In the past few years, cannabis in Virginia has gone from a banished foe to an increasingly friendly acquaintance.
Since the 1930’s it has been propagandized as the “demon weed” that could cause everything from teenage zombiedom to desperate prostitution. The D.A.R.E. campaign in the 1980’s likened cannabis use to one’s brain frying in a hot skillet like an egg. Despite these colorful past categorizations, cannabis, along with other Schedule 1 substances like psilocybin and LSD, has reemerged in the medical community because of its potential therapeutic uses.
In 1979, Virginia passed legislation allowing doctors to recommend cannabis for glaucoma or the side effects of chemotherapy. In early 2016, Virginia allowed medical cannabis for the treatment of intractable epilepsy. The aforementioned medical use of cannabis was protected by the “affirmative defense,” the opportunity for a patient to present their medical documentation in court to quell legal charges.
Since July 2020, medical cannabis has been legal in Virginia and can be recommended by state certified medical practitioners for any medical purpose without the need for an affirmative defense. Presently, dozens of different cannabis strains, all of which have different amounts of phytocannabinoids like THC and CBD, are available in Virginia.
Virginia has also moved to change the legality of non-medical cannabis possession and distribution. By July 2021, most cannabis possession, whether it is medicinal or not, will be largely decriminalized. No penalty will be imposed for possession of up to 1 oz., and a small $25 civil penalty will be administered for possession of more than 1 oz. and up to 1 lb. of cannabis.
The state will also allow patients to grow up to four cannabis plants at their home for personal use. Finally, Virginia became the first Southern state to legalize recreational cannabis with a plan that will take effect in 2024. Yet, the question remains for doctors: is cannabis a friend or a foe?
Cannabis Safety Profile
The CDC has clarified that cannabis is not a gateway drug; it does not necessarily lead to the use of more harmful substances. Moreover, its abuse potential has been shown to be relatively low: cannabis is about as addictive as caffeine and is not associated with any mortality.
High THC strains carry with them a greater chance for cannabis use disorder (albeit a relatively small one), while more balanced strains or those high in CBD have a lower risk. Most adverse health effects can be mitigated if users avoid smoking or vaping and, instead, chose to use other available formulations such as tinctures, edibles, capsules, lotions, suppositories, and patches.
In general, it is safer for the average person to use cannabis when compared to alcohol and cigarettes, both of which increase mortality and have a high addiction potential. Likewise, cannabis is often safer than many commonly prescribed medications including opioids, benzodiazepines, and hypnotics, which can be highly addictive or deadly when taken incorrectly. Compared to other legal substances and non- Schedule 1 medications, cannabis is typically safer.
Cannabis as Medical Treatment
Cannabis has been shown to be an effective treatment for many common medical disorders. First, cannabis has been studied for chronic neuropathic pain and has been shown to reduce pain in patients by 30%. In states where cannabis is legal, it has been correlated with a reduction in the use of opioids for both medical and recreational reasons, and, consequently, a reduction in opioid overdoses and deaths.
Second, cannabis has been shown to be an effective antiemetic and appetite stimulant in patients receiving chemotherapy treatment for cancer. Other studies even show that cannabis can cause apoptosis in tumor cells and may even work synergistically with certain cancer treatments.
Third, cannabis has been shown to decrease spasticity and pain in those with neuromuscular disorders like Multiple Sclerosis, Amyotrophic Lateral Sclerosis, Parkinson’s disease, and Huntington’s disease.
Fourth, cannabis has been shown to decrease or even completely resolve intractable seizure disorders in children.
Fifth, there is growing evidence that cannabis can help treat insomnia as well as refractory anxiety disorders like PTSD. A list of potential medical uses for conditions such as IBD, glaucoma, HIV, addiction, Tourette’s syndrome, ADHD, and insulin resistance are also being investigated with studies and clinical trials.
In sum, cannabis is a substance with a relatively safe, medicinal benefit in multiple disorders, a fact that makes its categorization as a Schedule I substance incorrect and stifling to further research.
Cannabis, Social Justice, and State Revenue
Many advocates of recreational legalization cite issues of unnecessary government intrusion and inequities in the criminal justice system. Why should the government outlaw a plant that has been proven to be safer than alcohol and cigarettes, both of which are legal?
In recent years, cannabis legalization has been seen as a mechanism of social justice: freeing the legions of poor, minority prisoners who were unfairly targeted and brutalized with severe sentences that destroyed their own lives and the lives of their families.
According to a 2020 ACLU study, “Black people are 3.64 times more likely than white people to be arrested for marijuana possession, notwithstanding comparable usage rates. In every single state, black people were more likely to be arrested for marijuana possession, and in some states, black people were up to six, eight, or almost ten times more likely to be arrested.”
It is an unavoidable fact that laws banning cannabis possession and distribution have disproportionately led to the incarceration of minority groups and those with lower socioeconomic status.
Legalizing cannabis has also been seen as a way of increasing state tax revenues while taking money out of the hands of illegal drug cartels. Colorado, for example, which legalized cannabis in 2014, has seen increased revenues in the tens of millions of dollars. The state collects a 2.9 percent sales tax from both medical and recreational sales and a 15 percent excise tax when cannabis moves from grower to seller.
The 2.9 percent sales tax on medical marijuana goes entirely into the Marijuana Tax Cash Fund.
According to Amendment 64, the first $40 million or 90 percent (whichever was greater) was to go to a capital construction grant program, where schools, districts, and various education providers could apply for money to build new buildings, renovate existing facilities, and create other educational programs focused on youth prevention.
In 2018, more than $20 million went to grants for school health professionals, early literacy programs, and dropout and bullying prevention. Thus, legalizing cannabis could not only help treat medical conditions; it could also help mitigate other ails of society.
Cannabis Risks and Contraindications
Cannabis, however, poses significant risks to certain patient populations, a fact that makes its legalization for recreational purposes problematic.
There are certain patients for whom medical cannabis should be contraindicated, or, at least, monitored for the risks and benefits of use. First, cannabis has been shown to significantly increase the chance of a psychotic break in those predisposed to schizophrenia.
In recent studies conducted in the Netherlands, researchers estimated that 30%-40% of cases of psychosis in that country could be prevented by limiting recreational cannabis. The added issue is that many people seek out cannabis, whether recreational or medicinal, because they have not had a proper psychiatric evaluation or an optimized trial of psychiatric medications for common diagnoses like anxiety or depression. Self-medicating without the input of a doctor is common.
Second, pregnant women should not use cannabis. It crosses the placenta and is found in breast milk. Studies have shown that infants who have been exposed to cannabis in utero have a higher risk for various psychiatric disorders such as depression, anxiety, ADHD, and even autism.
Third, cannabis use has been shown to adversely affect the neurodevelopment of children, which can cause amotivation and lower levels of educational attainment later in life. Likewise, as with many substances, chronic cannabis use at an early age can prime the brain for psychiatric and substance use disorders later in life.
To be fair, newer studies challenge the aforementioned conclusions, arguing that amotivation, lower educational attainment, and a higher chance for psychiatric issues is only correlated, but not caused by cannabis use. In other words, children who are otherwise prone to negative educational outcomes and psychiatric disorders seek out marijuana.
The data is mixed on whether legalizing recreational cannabis has led to a significant increase in use by adolescents. A current and sizable project called “The ABCD Study” will hopefully shed more light on the prevalence and effects of adolescent cannabis use.
Fourth, while cannabis use has been shown to decrease overall opioid use, there are also studies that show that chronic cannabis use can cause relapses in patients with opioid use disorder because it may, over time, “disinhibit” those with preexisting addictive tendencies.
Just as we have yet to uncover all of the potential medical uses of cannabis, we may also have yet to uncover all of the possible adverse effects, which provides yet another argument for cannabis to be removed from Schedule 1 status so it can be researched further.
In addition to contraindications, the other concern with legalizing cannabis for recreational purposes is that customers will purchase products without necessarily knowing which products can help them with their specific symptoms and which products can actually worsen them.
For someone seeking to alleviate anxiety, for example, a high CBD strain of cannabis has been shown to be anxiolytic while high THC strains, the kind most popular on the illegal market, have been shown to increase anxiety. Likewise, someone with addictive tendencies could buy a high THC strain of cannabis, which carries with it an increased chance of abuse (albeit still a low one) when compared to a high CBD strain.
Furthermore, in an age when “medical information” can be posted by anyone with a computer, where can patients go for reliable, evidence-based advice on cannabis use if not physicians? With recreational legalization, patients would lose the mandate to be medically screened and assessed for the proper cannabis strain and product.
While cannabis is relatively safe for most people, and has many proven therapeutic benefits, its properties could be utilized best under the supervision of a doctor who can evaluate a patient’s history for contraindications and who can recommend proven strains and products to effectively help achieve their patient’s stated goals. Cannabis can be most beneficial if it is coupled with safety measures and medical knowledge. It is one of the rare instances in life in which we can take a former foe, and, under the right conditions, make them a friend.
Dr. Jeffrey Katra, DO is the current addiction fellow at the University of Virginia Medical Center. He received undergraduate degrees in history and government from Georgetown University, a Master’s degree in history from the University of Virginia where he studied the intersection of politics and science in America, and a medical degree from the Philadelphia College of Osteopathic Medicine.
Dr. Katra completed his Family Medicine training at Lower Bucks Hospital Family Medicine Residency in Bristol, PA. He is also a certified hypnotherapist who specializes in chronic pain, phobias, and addictive behaviors.
Dr. Katra has certificates in psychopharmacology from the Neuroscience Education Institute as well as in cannabis medicine from the Lambert Center for the Study of Medicinal Cannabis & Hemp at Thomas Jefferson University.
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