A Six Part Review of the Medical Literature and Evidence on Marijuana and Legalization −  For Families, Leaders and All Texans

As Texans, most of us care about preserving safe, family-oriented, Christian communities. How do we know if supporting the legalization of marijuana is the right thing to do? When our decisions affect our community and families, and when people look to us for guidance, as Christians or as healthcare professionals, I believe there is one overriding moral principle in doing the right thing.

Truth. 

It means basing what we choose to stand behind on information that is as honest and as sound as we can know it to be – and not let ourselves be lured by falsehoods, or by those trying to sell something or steer us down a potentially harmful path that isn't in our best interests. 

The question really isn't if we support legalization – the real question is do we support drug use? Have we studied the science for ourselves, sorted out the costs and benefits, and understand the impact for our communities? Will we put our name to something that makes our community, Country and world a better place, and helps people and our children be the very best they can be?

When the legalization issue first came to Texas, some argued for the innate goodness of everything made by God, saying God didn't make a mistake when he made marijuana. Christians hold that God provided a bountiful earth of natural resources to nourish us and enable us to flourish. But, as my scientist father taught me, he also gave us intellect to reason and use our free will to make good choices. Choosing to use our brains for good comes with responsibility to do the hard work necessary, which means educating ourselves about what makes sound scientific evidence and recognizing if the supported benefits of what we advocate outweigh the risks of harm to people.

It's easy to believe that if something is all-natural and God-given it must be safe and good. But we would never in good conscience advise people to use poisonous arsenic or hallucinogenic opium, or reassure people these are safe. This principle also applies to marijuana, and calls upon us to step back and question our preconceived beliefs, as well as ideas that may be popular. As pharmaceutical and neurology experts wrote in the journal Neurotherapeutics, the majority of the public equates "natural" with "safe" and believes marijuana is safe – while a minority of medical professionals hold that view. 

Why is that? Why has the public come to believe things so extraordinarily different from most medical professionals?

"This significant disparity in opinion between professionals and the lay public, possibly swayed by the appeal of natural remedies, emphasizes an increased need for further research and public education regarding medicinal cannabis and epilepsy," the neurology experts said. The power of belief and high expectations are behind the placebo response seen especially in children and teens with epilepsy and other psychiatric disorders, they added. But beliefs are not science. 

Widespread enthusiasm and wishful belief are not substitutes for careful reasoning and real science. Anecdotes, surveys and case reports dominate cannabis studies, but sound evidence is lacking and most studies that appear to support cannabis are of such poor quality, they are antithetical to evidence-based medicine.

The greatest advances in modern medicine have come from the scientific process. It has enabled modern medicine to help save and improve the lives of millions of people. It has proven to be the best way we have to determine if a treatment actually works, and doesn't put people at greater risk. 

The core of the scientific method in evidence-based medicine is well conducted, randomized, double-blind, placebo-controlled clinical trials. These are the studies that help eliminate "bias" and the placebo effect to ensure that it's a valid, or "fair test," of a treatment. Few in the public realize how powerful placebos can mislead us into believing something works, and make us vulnerable to being taken advantage of by sham and often expensive treatments, while diverting critical medical resources  − and people needing help − away from truly helpful medical care. That's why good science is also ethical.

For years, we've been surrounded by intense marketing and heavily funded special interests, all trying to convince us that pot is natural, harmless, and even healthful. It's become nearly impossible to even find objective and trustworthy information, or good science, amidst today's online censorship. Worse, a lot of information we encounter is intentionally misleading, confusing and even downright false.

Most of what appears in media is marketing and is considerably different from the medical literature. So, it's not surprising that there's widespread confusion about marijuana. Texans have largely been shielded from the reality of legalization of marijuana and "medical marijuana" – a reality that people in neighboring States have experienced first-hand. We can learn a lot from what their States, communities, families and children have encountered with legalization. Washington and Colorado were the first States to legalize recreational marijuana in 2012, but each had also started with "medical marijuana" more than a decade earlier. We have the opportunity to use this valuable information and the lessons they've learned to guide us and decide if we want to follow that path. 

This extensive paper, generously reprinted as a special six-part series in Crit-Large to help Texas families, looks at the science and evidence from the most credible and objective sources available. We've heard the marketing, now we'll learn the other side of the story.

What is Marijuana?

Marijuana refers to the raw cannabis plant (Cannabis sativa L) which contains some 483 chemical compounds, 80 of them are biologically active, including 60 cannabinoids. 

The most known cannabinoids are the psychoactive compound delta-9-tetrhydrocannabinaol (THC) and cannabidiol (CBD). THC is the psychoactive, hallucinogenic, intoxicant that gives the "high" that is sought after by recreational users.

It's important to understand what the words surrounding marijuana mean:

• Cannabis refers to marijuana –the plant. It is the same as weed, the same as street pot, the same as recreational pot. This plant can be smoked or eaten in foods, candies and other edibles. It can be concentrated into THC tinctures and extracts and added undetected to anything that can be consumed or vaped. Marijuana contains the THC for "highs."

• "Medical marijuana" or "medical cannabis" is precisely the same thing as marijuana, identical to street pot, and no different than recreational pot. Its only differentiation from recreational pot is legislative terminology, not in the actual substances. It's important to understand this, because the marijuana special interest certainly do.

• Cannabidiol (CBD) or "low-THC cannabis" is one of the 60 cannabinoids in the plant; it's a specific component derived from the cannabis plant (usually hemp) that doesn't contain the THC "high" of pot and is usually consumed, as a CBD oil tincture or in edibles. 

Today's Marijuana is NOTHING Like Old-Fashion Weed

Popular beliefs that marijuana is benign come from old anecdotes and personal experiences, as well as outdated studies, back when marijuana was a fraction of today's potency. Today's marijuana is dramatically different from the Woodstock weed of the 1960s. In fact, it's unlike pot available throughout the 20th century! Much of the medical literature has failed to put the data together to see the full picture and many sources continue to cite obsolete figures. 

Marijuana isn't all natural, anymore. It has been genetically engineered to be higher in potency and psychoactive THC for more powerful "highs." The University of Mississippi has been monitoring THC content in illicit marijuana seized by law enforcement every year for 50 years. In 1972, their testing reported THC levels of 0.18%; 0.48% in 1975. In fact, throughout the 1970s, the average THC content was less than 2%. In the 1990s, pot increased from 3.4% to 4.5%, averaging 4% in 1995, as they reported in Biological Psychiatry. 

By 2008, they reported in the Journal of Forensic Sciences that average THC levels were 8.8%. 

The 4,888% increase in just 36 years led them to comment that plants are being produced with "potencies inconceivable" when they began monitoring. While psychoactive THC content has been increased, its ratio to cannabidiol had also increased 80 times by 2014.

By 2017, they reported the average THC levels of illegal marijuana seized by DEA agents had nearly doubled again to 17.1% − 9,400% higher than the early 1970s. 

Marijuana THC levels increased 9,400% between 1972 and 2017.

Laboratory tests of marijuana being sold commercially in legal states reveal generally even higher potency pot being sold for "medical" or recreational use. As reported in 2018 Nature Scientific Reports, THC levels ranged 17.7% to 23.2% in Washington state, for example, with highs approaching 30%.  

A comprehensive study of 8,505 products from 653 dispensaries across the country that were being sold online to consumers as "medical cannabis," was conducted by North Carolina researchers. They found that the advertised THC potencies ranged from 15% to 30% and were no different than the potencies being sold for recreational use by dispensaries across the country, such as in Colorado and Washington. 

The average potency of cannabis products on the market in Colorado was 19.6% in 2017, according to Colorado state laboratory. However, the portion of higher-potency products has increased significantly over recent years – increasing 500% during just the two years from 2015-2017. By 2017, a quarter of all cannabis samples tested had THC levels over 75%.

Today, extraction methods commonly using highly flammable chemical solvents − butane, hexane, propane, isopropyl alcohol or methanol – extract ever higher THC concentrations that are almost 100% pure psychoactive THC. These concentrated oils and tinctures are used in edibles or vaping liquids, and hashish or hash oil, called dabs. 

Today's edibles average 55.7% THC, and some specialty products contain up to 95-99% pure THC.

No honest or informed professional can claim that increasing the psychoactive hallucinogenic content of any substance to these levels can possibly be benign, let alone healthful.

This higher toxicity is one reason marijuana is considered by medical professionals to be such a harmful drug, especially more so today. International addiction medicine and psychiatric researchers have concluded that empirical data has clearly shown that regular or early use of cannabis increases the risks of a vast range of mental and physical disorders that are destructive to users, even life threatening, and to communities around them. 

Pharmacology of Cannabis

Marijuana ("cannabis") affects almost every system in the body. Once absorbed through the lungs or the gut, THC, THC metabolites and nearly 100 other cannabinoids are rapidly distributed throughout body tissues. Being lipid soluble, they accumulate in fatty tissues and reach peak concentrations in four to five days. Then, they're slowly released back into the body, including the brain. With a half life of about seven days, it can take up to a month for a single dose to be completely eliminated from the body. With repeated use, high levels of cannabinoids can accumulate in the body and continue to affect all of the body's organs, including the brain, where they alter the neocortical, limbic, sensory and motor areas. Because of these pharmacokinetic characteristics and slow elimination of cannabinoids, blood or urine levels are very poor measures of cannabinoid-induced intoxication or impairment.

THC causes its psychoactive effects by stimulating the cannabinoid receptors in the brain. Low dose joints (such as 10 mg THC from the 1960s) produce feelings of intoxication, relaxation, and sociability within minutes of smoking and last a few hours. But, especially as doses increase or with inexperienced users, the psychoactive compounds can also produce panic, paranoia, and psychosis, including precipitating schizophrenia. The average marijuana joint today, with marijuana that's 20% THC, has about 140 mg available THC. Today's joints would have been unthinkable to use a few years ago.

The endocannabinoid system is a very complicated neurochemical signaling and pathway system that affects a wide range of biological functions in the body. It can simultaneously give desirable or opposite undesirable effects, and the effects can be short term to long lasting. The endocannabinoid system is the epicenter of functions that are critical to human survival. These include appetite so we enjoy eating food for survival, pain sensations, mental functions, sensory and pleasure perceptions that give joy to life, reproduction, and the immune system for healing to pathological inflammatory responses or cancer. 

Anytime we mess with this extraordinarily complex system seeking some desired effect,
it causes a cascade of side effects to every other system in the body that may be
very dangerous and even life threatening.

Far Reaching Effects on the Brain 

The ability of cannabis to induce paranoia, lasting as long as a week, was first recognized in 1845 and the evidence of psychiatric issues has grown since. Cannabis use has been shown in over 20,000 published studies to be associated with severe mental health outcomes, including addiction and psychotic disorders, as well as potentially anxiety, depression and increased suicidality, especially from adolescence to young adulthood. High potency marijuana exacerbates many of these adverse effects, according to Smart Approaches to Marijuana. The brain is particularly vulnerable to psychiatric and addiction complications during adolescence, as the pre-frontal motor cortex ("the seat of judgement") is the last part of the brain to develop. This development isn't completed until age 25-30 years. 

Psychosis. When the public hears about the links between marijuana and psychosis, those who remember the old reefer madness scares may be incredulous. But times have changed, just as marijuana has become a dramatically different substance than decades past. 

Contemporary converging lines of evidence are finding several distinct links between cannabinoids and psychosis, which have been a growing concern among medical professionals. These concerns have increased as more people are using cannabis and beginning at younger ages, as well as the growth of edibles and high potency cannabinoid products. These are the very risks for psychosis: more cannabis exposure – frequency, duration or potency − and use at younger ages. 

In an ongoing study, published in the British Journal of Psychiatry, of more than 9,000 youths, the adolescents who had tried cannabis just five times or more had a 6.5-fold higher risk for developing psychosis.

One of the most comprehensive studies on marijuana and psychotic disorders was conducted by international researchers reporting in Lancet Psychiatry. They found a three-fold higher risk among daily cannabis users compared to nonusers. But among users of high-potency cannabis (which was defined as THC concentrations of 10% or more), risks for psychotic disorders were more than five-times higher. These findings were not new. This research confirmed a large number of other studies linking marijuana and serious mental health problems. 

There is a large body of evidence that cannabis use and psychosis are linked, that chance is an unlikely explanation for the link, and that cannabis use often precedes psychoses. While some severe psychotic reactions are transient and short term, clinical research is demonstrating that cannabis can trigger long-lasting psychotic disorders even in healthy people, can worsen underlying psychological disorders in these vulnerable people, and even induce psychotic symptoms in patients taking the prescription synthetic THC medications for chemotherapy nausea or pain.

Medical researchers are increasingly finding marijuana linked not only to the onset of psychosis, but also schizophrenia. In a study of more than 18,000 patients being treated for cannabis-induced psychosis, for example, 46% developed schizophrenia over eight years of follow-up, with most occurring during the first three years. 

To determine if cannabis actually causes psychosis or if the correlations could be related to something else, researchers followed about 50,000 young people in Sweden and found that those who smoked cannabis before age 21 had twice the risk of developing schizophrenia over the next 15 years, later in life. More frequent users had a six-fold increased risk of developing schizophrenia. This is the most convincing evidence that cannabis use can precipitate schizophrenia in some people. The researchers had adjusted for variables that were related to developing schizophrenia, including family history or other drug use, and the findings remained significant. The researchers went on to test the schizophrenia cases and found that 80% met the DSM-III diagnostic requirements, and their symptoms had been present for at least six months, excluding the possibility that the symptoms were transient.

Nine large studies from the U.S. and around the world of nearly 100,000 people examining the effects of cannabis use and the development of psychosis disorders in later adulthood have shown, with surprising consistency, that cannabis use doubled the risk. This association was consistent even when the researchers controlled for the use of other drugs and family and social circumstances. 

Studies showing psychotic symptoms developing three to seven years after use also debunk the theory that people already suffering from mental illness are self medicating to explain the association with cannabis use. 

Violence. An association between cannabis use and violence has also been recognized in the medical literature. International researchers followed young males from age 8 to 56 to determine if it is causal or simply a correlation related to social and environmental factors. Even after controlling for other violence-related risk factors, they found that cannabis users were seven times more likely to have criminal convictions for violent offenses and nine times higher rates of self reported violent offenses later in adulthood. As they reported in Psychological Medicine, they believe their study provides empirical evidence suggesting a causal effect.

Suicide. With the increased availability and higher toxicity of cannabis, medical and police professionals are seeing increases in psychotic episodes resulting in hospitalizations and deaths by suicide or homicide. According to Colorado Violent Death Reporting System, 23.3% of all suicides in Colorado in 2018 tested positive for marijuana. Marijuana was even the top toxicology finding among suicides in kids ages 10 to 19 − with 20% of these deceased youngsters testing positive for marijuana. 

Children 10 to 19 years of age committing suicide and 20% of them had marijuana in their system is tragic and a huge concern for doctors and parents, especially in states legalizing and normalizing pot use. No state that has legalized "medical" or recreational marijuana has been able to keep pot from kids and the consequences are literally costing young people their lives.

Addiction and withdrawal syndrome. It is popularly believed – and certainly most stories in the media report – that cannabis is not very addictive and marijuana substance abuse and withdrawal are not serious problems. The body of research in the medical literature and reality for addiction specialists, however, give a vastly different reality. 

Twenty years ago, cannabis withdrawal was not even formally recognized as a diagnosis in DSM-IV. But since then, "evidence has accumulated demonstrating that cannabis withdrawal is not rare in the general population, and indeed, is very common," according to a review of the evidence in Israel Journal of Psychiatry Related Science. 

Cannabis withdrawal became recognized in 2013 under "Substance-Related and Addictive Disorders" in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the international authoritative manual that defines and classifies mental disorders. Ten years of research led to the recognition of cannabis withdrawal and its physiological symptoms. 

Cannabis withdrawal is clinically significant, with "difficulty quitting and worse treatment outcomes associated with greater withdrawal severity," the DSM-5 Working Group concluded. 

They looked at findings from over 200,000 study participants before combining abuse and dependence criteria into a single substance abuse disorder. "Addiction" is a general term, now, according to the DSM-5 authors, and "dependence" is now used to refer to tolerance and/or withdrawal. Combining "abuse and dependence criteria were conclusively addressed because an astonishing amount of data was available and the results were very consistent," they wrote. While the medical community hasn't reached a consensus of how to precisely define "addiction," the American Psychiatric Association uses "substance use disorder" and "addiction" interchangeably. 

Regardless of how it's defined, cannabis use undeniably leads to problems. 

In one study population, for example, 40.9% of users attempting to quit met the DSM-5 criteria for withdrawal. Doctors researching the criteria for cannabis withdrawal syndrome, reported in the American Journal of Psychiatry in 2004, that studies had found 55% to 89% of inpatients met true withdrawal and more than 50% of heavy marijuana users in outpatient treatment experienced withdrawal.

Large studies show withdrawal occurs more often among regular users, with more than 50% in the general population experiencing multiple withdrawal symptoms, according to the doctors from the Departments of Psychiatry and Psychology at the University of Vermont. "A substantial amount of scientific data has been obtained in recent years concerning reliability, validity and clinical importance of cannabis withdrawal," they concluded.

Contrary to common beliefs, marijuana is addictive, said the National Institute on Drug Abuse. More than a decade ago, risks for marijuana addiction was popularly thought to be only about 9%. A review of a decade of epidemiological evidence between 1997-2007,was published in the October 2009 issue of Lancet. It reported that among those who begin using during adolescence, however, the lifetime risk of dependence with cannabis use was much higher (17%) – one in six. And among daily marijuana users, addiction rates were 25 to 50%. 

By comparison, "the equivalent lifetime risks are 32% for nicotine, 23% for heroin, 17% for cocaine, 15% for alcohol, and 11% for stimulant users," the researchers said. Heroin is well-known for its dangerously high addiction rates. Like cannabis, heroin was once considered a wonder drug and used medicinally, too. Heroin was added to "patent" remedies around the turn of the past century and even once believed to be safe and non-addictive. But heroin proved so destructive to people and society, it was banned in 1924.

Because so many more people use marijuana than other illicit drugs, though, cannabis dependence is twice as common as dependence on any other illicit psychoactive substance (heroin 0.7%, cocaine 1.8%), according to research in 2007 in Addiction Science & Clinical Practice. More worrisomely, specialists were seeing marijuana abuse and dependence disorders increasing in all age groups since 1997, along with more people entering treatment primarily for marijuana, increasing to 16% of all admissions by 2003. More recently, after legalization, addiction among teens in legalization states has increased 25%. 

The newest research is revealing even more troubling effects of the marijuana legalization movement and the heavily-capitalized marijuana industries that have resulted in pot with higher psychoactive potencies, increased regular use and initiation of use at younger ages. 

Brain scans show physical changes in cannabis users consistent with addiction, and regular users of cannabis or cannabinoids have been shown to experience withdrawal at unimaginably high rates. A systematic review and meta-analysis of 50 clinical studies on nearly 24,000 regular users of cannabis or cannabinoids reported in an April 2020 issue of  the Journal of the American Medical Association that overall, 47% of users had cannabis withdrawal syndrome. 

Among users in mental health treatment, 87% of inpatients and 54% of outpatients had withdrawal syndrome and 17% in the general population. These findings are not unusual, but are similar to other recent studies finding that addiction among regular users is extraordinarily common. Where are the headlines?

Withdrawal is the diagnostic indicator of substance abuse. 

Addiction specialist, Dr. Drew Pinsky, speaking at a Denver substance abuse treatment center, said that marijuana acts similar to an opiate in causing severe addiction, and withdrawal can last weeks. People who are addicted can do fine for years before they run into trouble. Having treated addictions for twenty years, he said the drug people have the most difficult time giving up is cannabis, adding, "since cannabis has been medicalized in California I have not treated one single drug addict who didn't have prescription for marijuana."

The problem of addiction and withdrawal has largely gone unreported in mainstream media and many in the public and even some medical professionals are unaware that it is so prevalent. By not understanding or recognizing the symptoms of withdrawal – nervousness, anxiety, irritability, anger, aggression, sleep disturbances, restlessness, depression, headache, sweating, nausea and vomiting, or abdominal pain − some users seek relief for the symptoms by using even more pot or other drugs…leading to more serious and longer-term problems.

By learning to recognize the signs that someone is running into trouble and developing cannabis use disorder ("addiction"), they can also receive treatment before they get into dangerous situations, said Samantha Miller, a psychologist specializing in children and teens at the University of Texas at Austin.

Cognition and Function. Along with the "high," cannabis changes sensory perceptions − color, sound, emotions and spatial – to the point of hallucinations. A wide range of studies have demonstrated that cannabis impairs cognitive and psychomotor performance, slowing reaction times, hampering coordination, lowering short-term memory and concentration. The effects are multiplied when used with other depressants, such as alcohol. Driving and work performance where judgment, alertness and quick, appropriate reactions are critical, including operators of machinery, commercial transportation, air traffic controllers and public safety-related jobs, are contraindications for using pot. 

The National Drug and Alcohol Research Centre in Sydney, Australia has conducted extensive research on the cognitive effects of cannabis and found that the degree of cognitive impairment (memory, attention, and ability to process complex information) is higher with long-term users. In follow-up studies of long-term users after two years of abstinence, some partial recovery of function was found, but former users continued to show impairment in their ability to focus two years after not using cannabis.

Examples of how these cognitive and physical effects with cannabis use endanger local communities, impact local economies and cost employers are numerous:

• Jobs impacting public safety are subject to periodic drug testing and are regulated by the U.S. Department of Transportation, which has a strict no-drug use policy and forbids the use of any Schedule 1 drug, including marijuana. "Medical" marijuana use is not exempt. 

• Research and evidence from twenty States have found legalization hurts economic development in communities, turns away prospective businesses, raises companies' legal costs and insurance rates, and employers and contractors risk losing federal funding or being fined for failing to maintain drug-free safe workplaces. Cannabis users are ineligible for federal security clearances and other government jobs. 

• Marijuana legalization, which increases pot use, has been shown to increase liability risks and to be especially costly for employers. According to the National Council on Compensation Insurance, up to half of all workers’ compensation claims are related to the abuse of alcohol or drugs in the workplace. Drug users, as a whole, use medical benefits at a rate eight times higher than non-users. Marijuana users have been found to have 55% more industrial accidents, 85% more job injuries and more worker's compensation claims, 75% higher absenteeism and tardiness, lower productivity and more sick time usage, and higher job turnover. 

In Part Two, we'll look at what marijuana does to our bodies, what the research shows and experts have concluded about cannabis as a medicine.

Sandy Szwarc, BSN, RN is a health and science writer who lives in the great state of Texas.