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Trends & Times

Without Good Research, Doctors Are In The Dark On How To Treat Weed-Related Illness

marijuana

Physicians prescribe marijuana for medical use in 21 states, mainly for treating pain and nausea, but its effects are not always benign. In Colorado, where the drug has been legal for recreational use since January 2014, hospitals are reporting an influx of patients with marijuana-related health problems--including many from consuming marijuana edibles--such as severe nausea and vomiting and paranoia. And weed use may lead to more serious health effects as well. In a study published early this year, the Colorado Department of Health and Environment found substantial evidence that heavy marijuana smoking is associated with chronic bronchitis, including chronic cough and wheezing, as well as with pre-malignant lesions in the trachea. Evidence was mixed on whether there's a link between marijuana use and lung cancer, or whether its use during pregnancy can cause birth defects. 

As Jason Persoff, an internist at University of Colorado Hospital in Denver notes in a recent blog post, it can be challenging for doctors to treat these cases in the absence of good research on marijuana’s health effects of marijuana, which is lacking because of the drug’s classification as an illegal substance.  Sound Medicine's host Barbara Lewis spoke with Dr. Persoff to learn more.

Sound Medicine: After marijuana became legal, how long did it take for you and your colleagues to see a bump in folks coming to the hospital for marijuana-related problems?

Jason Persoff: It took probably a couple weeks as everyone got excited about that. It was kind of a funny January day when that all happened. There were lines around the block for these dispensaries that had opened up. 

Initially the big pull was smoked marijuana. But as we've learned from the medicinal marijuana boom, if you will, a few years back, a lot of people were interested in edibles. The edible marijuana seems to be our biggest problem agent as far as medicine is concerned, because it has such a long half-life. So within a few weeks of seeing people experiment with different things we began to start seeing patients who were suffering the side-effects of marijuana intoxication.

SM: You wrote an article about the surge of people you've treated for marijuana overuse, which you call "a bit disheartening, if not occasionally humorous." What are some of the symptoms?

JS: It's always disheartening to see an increase in any disease that is preventable. We've seen patients who suffer from acute intoxication where they get very nervous, very paranoid, and extremely nauseated and break out in sweats. They can even have episodes of memory loss, which ads to the paranoia. And that usually with an edible can last up to eight hours. Whereas when marijuana's smoked it's usually out of the system within a one-to-two hour time frame. 

And then the other part is what we call marijuana hyperemesis syndrome, where patients develop a tolerance over time to marijuana, and what ends up happening is a paradox. Most people think marijuana helps with nausea. But what ends up happening is in some people, they develop this cyclic vomiting syndrome. 

Usually it starts out innocuously. Somebody gets a viral illness, let's say. And then they get nauseated, and somebody says "Hey, what will really help that is some marijuana." And what happens is the person will continue to use it intermittently, to the point where they get habituated to it, and the marijuana induces vomiting. We don't know exactly what the mechanism is. Some of my colleagues and I believe that it's a withdrawal phenomenon from the marijuana.

So they'll come in vomiting, with very high blood pressure, high heart rate, feeling awful, thinking that the only thing that will help them is the marijuana. And these patients also have this need to be in a hot shower to help with the side effects of these symptoms. More than one patient has required that I interview them while they were in a hot shower, which is an interesting experience to say the least. 

SM: Is the vomiting tied to edible marijuana, or is this just people who are chronically using it whether it's smoking it or eating it?

JS: It's seems to be more with the edibles, but it can be just with habituated use. But I do want to put context in this. Two things. The first is I'm a hospitalist, and as a hospitalist I'm only going to see patients who are sick enough to warrant admission to the hospital. So I'm seeing a very select group of individuals. There’s no question that this is tied to recreational marijuana legalization in the state. We have seen a doubling of the incidence of these episodes since legalization. But that number still is fortunately quite small. 

SM: What about burns?

JS: Burns have been an issue with marijuana. They're perhaps the most life-threatening thing we've seen come out of legalization, in addition to children being intoxicated by edible. We had a gentleman who was admitted last night because... he's also on oxygen, and he takes medicinal marijuana. He used a butane lighter and that ended up leaving his face burned. We've seen a lot of people who want to get the more concentrated hash oil, which is extremely flammable. 

SM: How about the first-time users? Do you see cases that are serious enough to warrant admission to the hospital?

JS: Fortunately most of the first-time users who have an adverse reaction are able to be treated in the emergency room and released. 

SM: Let's talk a little bit about figuring out the dose of marijuana that someone used. It's harder than figuring out how many pills they took or how much vodka they drank. 

JS: Absolutely. Trying to get a history in the use of marijuana is a challenge. 

We're in this weird zone where marijuana is not really a medicine, and it's not really diet. And we're required to enter whatever the patient is taking at home into our medical records. Which brings up the question: how is marijuana dosed? Is it based on the number of inhales, or could it be the number of edibles you ate? One or two joints? These numbers are very difficult for me to grasp as a physician. I have no idea how to quantify that. 

At the present the best I can say is lock up your edibles, make sure your kids don't get at them, and use marijuana with caution, whatever that means. It sounds like an after-school special. Kids, don't do drugs. We don't know why not, but trust us.

So I do the best that I can in our electronic medical records system. But our system also demands that at the end of a patient's hospitalization that we discharge them on certain medications. And the question that always comes up for me is: do I discharge them back onto marijuana, or do I stop them, or where do we go? There's no standard preparation for marijuana. And there’s so many different ways to ingest it, from eating it in a brownie, to candy, to aerosolized inhalers. It's very confusing. 

We actually don't know very much about marijuana at all in the medical community. The irony of it being legal in the state of Colorado is that at the same time it's still registered as a Class One drug with the DEA. Which means that it can only be used for research in very specific centers in very specific ways. And yet the researchers that would hopefully be able to provide us data can't actually do the research we really need to know about the safety and efficacy of marijuana. Most studies are extraordinarily confined, low population, and usually to answer one or two clinic issues. 

Only now that we're seeing more side effects has one of my colleagues at the University of Colorado Andrew Monte been able to put together a correspondence which was recently published in JAMAwhich demonstrates that we see the harms that come from marijuana. But there's a whole lobby of people who also have us engaged in the potential benefits of marijuana as well. And we just don't have the information to tell them.

SM: What kind of information could you really use now in your job to help take care of these people?

JS: For these patients that have this hyperemesis syndrome: we treat that like any other drug. It's a form of drug addiction and toxicity. And it's important to kind of get them towards thinking of that as the untoward side effect of using that medication. It would be akin to someone who gets the shakes after drinking lots of alcohol. 

But at the present the best I can say is lock up your edibles, make sure your kids don't get at them, and use marijuana with caution, whatever that means. It sounds like an after-school special. Kids, don't do drugs. We don't know why not, but trust us. It feels very empty to me as a hospitalist.