How the legalization of recreational marijuana is changing the landscape of medical use

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The legalization of recreational marijuana has become a hot topic in politics, with 18 states and Washington, D.C. legalizing1 recreational marijuana use starting in 2021. Both New Jersey and Connecticut have announced the opening of recreational marijuana dispensaries in 2022, with New Jersey dispensaries opening April 21.2

With 37 states already legalizing medicine3 marijuana, including the aforementioned 18, it stands to reason that the way medical marijuana is prescribed and dispensed will change. As medical marijuana proves to be a valuable pain reliever among other uses, how can doctors, dispensaries, and marijuana users help prevent the medical benefits from becoming less effective with increased recreational use?

Medical Marijuana: A Valuable Medical Industry

With both forms of marijuana becoming more common and accessible, it’s important to note the differences between them. Recreational marijuana is made entirely of tetrahydrocannabinol, or THC,4 a chemical compound that binds to receptors in the brain that control pain and mood, among other feelings. Instead, medical marijuana is composed primarily of cannabidiol, or CBD, which is linked to feelings of well-being.

“The main difference between medical and recreational use is the desired end result and how it is consumed,” said Gregory Carter, MD, MS, physician at Providence Medical Center in Spokane, Washington. “Medical users are looking for relief from a symptom and usually use edibles…whereas recreational users often smoke with the end result of getting high [or intoxication].”

Medical marijuana must be registered by the state before a prescription is written and can be used; about 5.55 million US citizens were registered for the use of medical marijuana in 37 states in 2021. With several states without legalization of any form of marijuana, the benefits of medical marijuana cannot be used for all residents the United States.

Mitchell Prywes, MD, medical director of the Center for Pain Rehabilitation, said marijuana doesn’t have the ability to cause a fatal overdose like opiates do, making it an attractive drug to prescribe for pain.

He also stated that the endocannabinoid6 is an ancient body regulatory system found in mammals that synthesizes marijuana-like chemicals that activate receptors to maintain homeostasis in the body; medical marijuana similarly activates these receptors.

Although future research is needed, this relationship demonstrates how useful marijuana is and can be for treating many medical conditions. But with the increase in legal recreational marijuana, can the effectiveness of medical marijuana be reduced?

Is recreational marijuana a potential medical disruptor?

Marijuana had limited legality in the United States before 2012, when Colorado and Washington became the first7 States to completely legalize marijuana. California was the first to legalize medical marijuana in 1996. Marijuana legalization across the country has been rapid over the past decade, with 35 states following the lead of Colorado and Washington in 10 short years. South Dakota, New Jersey, Arizona and Montana passed voter-backed laws to legalize recreational use as recently as 2020.

However, this recent boom in the recreational marijuana industry has hurt the medical marijuana industry, according to Jordan Tishler, MD, president and CEO of Inhale MD and founder of the Association of Cannabinoid Specialists.

“The industry wants to treat everyone as a recreational user and would like to marginalize physician care and oversight. All of this with the goal of selling as much cannabis as possible,” he said. “The result of their approach is higher sales, increasing tolerance and possibly the likely development of cannabis use disorder.”

Tishler said many recreational users develop symptoms that could be effectively treated with medical marijuana. However, their past marijuana use often leads to such tolerance that medical marijuana is no longer effective, which he says happens more often now that recreational marijuana is legal.

According to WebMD,8 a 3 week break from marijuana products may help restore tolerance to the drug. However, in patients who regularly use marijuana for medical reasons, this may not be possible and may present problems.

Tishler also said that some dispensaries, both medical and recreational, give medical advice they are not qualified to give in order to sell more marijuana products. “What really upsets me is when I come across a patient who was cannabis naïve 6-12 months ago but now, through recreational self-medication, has gotten behind the eight ball,” a- he declared.

The legalization of recreational marijuana has proven to be yet another roadblock in efforts to make medical marijuana a legitimate treatment for patients of all ages. Finding a way for the two types of dispensaries to work together and co-exist can be key to ensuring effective medical treatment.

Working together: what does it entail?

How can medical and recreational dispensaries work together to ensure that all marijuana users, both medical and recreational, get what they need without overuse or possible high tolerance?

Tishler suggests that marijuana should have a distribution system that acts more like a pharmacy. “We need to be able to write an actual prescription and be obligated to do it and know that the dispensary will honor it as written,” he said.

In Connecticut,9 Pharmacists will be available on-site at hybrid and medical dispensaries once recreational dispensaries open later this year.

“We were one of the first states to create a pharmaceutical model, which means that the 4 producers in our state are set up like pharmaceutical companies and they have to meet very high quality standards,” Prywes said. “And similarly, all dispensaries are treated as pharmacies and must have licensed and trained pharmacists.”

This step is one way states can ensure their focus on the health and safety of their consumers is a top priority. However, this requirement is not found everywhere. This underscores the importance of communication between marijuana users and physicians trained in the use of medical marijuana to ensure the correct dosage and medication choices are made.

Prywes said: “It has to start with a real doctor-patient relationship…Having a doctor-patient relationship means you have carefully assessed the patient, you understand what they had, what they didn’t have, what his experience has been… This is not a rubber stamp. He said these open conversations can also potentially rule out medical marijuana for patients who have a history of substance abuse or addiction.

Tishler also said open conversations between patients and doctors about non-judgmental marijuana use can help patients be properly evaluated for potential drugs, starting with doctors initiating medical marijuana.

“Frontline clinicians need to start proactively suggesting cannabis to their patients instead of seeking out more dangerous products. [such as opioids] or less effective [such as gabapentinoids] alternatives… We need to start volunteering so that our patients get the care they need,” he said.

He also said that referring clinicians to cannabinoid specialists, the same way you would refer patients to a cardiologist or dermatologist, could help ensure that patients receive the appropriate cannabinoid care.

Ease of access can make it easier to use more recreational or medical marijuana than is beneficial, so proper counseling by medical professionals alone, initiated by both parties, can provide patients with the health care they need while avoiding overconsumption or not receiving the care they could benefit from.

References

  1. Hansen C, Alas H, Davis E. Where is marijuana legal? A guide to legalizing marijuana. American News. April 20, 2022. Accessed May 20, 2022. https://www.usnews.com/news/best-states/articles/where-is-marijuana-legal-a-guide-to-marijuana-legalization
  2. Kilgannon C, Morris J, Piccoli S. First Lines and Free Donuts: Legal Marijuana Sales Begin in New Jersey. New York Times. April 21, 2022. Accessed May 20, 2022. https://www.nytimes.com/2022/04/21/nyregion/nj-marijuana-sales.html
  3. Avery D. Where marijuana is legal in the United States. CNET. April 21, 2022. Accessed May 20, 2022. https://www.cnet.com/news/politics/where-marijuana-is-legal-in-the-us/
  4. DiLonardo MJ. CBD vs. THC: what’s the difference? WebMD. December 15, 2021. Accessed May 20, 2022. https://www.webmd.com/pain-management/cbd-thc-difference
  5. Medical marijuana patient numbers. Proposed Marijuana Policy. May 27, 2021. Accessed May 20, 2022. https://www.mpp.org/issues/medical-marijuana/state-by-state-medical-marijuana-laws/medical-marijuana-patient-numbers/
  6. Grinspoon P. The endocannabinoid system: essential and mysterious. Harvard Health Publishing. August 11, 2021. Accessed May 20, 2022. https://www.health.harvard.edu/blog/the-endocannabinoid-system-essential-and-mysterious-202108112569
  7. Berke J, Gal S, Lee YJ. Marijuana legalization is sweeping the United States. See all states where cannabis is legal. Initiated. February 23, 2022. Accessed May 20, 2022. https://www.businessinsider.com/legal-marijuana-states-2018-1
  8. Brennan D. How to avoid high cannabis tolerance. WebMD. May 15, 2021. Accessed May 20, 2022. https://www.webmd.com/mental-health/addiction/how-avoid-high-tolerance-cannabis
  9. Dispensary Establishment and Producer FAQs. Consumer Protection Department. Accessed May 20, 2022. https://portal.ct.gov/DCP/Medical-Marijuana-Program/Dispensary-Facility-and-Producer-FAQs


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