Legal Marijuana: Higher Potency Brings Higher Risks

0:00:14 William Moyers
Welcome to Let's Talk. A podcast series on substance use and addiction, treatment, recovery, research, policy advocacy, and a lot more. Produced and brought to you by the Hazelden Betty Ford Foundation. I'm your host, William C. Moyers, welcome. Thank you for joining us. Today we discuss the legalization of marijuana. Our guest is my colleague, Dr. Victor Vines, Hazelden Betty Ford's medical administrator based in Minnesota. You may have seen the podcast interview I did with Dr. Vines. If you didn't, you should have, and you can find it on our website. Welcome back, Dr. Vic.

0:00:49 Dr. Vic Vines
Thanks! It's good to be here.

0:00:51 William Moyers
Dr. Vines, let's talk before we talk about the decriminalization and legalization of marijuana, is it—is marijuana an addictive substance?

0:00:59 Dr. Vic Vines
It absolutely is for some people. It's much like alcohol or nicotine or any other substances in that not everybody that uses it will develop a dependence. We know that to be true. But for the people who are genetically predisposed to addiction, cannabis can be incredibly addictive to the point that probably somewhere around 8 or 10 percent of all cannabis users will develop a cannabis use disorder or dependence. That number goes up significantly if kids start using it. In teen years, people who begin using cannabis develop dependence probably closer to 20 percent. 15 or 20 percent. And for users of cannabis who use it daily, and say they can stop anytime they want to, that turns out not to be true in that 25 or 50 percent of them go on to develop dependence. And addiction. Understanding that addiction is that inability to stop, the inability to cut down, to develop a tolerance and then also the negative consequences that come along and then continued use despite those consequences. Those are all the hallmarks of addiction and cannabis absolutely falls into that category.

0:02:17 William Moyers
And as marijuana is decriminalized and in some cases legalized, you can consume it in different forms now. The way that older generations use it was by smoking it. But talk just a little bit about how people use it today and whether there's a difference between smoking it and ingesting it in other ways.

0:02:37 Dr. Vic Vines
Sure. So the cannabis that was around when you and I were growing up was—it had a much lower THC level. So that—you know, Tetrahydrocannabinol, the active ingredient in cannabis, was much lower and there was certainly not the purity that exists now. And so, over time, through the 80s, 90s, and on into today, the percentage of THC in cannabis products has gone up significantly. Making it much more potent. Probably somewhere between 200 and 500 percent more potent than it was back in the 70s. That purity of the THC has now meant that there is a much more intense development of addiction for people that do use it regularly and it does mean that it can now be developed and put into products other than smoked forms. Whether vaping or in a blunt or in a pipe, it can be put into edible form. And the difference in the experience that the user gets is that when they smoke it, it is inhaled in a vaporized form into the blood stream and then goes directly into the brain where it crosses the blood-brain barrier. And you get that psychoactive effect that you're looking for in smoking it much more quickly than you would if you were to consume it. In an edible form. Where it has to be processed through the intestinal tract and then taken up and into the bloodstream. But the percentage of THC in all of the products that are raised right now and distributed is much higher. And so there's a much more likelihood of development of tolerance and of dependence in today's products than there would have been back in the 70s.

0:04:29 William Moyers
And yet here it comes, the train has left the station and rolling down the tracks, not just in terms of decriminalization but legalization. Many, many states now have adapted marijuana as a legal substance. What is the difference between legalizing marijuana and decriminalizing it?

0:04:45 Dr. Vic Vines
That's a really important distinction. And I think one that sometimes gets wrapped up together because often times, the legislation that is put forth has elements of both. So, decriminalization means removing the criminal penalties for personal use or personal consumption. And instead of it being a penalty of incarceration, you know, like what was came about with cannabis being put on the Schedule 1 for the Controlled Substances Act, now it's more a civil fine. Or a civil penalty that for use that would be somehow tied to contingencies like going into treatment or getting help. And removing the incarceration as a part of an arrest for or being stopped for, cited for, possession or use. You know, and in the decriminalization we also have to say that the criminal penalties for wholesale you know distribution or importation are gonna stay in place. So the dealing aspect of that is not being decriminalized.

0:06:01 Dr. Vic Vines
[continued]
And then legalization goes a step further and says—it now implies a marketing process. Where it's manufactured and it's distributed and it's marketed. And it's wholesale made available for retail sale. And there would be a taxing structure. And this legalization would be something similar to what we see with alcohol and tobacco. And of course those are not benign products either. They have their significant health issues for sure. And that's one of the things that we're concerned about with cannabis products going the same route as alcohol and tobacco.

0:06:39 William Moyers
One of the arguments made by advocates for the legalization of marijuana is that it has helped to reduce the number of overdose deaths in the states that have legalized it. What's your response to that?

0:06:53 Dr. Vic Vines
You know, that is a—that was some research that came out probably six or eight years ago showing that the number of overdose deaths from opioids decreased in states where recreational cannabis or medical cannabis was made available. A follow-up study was done to look at those states not just at a point in time but over time, and it turned out that that data was incorrect. That in fact, what we've seen is in subsequent studies that the number of opioid overdose deaths actually increased. From beyond what they were at the time of the legalization. So, in trying to confirm which is which, another study was done. Which shows that neither of those is exactly right in that for sure there is not a decrease in the number of opioid overdose deaths. We're not sure if it's an increase, but, either way, there is not that hope for the removal of opioid overdoses used as a consequence of legalizing cannabis.

0:08:02 William Moyers
I just gotta ask as a follow-up question: is there any applicability of marijuana in the treatment of opioid use disorder?

0:08:12 Dr. Vic Vines
It does not seem to be true. There are thoughts that—and it's been speculated—that in areas where cannabis is made legal and is made medicinally available, that we would see a decrease in the number of opioid use disorder patients and in fact that is not true. What we have seen is a consistent rise in elevation in the number of people who have opioid use disorders in states where cannabis has been legalized. And the reason for that is that people who use substances don't tend to use just one substance. They tend to use multiple substances. And so, when cannabis is introduced to an individual and specifically, somebody who is young, the risk of developing another substance use disorder is much increased. And so, what we have seen is that when brains are altered by the use of cannabis, it makes it much more likely that they would be susceptible to opioids and the disorder that goes along with opioid consumption. Whether prescription or illicit.

0:09:21 William Moyers
Very early on in this debate between the decriminalization and then the legalization of marijuana, even actually before that debate was raging or resulting in policy, we did have medical marijuana in this country, specifically in some states. What is medical marijuana?

0:09:40 Dr. Vic Vines
That's a really important term to discern as well. Purely speaking, there is no such thing as medical marijuana. Medical marijuana refers to a distillation of a single drug which is Delta 9 THC. Into a form that can be consumed for a specific purpose and has been tested for a specific purpose. And the one that we have, Dronabinol, which is what's in Marinol, is one that has been approved for and shown to work for people with HIV-AIDS who have the anorexia or the weight loss that goes along with that. For people with nausea and vomiting from chemotherapy, where other things don't work, and then for some forms of glaucoma it can work. But the—when we apply the term "medical," what we're saying is that something has been tested rigorously, scientifically, and has been approved by the FDA. And marijuana is a botanical product. It's a plant product that has 85 different cannabinols in it. And to consume edibles or to smoke marijuana and call that medical, there's not any dose effect relationship that we can study. We can't—we're not able to study placebos where we compare somebody who is using the marijuana to somebody who's not. Those are the kind of studies that have to be done to give the legitimacy of a medical term. And so, medical marijuana is more of a slang term than anything of accuracy.

0:11:15 William Moyers
What is the FDA's position on medical marijuana?

0:11:20 Dr. Vic Vines
So the FDA right now, the Controlled Substance Act has marijuana as a Schedule 1 Drug. And as a Schedule 1, that means it doesn't have any medicinal benefit, it's shown to be potentially harmful, and is not gonna be available for use. Marinol, which is the synthetic derivation of Delta 9 THC, is a Schedule 3 drug. And so, what we're looking at with this decriminalization and with this legalization effort is a—is to move the—move marijuana off of its Schedule 1 status. And in fact to de-schedule it completely. And therefore make it available for research study, make it more available for control. The problem is there that the whole issue around taxation and the issue of distribution and government oversight all comes into play. But for right now, as it stands, at a federal level, the FDA is still considering cannabis or marijuana to be a Schedule 1 drug even though many states—many, many states, have begun to decriminalize and legalize it.

0:12:34 William Moyers
So are there any approved medical uses of marijuana?

0:12:39 Dr. Vic Vines
The approved medical uses of marijuana in—as a botanical, botanical marijuana, does not have any approved medical uses. There have been reported and anecdotal reports that various elements and various parts of the cannabis plant specifically cannabidiol, that has been shown to help with spasms for people that have multiple sclerosis. It helps with epilepsy, it helps with some people who have nausea and vomiting. There are some uses for cannabidiol that have been shown to be active. And then Delta 9 THC, which is what's in Marinol, does work for the anorexic effects of HIV-AIDS and it helps with chemotherapy. So, it's very limited. And the number of rigorously studied findings out there to support medical uses of marijuana are lacking at this point.

0:13:42 William Moyers
We have just a couple minutes left, Dr. Vines, a couple more questions before we close this edition of Let's Talk. I have friends who say they use marijuana to help ease their anxiety, their PTSD, their stress. I don't know whether they're saying that they're doing that in a way that would be medically appropriate, but they swear that it works. What is your response as a doc, an addiction doc, on the use of marijuana to relieve anxiety and other mental health issues?

0:14:20 Dr. Vic Vines
Well, it turns out that for a lot of people, they can use cannabis in the way that your friend is describing. For anxiety or for resolution of feelings of sadness or aloneness. And similar to alcohol, there are people who can and do use it intermittently and don't develop dependence. And don't develop the psychosis. And don't develop the cognitive blunting that happens. But there are a significant percentage, eight or ten percent of people who use it as your friend is describing, who go on to have worsening of their anxiety, a withdrawal syndrome that goes along when they stop using it, physiologic dependence, irritability, all of those things that when they don't use it, it causes a significant dysregulation in how they feel. And that's—and that's very real and for people that start using it younger, and use it for a lifetime, that impairment in their overall life trajectory is very real. We see—we see increases in psychosis, we see increases in mental health disturbances, we see cognitive impairment, we see traumas related to motor vehicle accidents. I mean there are a lot of people who can use it intermittently and get the reported beneficial effects by their self-report, but, that's not something that we can recommend based on any medical science.

0:15:56 William Moyers
Our last question, Dr. Vines, is a reality check for parents. So we have decriminalization. We have legalization. We know the United States Congress at least the House of Representatives recently, later in 2020, passed legislation to move this issue along and make marijuana more available. It's doubtful that the Senate will pass it but you never know. I mean here it is. And here it comes. What should parents do in terms of talking to their children about the fact that when it comes to public policy, marijuana is being decriminalized and legalized, and yet is still a dangerous and addictive substance? What's your recommendation to parents?

0:16:44 Dr. Vic Vines
I think that the thing I would suggest for parents is to get comfortable with being able to talk about subjects that, with their kids, that are real and are based on science and based on facts and try to remove the judgment of people who use. So the whole issue around decriminalization of course has been that when something is criminalized and it's deemed to be evil, deemed to be bad, deemed to be a public enemy, there's this natural human instinct to say well if it's that bad I think that sounds like something I should really—I wanna do. And when we as parents can sit with our kids and say look, here's what we know. When young brains that are still developing and still learning to coordinate what they see and what they experience and what they feel, our adolescent brain is not yet completely developed and in fact doesn't really—the prefrontal cortex, that thinking part of our brain—continues well into our mid-twenties. That if we can convince our children that if they're going to use something that they delay it. That they push it back. That they wait until they're—they're older. Older than 20. Older than 25. And say what we know is that when kids start using it early, there's a higher instance of developing psychosis. A more likely to not finish school, to do poorly in school, to drop out of activities that are fun and exciting and just be real about it.

0:18:18 Dr. Vic Vines
[continued]
And when—and when I had this discussion with my kids, so I've got daughters that are in their thirties now. They wanted to say they said well how about you? I mean, you grew up in the 70s and there was a lot of pot back then. And you know I—the honest thing and where we can be taken seriously by our kids is when we say, yeah I did try that and here were some of the negative things that happened. And here's what's different about cannabis now compared to cannabis in the 70s. And just be real. And be—be honest and be transparent. You know, developing a trusting relationship between parent and kids is probably the most important thing we can do as parents. Because kids are gonna be what they're gonna do, but when they know they can turn back to their parents for accurate information, they will come back. And try to make better decisions for themselves I think. So, you know, warning that it's not—it's not benign. The cannabis marketing industry would have you believe otherwise. But it's similar to alcohol, similar to tobacco, similar to opioids. There are a lot of dark sides to substances. All of which can lead to a substance use disorder.

0:19:29 William Moyers
Dr. Victor Vines, thank you very much for enlightening us today. On marijuana. The reality that decriminalization is turning into legalization. And yet still, it is a risk particularly for younger people. Thanks for being with us today.

0:19:43 Dr. Vic Vines
Thank you! It's good to be with you.

0:19:45 William Moyers
[turns to camera]
And thanks to all of you for tuning into Let's Talk, our award-winning podcast series. There are more to come, so keep coming back. On behalf of all of us at Hazelden Betty Ford, I encourage you to stay safe, stay healthy, and stay the course in these challenging times. Take good care. We'll see you again.