his assertion that there are “likely some very effective ways to use cannabinoid receptors” and the need for unbiased education, his main premise is deeply flawed and stigmatizes the millions of patients who are helped daily by medical cannabis.

Many key facts were omitted from Dr. Roberts article, including recent studies that show decreases in overall prescriptions as well as hospitalizations and overdoses related to opioids in states that have legal and regulated medical cannabis programs.^1,2 In fact, one study even showed a decrease in 21- to 40-year-old drivers who tested positive for opioids involved in fatal car crashes in medically legal states.³ Also absent was a description of the draconian restrictions that remain to this day on cannabis research, making it difficult to perform the type of double-blind, prospective, peer-reviewed studies that validate what countless patients already know about these medicinal compounds.⁴ I find it difficult to understand how Dr. Roberts can assert that medical cannabis should have a “black-box warning” since it is typically well-tolerated and there has never been a case of fatal overdose. Perhaps instead he should advocate for similar warnings for diphenhydramine, which not only causes cardiotoxicity and anticholinergic syndrome but also has psychoactive side effects?

To say there is no cited research related to cannabis use is simply untrue. Earlier this year, the National Academies of Sciences, Engineering, and Medicine performed a rigorous and conservative review of the scientific literature regarding the therapeutic use of cannabis and cannabis-derived products published since 1999. Among other conclusions, the report found strong evidence that cannabis preparations were effective in treating chronic pain, muscle spasms related to multiple sclerosis, and chemotherapy-induced nausea and vomiting.⁵ Another recent article reviewing 140 studies performed over the past 40 years concludes that cannabis-based medicines show promising effects in the treatment of anxiety disorders, dystonia, and some forms of epilepsy.⁶

We, as the medical community, suffer from a collective amnesia as it pertains to cannabis as medicine. In fact, before the arbitrary application of the Marijuana Tax Act of 1937, which effectively made cannabis illegal, physicians had published hundreds of papers recommending its use for myriad medical conditions.⁷ It was even listed on the American Pharmacopeia as a medicine until 1941. With recent studies reaffirming what we already knew 100 years ago, where is the outrage from medical professionals about the virtual impossibility of doing clinical trials in this country to validate formulations, dosages, and efficacy?

Dr. Roberts questions why so-called “cannabis refugees” move to Colorado for medicinal cannabis, thereby leaving “established medical care” for their illness. I think the more appropriate questions are, Why should these patients need to leave their home state in the first place? Why should crossing a state line determine whether patients are entitled to avail themselves of all potential treatments for their illnesses?

I agree that we should improve medical education as it pertains to medical cannabis. Furthermore, as a physician, I am not completely comfortable with so-called “budtenders,” who may lack proper training about medical cannabis products. However, if the medical profession does not step in, what alternative source of information do patients have?

As legalization spreads around the United States, public education is paramount. Many of the problems portrayed in Dr. Roberts’ article were likely the result of overconsumption or accidental ingestion, especially with edible formulations. These enterically absorbed preparations have a slower onset of action than inhalation, the more traditional method of consumption. Those who have not been properly educated about the associated delay in onset may ingest more edibles, resulting in a larger than desired dose.

This is no different than naive alcohol consumers overindulging as a result of their unfamiliarity with alcohol’s effects. Furthermore, the vast majority of cannabis ingestion–related emergency patients I have cared for in my 13-plus-year career have presented after consuming cannabis laced with other chemicals such as methamphetamine or formaldehyde. These preparations are almost exclusively the products of the illegal market, which would be greatly curtailed by a legal and regulated cannabis industry.

Whether referring to medical or adult recreational cannabis, we must educate the public about improper storage of all drugs, given the associated risk of accidental ingestion. There have been instances in which cannabis-containing preparations that were not properly labeled have been ingested, leading to untoward effects and even hospitalization in some cases. This is an issue that many states with legal programs have attempted to remedy alongside the cannabis industry, which has done an admirable job of self-regulating. Potentially harmful substances, whether prescription opioids, alcohol, or cannabis, should be secured away from children and unsuspecting adults to avoid these situations.

Dr. Roberts’ article represents the antiquated thinking that allows this process to continue unchecked. The medical community should educate itself about cannabis and provide guidance to patients and dispensaries on its use. I urge readers to do their own research, attend a conference, or take a CME course rather than make broad statements about cannabis based on selected anecdotes and 80 years of drug war propaganda.

Dr. Bier is vice chair of emergency medicine at Memorial Hermann The Woodlands in Shenandoah, Texas. He is also CEO of Green Well, a Texas-based company that aims to provide a full range of wellness solutions.

References

1. Bradford AC, Bradford WD. Medical marijuana laws reduce prescription medication use in Medicare Part D. Health Aff (Millwood). 2016;35(7):1230-1236.
2. Shi Y. Medical marijuana policies and hospitalizations related to marijuana and opioid pain reliever. Drug Alcohol Depend. 2017;173:144-150.
3. Kim JH, Santaella-Tenorio J, Mauro C, et al. State medical marijuana laws and the prevalence of opioids detected among fatally injured drivers. Am J Public Health. 2016;106(11):2032-2037.
4. Kovaleski SF. Medical marijuana research hits wall of U.S. law. The New York Times. Aug. 10, 2014:A4.
5. National Academies of Sciences, Engineering, and Medicine. The health effects of cannabis and cannabinoids: the current state of evidence and recommendations for research. Washington, DC: The National Academies Press; 2017.
6. Grotenhermen F, Müller-Vahl K. Medicinal uses of marijuana and cannabinoids. Crit Rev Plant Sci. 2016;35(5-6):378-405.
7. Mikuriya T, ed. Marijuana: Medical Papers 1839-1972. Oakland, Calif: Medi-Comp Press; 1973.