Many medical marijuana program websites are silent about possible risks [PODCAST]

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“There are roughly 221 million people — including 48 million kids — in states where marijuana has been named a medicine. These include patients who suffer from depression and could see their symptoms worsen. Mothers who could give birth to babies with low birth weights. Children who could face an increased risk of addiction, depression, and suicide.

We must allow our citizens to make informed choices. A page on a website, a label on a box. The platforms exist. It’s time we use them properly.”

Erik Messamore is a psychiatrist and can be reached on Twitter @ErikMessamoreMD and LinkedIn.

He shares his story and discusses his KevinMD article, “Many medical marijuana program websites are silent about possible risks.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Erik Messamore. He’s a psychiatrist, and he wrote the KevinMD article “Many medical marijuana program websites are silent about possible risks.” Erik, welcome to the show.

Erik Messamore: Thank you for having me. Pleasure to be here.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Erik Messamore: Sure. I think that we could start back from when I was in college. I had interests both in medicine as well as in science, and I finished my undergraduate career a bit confused. I did know that drugs were among the most fascinating things I’d studied, and so I decided to go for studying pharmacology. That ultimately led into a PhD in pharmacology, and I was set for a research career looking at aging and Alzheimer’s disease drug development.

During my postdoctoral training at the Karolinska Institute in Stockholm, I was impressed by the breadth of knowledge that my physician colleagues had and could bring to thinking about and solving problems related to human illness. So partly inspired by that, and with the desire to try to get better care and life quality for people who are affected with neuropsychiatric illness, I decided to go to medical school and ultimately became a psychiatrist.

When you come into psychiatric practice with a PhD in pharmacology, there is a tendency for people to just give you the complicated, the hard, or the more challenging cases. So I didn’t set out to design a career as a consultant with so-called complex or complicated cases, but that’s more or less what I’ve done. It’s been a very satisfying career, because I’ve very much learned a lot about neuroscience, neurology, and multiple fields of medicine, to the benefit of my psychiatric consultation patients, and it’s been a very satisfying career up to now.

Kevin Pho: So let’s get into your KevinMD article, “Many medical marijuana program websites are silent about possible risks.” Now, for those who haven’t read your article, can you walk my audience through it and perhaps share the story of why you decided to write it?

Erik Messamore: Sure. Well, as I said, I was doing consultation with patients who were not getting adequate results from psychiatric care that looked appropriate to their diagnosis, and many of my consultation patients would come to me on very large lists of medicines, having tried many, many different regimens up to that point. So way back in the early 2000s, in Portland, Oregon, of all places, which is very, very, very cannabis-friendly, I would counsel my patients that we should probably look to get rid of every single medicine, herbal supplement, and vitamin that’s not clearly showing a benefit, because when we’re looking at so many different medicines, it’s difficult to make sense of what’s what.

I noticed in the early 2000s that for many of my cannabis-consuming patients, when I would say we should put a pause on the cannabis use for a while and see how that goes, I got very little pushback. And actually, many of my patients started to say that they were surprised about how much better they were sleeping or how much less anxious they were feeling. Around about 2014, I was still doing the same kind of work and having the same kind of counseling, but I started to get a lot of very serious questions, or kind of opposition, to that advice, with frequent references to “It’s a medicine. It’s supposed to be helpful. And all this stuff about side effects and risks that they talk about is propaganda for people to maintain prohibition.”

I should also insert here that I’m speaking for myself as a person and not representing the views of my employer, Northeast Ohio Medical University. I say that because talking about cannabis and legalization is a bit controversial. And also to the point of the controversial nature of cannabis speech, I’ve noticed that if I say it may have some potentially serious risks for some people who consume it, not infrequently I get accused of taking a prohibitionist stance, advocating for prohibition, or doing fear-mongering tactics. So I want to say at this moment that I have always been in favor of informed adults who choose to use cannabis having the right to do so without fear of prosecution. So I’m in favor of legalization, although that’s a big concept with a lot of spectra to it, but I’m absolutely not a prohibitionist by any means.

Nonetheless, I can tell you, as any physician or pharmacologist would know, that anything that is strong enough or powerful enough to produce some potentially beneficial effects, be those in mood or in pain or what have you, is also more than strong enough to produce some side effects and risks, and those may be serious in some people who are vulnerable. So I was inspired by the fact that so many states are now naming cannabis as a medicine, and I meet so many people who believe that because it’s medicine, because it is natural, and because nobody has told them that it does have side effects. In fact, to the contrary, many legalization advocates try to suppress the information or discredit the information about side effects. I meet a lot of casualties of cannabis legalization, and when I inform them that things like mood disturbance, psychosis, or intractable vomiting are well-documented risks and side effects of cannabis, they will look it up for themselves, and not infrequently they will say, “Wow, why didn’t anybody tell me?” or “Had I known about this, I would have thought differently.”

So then I was looking at various state medical marijuana program websites, and I was impressed by the fact that they name so many diseases that are treatable with cannabis, clearly conveying a message to consumers that this is a beneficial and useful medicine for, on average, 17 different diseases, although some states, like Illinois, recognize 40 diseases that are treatable by cannabis. Together, there are 34 state medical marijuana programs, 33 states plus D.C. Every one of them has a website that the state maintains to describe the medical cannabis program, and they list all of these diseases that ostensibly cannabis can treat. Two-thirds of those websites say not one word about risk.

So my contention is that if states are going to name this as a medicine and signal to their citizens that this is medically valuable, they need to match that privilege of naming something as a medicine with the responsibility of informing people about basic, agreed-upon, scientifically credible risks that we’ve known about for decades.

Kevin Pho: Now, for those in the audience who are primary care clinicians who may be having a discussion about cannabis with their patients, what are some of the risks that they should inform their patients about when considering cannabis?

Erik Messamore: I would refer them, if you can, to simply Google “National Academies of Science marijuana report.” That should show up as the top hit: a very large, comprehensive survey that was published in 2017. It’s available free online. The entire report is free online, and there are executive summaries of each of the things. The National Academies reviewed all the evidence, and they ranked the risks according to the quality of evidence to support them. So risks that have very strong statistical associations with cannabis include motor vehicle accidents and birth complications. Notably, it doubles the odds of giving birth to a baby who’s less than five and a half pounds. There are respiratory difficulties associated with smoking cannabis, and there’s also extremely good evidence for an association with schizophrenia.

I would also refer physicians simply to the FDA prescribing information. Both THC and CBD, which are the main active ingredients of cannabis, are in fact clinically tested and approved medicines in the United States, and they have prescribing information available that goes along with placebo-controlled trials to generate side effect data. Looking at THC, you’ll find warnings about paradoxical nausea and vomiting. You’ll find warnings about psychiatric disturbances. You’ll find, actually, a little-known side effect: Cannabis can increase blood pressure and pulse. And so in patients who may have fragile vessels in their brain or a lot of plaque in the arteries of their heart, it does seem to pose a risk of stroke or heart attack, and many case reports are reporting about that. That’s, again, a documented warning in the FDA information. And for CBD, at pharmacological doses, there are warnings for hepatocellular injury, as well as a variety of neuropsychiatric disturbances, including agitation or anger.

Kevin Pho: How common are some of the side effects that you’re talking about in medical doses of cannabis?

Erik Messamore: Well, it’s an interesting question, about medical doses. If we look to FDA dosing guidelines for THC, you’ll see: Start at 2.5 milligrams of THC per day, and advance to a maximum of 10 milligrams twice a day. And so that would be, at the higher end of FDA-regulated dosing, 20 milligrams per day. A person can now consume 20 milligrams of THC in a single joint. Today’s marijuana is much stronger, and in actually every medical marijuana state whose laws I’ve reviewed, there is, in the fine print, no legal definition of what constitutes medical cannabis. It can be, in many states, 70 percent THC or higher. So what’s being labeled as medical marijuana is available now in forms and in strengths that are never found in nature. So the point being that it is possible for a medical marijuana user to encounter doses that are extremely high compared to what the FDA recommends for medical use, for cancer chemotherapy nausea prevention and so forth.

Kevin Pho: And what are some of your proposed solutions to address the issue you bring up?

Erik Messamore: Well, it’s basically very simple. We actually have models for how to inform the public about medical benefits and risks. We’ve been doing this under the FDA guidelines for decades, and that is: If you’re going to list medical benefits, you also list credible risks. If you are going to be selling a package of medicine, you include on the label or within an insert all the known scientifically credible risks. And it’s really simple to just modify state websites so that they will have easy-to-find, very clear-to-understand information about what risks are known and what the probability of those risks is.

Kevin Pho: We’re talking to Erik Messamore. He’s a psychiatrist, and he wrote the KevinMD article “Many medical marijuana program websites are silent about possible risks.” Erik, I have a lot of patients who ask me about medical marijuana waivers. What are some characteristics a patient should have in order to be candidates for medical marijuana?

Erik Messamore: So it varies according to states. The most permissive state guideline that I’ve read was from the state of Oklahoma, where essentially any condition that a physician feels might be helped by cannabis can be a qualifying medical condition. Most states set up a list of diseases or symptoms that they list as qualifying for medical marijuana use. And in the states that have physicians involved in the process, the physician’s role typically is to document that there’s a bona fide doctor-patient relationship and that, based upon this bona fide knowledge, the qualifying condition definitely exists. Under federal law, physicians cannot prescribe marijuana. It’s a Schedule I substance. So most states get around that block by simply having the physician document the presence of a qualifying condition. And then, in my view, a significant weakness or area for improvement in these policies is that the actual dosing recommendations or strain recommendations are oftentimes given by people who don’t have medical training.

Kevin Pho: And on the flip side, are there any red flags we should look out for that would disqualify patients from medical marijuana?

Erik Messamore: The biggest red flag is a past history or a family history of mental illness, particularly illnesses that involve psychosis. Among the psychiatric adverse effect risks, based upon surveys of actual cannabis consumers, you have two conditions that stand out as the most likely, one being severe anxiety or panic attacks and the other being psychosis or psychosis-related symptoms.

So it’s very curious in the anxiety spectrum, because for many people with anxiety, there is at least initial relief, but for some people with anxiety, and according to survey data maybe as many as 20 percent, there can be a paradox, a so-called severe worsening of anxiety. So that’s a caution, and consumers should be aware of that possibility. And then second is if there are risk factors for psychosis, and certainly anybody who’s had a history of psychotic illness, then the risk goes much higher. Again, for all comers, it seems that the risk of psychosis in response to THC or cannabis ranges from a low estimate of 3 percent to higher estimates of 20 percent. So within that range is probably the natural number, and having risk factors for psychosis probably puts one into a more likely category to experience it.

Kevin Pho: Sure. My final question: Do you have a take-home message that you want to share with the KevinMD audience?

Erik Messamore: Yeah, I would like to reiterate what I said earlier: Anything that is powerful enough to fight disease or change mood is more than powerful enough to create significant side effects and risks for at least some people. And I think, to physicians and patients alike, from my years of doing this consultation practice, anybody can have any side effect from anything. So respect the positive, respect the benefits, that drugs do good, but respect the possibility that drugs do harm at the same time.

Kevin Pho: Erik, thank you so much for your time and insight, and thanks again for being on the show.

Erik Messamore: My pleasure. Thank you.

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