By Dr. Jordan Tishler
An interesting study from Canada recently showed that recreational cannabis users couldn’t report how much THC and other cannabinoids were in the products that they use. This has prompted some worried discussion about the development of Cannabis Use Disorder (CUD) in the general population. Coupled with the general “more THC is better” attitude of some recreational users and an industry capitalizing on this idea, it’s fair to say that this is a reasonable concern and we’re going to see more CUD over time. It’s also clear that more than simple labeling of product is needed to keep our citizens healthy.
We must acknowledge that medical and recreational use of cannabis are fundamentally different. Medical use is focused on treating a specific problem or problems, and the goal is relief from those symptoms. This goal is not well suited to a DIY approach and patients really do better with physician guidance. This leads to specific regimens in which “less is more.” Ultimately, with cannabis medicine, as with any other medicine, we want to use the least amount that is necessary to achieve benefit. Dose and timing of the dose become the paramount variables. The intoxication caused by THC is not a goal, it is a side effect (often an unwanted side effect).
Patients are undoubtedly somewhat better at describing their dose and regimen than recreational users. However, in my practice, I still see some confusion around these issues, particularly when the sales tactics of dispensaries are factored in. We must remember that with conventional medications, most people are hard pressed to know their dose too, and most people simply take the pills they are given (mostly inaccurately as well). It is for these reasons that I provide my patients with specific recommendations about what to buy and how to use it – in both verbal and written form several times. This is fundamental to medical care.
I often need to review the products that a patient is considering buying to be sure they get the right thing. This could be better solved by an actual cannabis prescription, but such a thing isn’t presently available.
By focusing on dose and timing, we can avoid much of the risks associated with cannabis. We can usually avoid overdosing that leads to bad experiences like paranoia. We can avoid the development of tolerance which can lead to using higher doses, development of physical dependence, and even negative behavioral consequences (the definition of CUD).
Unfortunately, on the recreational side things aren’t so buttoned down. For recreational users, the goals are different. For those folks, the intoxication isn’t a side effect; it’s the main event! This pushes for ever higher doses as well as new and exciting products to try. Coupled with lack of awareness of their actual dose, or even their likely increasing purchase amounts, this is a precursor to problematic use.
How are we to address these problems? The answers will differ based on the type of user.
For medical patients we need a nationally regulated prescription. This should be nearly exactly what we do in the conventional medical world. It must stipulate the product (or type), how much to use, how often to use, and how much to buy. In this way, we not only assure that patients get what they need, but also put the onus on physicians (and other clinicians) to take responsibility for their patient’s care. We also need dispensaries and product manufacturers to stop making claims about what their products do. This removes the smoke and mirrors as well as the pressure they apply to patient decision-making. It gets the conflict of interest out of the sales process.
On the recreational side, we need to maintain limits on how much people can buy and the amount of cannabis in available products. This needs to be done intelligently so that nobody goes to jail in the process. Furthermore, we need the same moratorium on medical claims in the recreational environment to stop the current marketing practices that are designed to convince people who have medical problems to DIY their healthcare.
It’s also important to stop pretending that cannabis, whatever the intended use, is either astronomically dangerous or absolutely harmless. The reality is, as always, in between. We need, as a society, to encourage medical problems to be addressed by medical professionals, and while allowing for recreational use, be ready to address a small but growing segment of the population that will develop problematic use.
It’s clear that prohibition didn’t work and was harmful. It’s also clear that the current trajectory of the cannabis industry will lead to a different set of harms if we don’t act thoughtfully now. We need to understand that medical and recreational are different and set up systems to appropriately take care of both groups. We need to acknowledge that some problematic use will occur and be ready to help those folks. We can have a vibrant and innovative cannabis industry that serves both markets – we just need to set the guardrails now.
Dr. Tishler, MD is a leading expert and trained Emergency Physician in the field of Medical Cannabis therapeutics. After years of research and learning, Dr. Tishler brings his knowledge, reason, and caring to patients to Inhale MD, and through his advocacy work at the local and national levels. Dr. Tishler graduated from both Harvard College and then Harvard Medical School, trained in Internal Medicine at the esteemed Brigham and Women’s Hospital, and has spent many years working with the underserved, particularly our Veterans.
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