The problem with cannabis. Despite the fact that; there is arguably no other substance on the planet that treats such a wide assortment of health problems, its cost is low, it is easy to produce and widely used, there remains a predilection against cannabis. The main problem with cannabis is the variability of its effect and effectiveness. Marijuana fell somewhat out of favor when aspirin and morphine became available. This was precisely because these (new at that time) drugs had very predictable clinical results and side effects. Ultimately, when taking cannabis, it is a matter of trial and error to know:
1 what result can be expected
2 what side effects may be experienced
3 what form is most suitable (edible, smoke, topical, vaporizer, capsule, spray)
4 what strain (cultivar) is most suitable (sative, indica, hybrid).
Even after you get all of that figured out, the results also may vary with mood, time of day, prior use or lack of use, the cell receptor structure of your nervous system and the health and potency of the cannabis that is being consumed. Fortunately, as our understanding of the effects and dosing of individual cannabinoids grow, we can look forward to less unknown variability in the future. see chemistry of cannabis
Common side effects:
Change of alertness
Impairment / alteration of short term memory
Dry eyes and mouth
Elevated heart rate
Coughing (which can lead to bronchitis)
Rare side effects:
Anxiety (most associated with smoking)
Paradoxical reaction (hyperactive, can’t sleep)
Amotivational syndrome (associated with frequent, large dosing over extended time)
Unstable heart disease
Driving or operating heavy machinery (not recommended)
The following areas need cautious consideration of the risks vs benefits.
Pregnancy / breast feeding; cannabis is associated with low birth weight when used in pregnancy and there is theoretical concern for hormonal disruption for male fetus. More info
History of substance abuse
Unstable psychiatric problems
Respiratory problems / bronchitis (with smoking)
Under age 18
Long term effects:
Effects to the brain from chronic long term use is unclear in adults. Nothing clearly profound or debilitating has been proven so far. A recent study that followed cannabis users for 38 years found almost no long term ill effects with the exception of increased gum disease.
The amount of time required to normalize from all effects of using cannabis is still not understood, but typically is 1-4 weeks depending on level of use. The CMCR has tried to figure this out with multiple methods. People with existing brain pathologies seem to be affected more than the rest of the population. The studies suggest that ill effects of cannabis diminish with time. A small study associated becoming dependent on cannabis before the age of 18 with a drop in IQ by 6 points 20 years later. This drop in IQ concept however, is now soundly disputed. More info.
Here is an article on 12 negative effects of smoking cannabis
There is a lot of surprising good news here. Despite the fact that crude cannabis contains some known carcinogens, and 4x the level of tar found in tobacco, smoking it has not been proven to actually cause lung cancer or COPD, even with heavy smokers. There is growing evidence that cannabis has anti-tumor properties as demonstrated by cell culture and animal models. There were some small case studies in the 1990s indicating increased cancer risk, but these have paled in comparison to more recent large controlled population studies.
If you chose to smoke, do expect increases in coughing, sputum and wheezes. Cannabis smoke basically clogs up the tiny cilia inside the lungs. This diminishes the lungs’ natural ability to clear themselves out. To compensate, your body will cough to clear the lungs. This does increase your chances of getting bronchitis. More info here
Reduction of effectiveness with cannabis is also highly variable. Different regions of the brain change their regulation to cannabis in different ways. Thus, tolerance (lessening of effect) can be expected to some of its effects and not to others. Clinically tolerance has been noted with nausea, mood, intra-ocular pressure, coordination, heart & blood vessels and to some extent with euphoria (getting high) and sleep. Tolerance does not seem to occur to the appetite stimulation effect, relief of neuropathic pain or spasticity. Using lower doses is a good strategy to minimize tolerance as well as taking periodic breaks from cannabis for 1-2 weeks. Patients using cannabis for epilepsy should not abruptly stop taking it, but should slowly wean themselves due to a small chance of inducing a seizure. Tolerance Article
There is very little consistent information regarding drug interactions available. Generally the effects of system depressants (including alcohol, sleep aids and opioids) are increased with cannabis. There are theoretical concerns based on enzymatic drug metabolization for drug interactions with cannabis. Drugs that might decrease the effectiveness of THC include: rifampicin, carbamazepine, phenobarbital, phenytoin, primidone, rifabutin, troglitazone, and Saint John’s Wort. Drugs that might raise the effectiveness of THC (possibly increasing adverse effects) include: fluoxetine, fluvoxamine, nefazodone, cimetidine and omeprazole, clarithromycin and erythromycin, itraconazole, fluconazole, ketoconazole, miconazole, diltiazem, verapamil, ritonavir, amiodarone, and isoniazid. Drugs that might have a stronger effect when using THC include: amitriptyline, phenacetin, theophylline, granisetron, dacarbazine, and flutamide. Although this list is long, in practice drug interactions with cannabis are very rare (if not unheard of). Article on interactions of CBD with drugs metabolized by enzyme P450.
Short term memory impairment. Memory is affected by most people on cannabis. This is an important aspect to address, as it is the most stereotypically misunderstood point. Cannabis tends to bring the attention fully to the present with heightened focus, and a greater level of perception. This is great for creative enterprises and has many favorable aspects. Americans are constantly bombarded with nonstop stimulation. This tends to drive people into subconscious modes of being (autopilot). Cannabis frees individuals to be fully present in their body, living their life. This is why so many people like to utilize it after the work day. This whole process can be viewed as absent mindedness, but it is more clinically relevant to explain it in the above terms. EG Cannabis is great for changing your focus to more enjoyable activities, but I wouldn’t suggest using it right before you sit down to figure out your taxes.
Adolescent brains show more cerebral blood flow changes than adults on brain scans. Differences typically normalize after a month, but teens are more at risk than adults.
The greatest harm, arguably, is from the political side: arrest, prosecution, conviction and the subsequent drop in social status and loss of options.
Amotivational syndrome. This phenomenon is real, but it is not common. So far there are no convincing animal studies or predictive patterns to indicate who might be at risk for this possibility. Amotivational syndrome is the classically stereotyped “pot head”. The person who just sits around all day with no personal drive, smoking large quantities of marijuana. The primary risk factors for this are youth and regular overuse of cannabis with no clear medical need. If you suspect this might be happening to you, try a holiday away from cannabis. Two to four weeks is usually enough to notice a shift in thought and attitude. Typically expressed as, “Wow, what was the big deal with needing to do that everyday?” after stopping use for a couple of weeks. Heavy users really need a month off to clear the residual cannabinoids out of the body’s fat stores.
Overdose. There are no documented cases of anyone dying from using cannabis. Panic “toxic psychosis” is the most serious risk. The most useful strategy for managing a cannabis overdose is reassurance that it will soon pass and to get busily engaged in a monotonous activity that requires little to no thinking. Things like sweeping the whole house, folding laundry, doing a puzzle etc. Basically avoid a lot of thinking. Benzodiazepine drugs (Xanax, Lorazepam, Valium etc) are very effective at stopping cannabis induced panic, and to a lesser degree the root of the Kava shrub (Piper methysticum). Panic is most often associated with smoking sativa strains of cannabis. The rapid intensity of smoking is much greater than any other delivery method currently available and sativa strains induce mental activity far more than indica strains. Overdose strategy article
A rare paradoxical effect of hyperemesis &/or cyclic vomiting has occurred from use of cannabis, typically in younger heavy users. Hot showers have brought relief to this in some cases.
Harm Reduction. Encourage patients to use OTC ocular lubricants (Visine is overkill) for dry eyes. There are many historical references to using lemon juice / lemonade (terpenoid – D-Limonene) to counter adverse effects of cannabis. Calamus root: Adding a dash of powdered Calamus to cannabis is alleged to lesson adverse effects on thinking and memory. Clinically Kava root is a good choice to take concurrently with cannabis if there is fear of panic. Here is an article on using pepper to stop cannabis induced anxiety or panic.
Moldy Cannabis. Cannabis can transfer spoors directly to the lungs, even when smoked. This is a risk for immune compromised patients.
Driving. This is a grey area. It is best to officially counsel patients not to drive or operate machinery on cannabis. Just ask the patient to take the police officer’s point of view: Are you impaired? Many people routinely drive on cannabis or opioids and it isn’t a problem, until there is a problem like a MVA. If you find yourself having a less then optimal encounter with law enforcement, you may consider requesting a field sobriety test to establish lack of impairment. The CMCR studies based at University of California indicate a 2x increase in MVA while intoxicated with cannabis. Alcohol intoxication is a 13x risk. Alcohol with cannabis at the same time further increases risk. Here is a link to a law group that offers a pictorial guide that compares statistics and regulations about driving under the influence of alcohol and marijuana in Canada and the US. OMQ law
Addiction. 8% of users develop problems associated with cannabis and continue to use it. As with other substances, some people become dependent in order to correct or balance a pathology. Cannabis does not cause physical dependence (like heroin), but psychological dependence (addiction) is possible. The most closely related substance is coffee. If you have used coffee for many years and suddenly you can’t get any, you aren’t likely to be very happy. Your work, sleep and play patterns will most likely be impacted and you won’t feel all that great. About two weeks later, though, things should normalize. This is basically the story with cannabis. Since THC is a fat soluble substance, the body will slowly release its stores of it after discontinuation. Heavy users and/or very sensitive users may experience predictable symptoms in about 24-48hr. These may worsen over the fist week then start diminishing during the second week. Most users, however, experience little to no withdrawal symptoms (that fat soluble slow release thing). After two weeks the vast majority of users are free from any cannabis-related symtomology. There shouldn’t be any exogenous cannabis left in your system after a month, and all physiology should be as it was prior to cannabis use (unless we are talking about decades of use and/or extremely young or old users).
Here is a Huffingtonpost article that disputes the validity of the claim that cannabis addition is as high as 9%. Another article that deeply challenges the notion that chemistry is factor and it explores likely social cause HERE.
Reported withdrawal symptoms include: irritability /anger, sadness, headache, anxiety, sleep disturbance, craving, restlessness, decreased appetite, depression, chills, stomach pain, shakiness and sweating.
Addictive personality and public health. About 12% of the human population has the personality trait know as the addictive personality. People with this trait are genetically predisposed to addiction, regardless of whether it is a substance or an activity. This is why the approach of attempting to restrict access (e.g., the war on drugs) has such an unsuccessful history. People with this trait can learn psychological and behavioral approaches to notice their addictive behavior when it starts and get help (intervention) before it becomes a compulsive habit. This is how drug addition is handled in many European countries. Instead of the police incarcerating addicts, public health professionals intervene and offer support. Whatever political or social beliefs you may hold, the facts are irrefutable. Portugal radically decriminalized cannabis and all illegal drug use in 2001 (even cocaine, crystal meth, MDMA & heroin). In that country health care professionals now manage drug problems. Today Portugal boasts some of the lowest recreational drug use rates, even among teenagers. The old Reefer Madness movies were just that: madness. The sky has not fallen in Colorado or Washington State.
The argument can be made that the whole war on drugs is actually a financial – political racket.