Cannabis Risks and Concerns | Special Episode
In this special bonus episode of “Growing Forward,” we investigate some of the concerns that still exist around cannabis use and the potential legalization of recreational use in New Mexico. Dr. Brant Hager, a Psychiatrist at UNM, reached out to us recently to point out some of those risks and concerns, in relation to both recreational and medicinal use of cannabis. He spoke with hosts Andy Lyman and Megan Kamerick about what exactly those concerns are and what lawmakers still need to be considering when debating a legalization bill next year. (Note: Dr. Hager is speaking from his own perspective and his opinions are in no way representative of UNM as a whole).
Episode Music:
Christian Bjoerklund – “Hallon”
Poddington Bear – “Good Times”
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“Growing Forward” is a collaboration between New Mexico Political Report and New Mexico PBS, and is funded through a grant from The New Mexico Local News Fund.
FULL TRANSCRIPT
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Andy Lyman: Welcome everyone. We’re running a Facebook Live for ”Growing Forward,” a podcast collaboration between New Mexico PBS and New Mexico Political Report. Joining us today, well joining me is my co-host Megan Kamerick. She’s not my co-host (laughs). But, the other the other host, Megan Kamerick. And, joining us today is Dr. Brant Hager. He’s a psychiatrist. Works for the University of New Mexico. But to be clear, before we start, he is not representing anything with UNM, the School of Medicine or the School of Psychiatry, but welcome Dr. Hager. Thanks for joining us today.
Brant Hager: Thanks, Andy. Thanks, Megan.
Andy Lyman: So just, so folks obviously don’t know this yet, but you had contacted us towards the end of the run of our podcast with some concerns that we didn’t speak enough, or really at all, about the potential risks or actually, you know, risks that have been, basically put down on paper, I should say. So, can you talk a little bit about what the data and sort of studies, you’ve seen that, that… what sort of risks does cannabis present to users?
Brant Hager: Sure. Yeah, whenever we’re talking about medicine, we talk about risks and benefits. And, it’s important to have a balance of risk and benefits and to allow people to make decisions about what they want for their health care. And with cannabis, it’s, it’s a little bit murky. The good data that we have on risks with cannabis…. So, we have good data from clinical trials on the risks associated with pharmaceutically-prepared cannabis products. So, for example, synthetic cannabinoids like dronabinol or nabilone. And, there’s a mixture of CBD and THC called Sativex that’s available in Canada and the UK, but not in the united states. So, these things have been studied in clinical trials and we have some good, reliable data to suggest what their common adverse effects are, in excess of what we would expect from placebo. Now, with regard to medical cannabis itself, we have a real dearth of information about what the adverse effects are of medical cannabis in comparison to an active comparator, for example, like placebo. And this is, of course, hindered by the fact that cannabis, as a plant, and THC as a substance, are listed as a schedule one substance, which I know you covered in a previous podcast.
Megan Kamerick: That means that people can’t, it makes it harder to conduct research, right?
Brant Hager: Yes, it does make it more difficult. You can conduct research utilizing cannabis, although there are some limitations. So, if, for example, if you’re going to do federally funded research using cannabis, there is actually a cannabis farm, I believe it’s in Mississippi, that grows cannabis for the purpose of federally-funded cannabis research. And the, the characteristics, at least the last time that I checked, of the cannabis grown for federal research do not really match well the characteristics that are available in many medical cannabis preparations. Like, if you look at the secular trends of medical cannabis, CBD and THC content, what you see is fairly steadily escalating THC content levels. And CBD content levels that really vary depending upon the strain that’s available, whereas much of the cannabis that has been studied, the sort of the federally available cannabis, if you will, has relatively lower THC content. And also, some of the information we have about cannabis use and its risks is through the lens of recreational-use. And so, we’re dealing with a different, a different population entirely. It may be overlapping substantially or minimally, depending upon where you’re at, but it’s a different population. And, just in terms of some basic nuts and bolts, like… from the clinical trials, we know that some of the most common adverse effects of the active arm of these clinical trials involving cannabis preparations are things like, you might expect, like dry mouth, euphoria. They list euphoria as an adverse effect. You know, it’s not necessarily an adverse effect, depending upon who you are and what you’re looking for. Other adverse effects that are common are dizziness, nausea, fatigue, sleepiness, vomiting, diarrhea, disorientation, a sort of a weakness or a fatigue called asthenia, which is sort of like a lack of drive, drowsiness, anxiety, confusion, imbalance and hallucinations. And these adverse effects appear to occur anywhere between one and a half times more likely, to up to five and a half times more likely than placebo. And, we know from clinical trials that people in the cannabinoid arm of most clinical trials tend to drop out more than people in the placebo arm of these trials by about a factor of two. And so… but, it’s difficult to take those, sort of those purified preparations, which oftentimes involve… most of the stuff that’s available, actually, the only purified preparations available, medically, in the united states are pure THC. Essentially, pure THC, either dronabinol or nabilone. And then, the other cannabinoid that’s available in the united states is also CBD… is available in the united states as a prescription medication. And, this is specifically FDA-approved for the treatment of certain types of epilepsy that occurs in young people.
Andy Lyman: So, I spoke with a few people over the years and kind of the sentiment I hear from… and these, to be clear, are proponents of legalization, or at least using medical cannabis… was they put it in perspective of either/or situation. So, if you talk about, let’s say opiates. And so, now just to back up a bit, opioid use disorder is now on the list of qualifying conditions to become a medical cannabis patient and there’s a lot of criticism that you’re just trading one substance for the other. But, the comment I heard numerous times was, “well, you’re trading a sort of non-toxic, or trading a toxic substance for a non-toxic substance.” So, as somebody who has the ability to prescribe medication, what are your thoughts on the dangers or adverse effects of cannabis versus things that are already, you know, prescribable?
Brant Hager: Yeah, sure. I think, if we’re going to talk more broadly about harms and so on, we should probably talk about some of the, some of the harms that can be observed in some of the prospective cohort studies. So, when you take a look at a group of people and you follow them for years. And so, what we see from some of these studies is that long-term cannabis use and especially if it’s heavy cannabis use, can associate with increase of a number of psychiatric disorders. There tends to be an increased risk of bipolar disorder and depressive disorders. There tends to be an increased risk of schizophrenia, in particular in people who have an enriched family history of schizophrenia. And, there does appear to be some, also some medical risk. Like, for example, there’s an increased risk of some testicular cancer, a specific type of testicular cancer called a non-seminoma testicular cancer. And, there also are some short-term risk. There’s… in the literature, there’s a description of about a four-times increased risk of myocardial infarction, or heart attack, around the time of acute cannabis intoxication. And, this risk may be carried forward over the next over, over a follow up period of about four years. But, somehow it drops off after you have followed up for four years. So, there are a number of… oh, go ahead Megan.
Megan Kamerick: Oh, I was curious what… when we say heavy use, what do we mean? Can you quantify that?
Brant Hager: You know, there are different definitions, depending upon the literature that you’re reading. I think the gist of the literature is, what it says is that, these risks tend to increase with increasing use. So, for example, if you move from occasional-use, to several times a week, to daily use. And, like a difference… Each different study will use its own definition of, like, what constitutes, quote, unquote, heavy use. Yeah. And, there is a risk… at least when we look at people with recreational-use, who initiate recreational use… There’s about an 8 to 10% chance of somebody who initiates recreational cannabis use, of developing a cannabis-use disorder. And, a use disorder is characterized by continued use in the face of adverse consequences, from a particular substance. That can also be accompanied by craving and some compulsion to use, sometimes withdrawal symptoms and so on. So, it’s, you know, cannabis is not unlike many other substances that we might call controlled substances. That it has, it has a misuse or abuse or use disorder potential and it does have some toxicities associated with it. Now, if you want… to stack up those toxicities in comparison with other substances, like say for example, just to compare it to opioids. Clearly, cannabis is orders of magnitude less dangerous than opioids, in terms of overdose risk. I mean, there is a small literature of cannabis-associated or cannabinoid-associated emergency departments… emergency department visits and cannabis-associated deaths. And so, there’s this link to myocardial infarction or heart attacks. There’s this link. There’s also links drawn to heart rhythm problems. There may be a temporal association between the acute intoxication period and stroke. And there’s also a pretty consistently demonstrated increased risk of traffic fatalities related to cannabis use, which is why, of course the, you know, you read the letter of the medical cannabis program statutes and they’re very clearly saying, you know, this does not protect you from adverse consequences if you are intoxicated while you’re operating a motor vehicle or a vehicle, so, it’s the… the gist of it, is that it’s non zero risk and needs to be taken into account, just like any other, any other medical treatment.
Andy Lyman: So, I have another question. But before I do that, I want to take a, just a moment to, if anybody’s just now joining us, obviously, you’re probably on Facebook. We are… This is sort of an extra episode, so to speak. A Facebook live for “Growing Forward,” which is our podcast collaboration between New Mexico PBS and New Mexico Political Report. I’m joined with Megan Kamerick and Dr. Brant Hager. If anybody has questions, if you’re watching on Facebook Live, feel free to type them in the comments. We’ll be watching for those and we can present them to Dr. Hager. And also, just a real quick additional plug… if you haven’t heard “Growing Forward” you can go to wherever you get your podcasts and search for “Growing Forward.” You can also go to nmpbs.org and find it there. But, Dr. Hager I wanted to ask, it’s sometimes really hard, especially for journalists and just anybody in the public, to sort of navigate these, sometimes conflicting, studies about anything, right? Statistics, studies, all this… that there’s, there seems to be a lot of studies coming out showing positive effects and of course they’re coming from medical doctors just like yourself. So, how do we, as the general public, sort of weed through these, no pun intended, get through these, sometimes conflicting reports?
Brant Hager: Yeah. Yeah, that’s a really great question, Andy, because there is such a deluge of medical literature, all the time, and it’s hard… it’s difficult for medical doctors to keep up themselves. And so, what we look for when we’re reviewing medical literature is, first we look at what type of study is being done? And what is the evidence based off of? And, as I had mentioned in the email that I had sent to you and Megan, the gold standard that we have in clinical medicine is what we call the randomized control trial, where you randomize somebody to receiving an active intervention and a comparator intervention. And so, usually, when you’re using medications, it’s a medication versus a placebo. And placebo is not nothing. Placebo actually has some great benefits and there’s interesting literature about the placebo effect. In fact, which includes the endocannabinoid system, which is curious. So, if you look at the literature of cannabis and cannabinoids and you restrict it to randomized clinical trials, you see a specific type, specific types of conditions for which it has pretty robust evidence. And so, not only is the randomized clinical trial, sort of our standard, our go to, what we’d like to see in medicine is larger trials versus smaller trials. And we also, of course, would like to see consistency across studies. Things that can be replicable. And these are some of the foundations of science. You need to be able to replicate a particular finding. So, for example, in the question about cannabis, in the setting of opioid-use disorder, there is good basic science evidence that there should be a mechanism by which THC, in particular, should have an opioid-sparing effect. And there’s been some animal studies to suggest that this might be the case. And then some of the observational studies in in humans have not really born this out yet. And the cannabis, in the context of opioid-use disorder, there’s one small randomized clinical trial that I’m aware of. And, there may be others, of course. This field is always changing. One small randomized clinical trial that shows some abatement, some decrease in withdrawal symptoms as people are moving from utilizing illicit opiates and shifting over towards opiate replacement therapy, which is called buprenorphine. And so, the challenges… that’s a far cry from saying that cannabis is effective for opioid use disorder. Because, when we look at the evidence, also, we’re having to pay attention to what the study studied? And so, this particular study studied the use of cannabis to abate opioid withdrawal symptoms, as a facilitator to getting on an evidence based treatment for opioid use disorder which is buprenorphine. And so, we’re looking for… and to summarize… what we’re looking for in medical evidence is, we’re looking for the level of evidence. And we like to see randomized clinical trials. We’re looking for consistency of evidence, so consistent findings across trials, run by different people in different settings and so on. We’re looking for a strength of effect. And we’re also paying attention to the specifics of how that trial was conducted. And we don’t have all that much with regard to medical cannabis in that light. It’s furthermore very challenging, of course, to study medical cannabis in that light because of all the active constituents that are in cannabis. So that, I mean that’s a brief snapshot of what we’re looking for.
Megan Kamerick: sS, what are… given, given all that, what are your main concerns with the existing medical cannabis program here in New Mexico, which has been around for, since 2008, 2007 and the potential to legalize recreational cannabis?
Brant Hager: Sure, sure. Yeah. Well, almost all other areas of medicine follow a certain stepwise progression, as we learn about new treatments and implement new treatment. For example, we just today, actually it was just yesterday, the New England Journal of Medicine just published the first clinical trial data from the coronavirus vaccine. The Pfizer Biontech vaccine. And that was a very important milestone in moving forward with initiating this treatment in a broad-based fashion. So, we like to see these kinds of studies in medicine, to know what we’re getting into, so that we can advise people about risks and benefits. And the medical cannabis program does stipulate that when you certify somebody for the medical cannabis program, that you’re certifying that the person has a diagnosis and that you’ve discussed the risks and benefits with the person. We know quite a bit about adverse effects from recreational cannabis. We know quite a bit about adverse effects from pharmaceutically-prepared cannabinoids. We don’t know all that much about the risks to people who are using cannabis for these specified purposes. We don’t know if the risk is greater than or less than the pharmaceutically- prepared cannabis. We don’t know whether or not the risk is greater than or less than for the same things with regard to people who are using recreational cannabis. So, primarily the concern is about a lack of good data to guide people. That’s one concern. The other concern is that the level of evidence required for inclusion of a condition in the medical cannabis program, first off, it’s not stipulated in the law. The law does not stipulate that a certain level of evidence is required to, for a condition to be included. It basically states that the medical cannabis advisory board will hear evidence pro and con and based upon those discussions, will recommend or not recommend. And there are a number of conditions on the medical cannabis program for which there’s really, there’s a lack of randomized clinical trials to support their use. And so, we‘re stuck in a situation where there’s questions about its usefulness from a systematic standpoint and also questions about its risks from a systematic standpoint. But, when I had reached out to you all. I had shared a sort of an aphorism that’s used in clinical medicine, which is that the plural of anecdote does not equal evidence and what this means is, of course, that anecdotes are very important. When people have an experience with a particular thing, like, for example, if a person has a good experience with medical cannabis, that’s a very important data point. It’s especially important for that person because it’s their life and their experience. It’s also important for their providers to pay attention to that experience. And, when you want to generalize from that experience, that experience becomes a testable hypothesis that you try to test across a large group of people. And right now, what we have is a number of conditions that have basic science evidence, maybe some case series, maybe one small randomized clinical trial and maybe that randomized clinical trial is not even using medical cannabis. It’s using a pharmaceutical cannabis preparation. And so, it’s very difficult to advise people, accurately, about the risks and benefits and it’s very difficult to recommend or not recommend for particular conditions. Those are the primary concerns that I have.
Andy Lyman: This question… it’s a good time to also add in that disclaimer that I mentioned at the beginning, again. We’re talking to Dr. Hager, who works for UNM, but very clearly is not speaking for UNM. So, given that, I don’t think you are doing clinical work. Maybe you are, but let’s just hypothetically say, you’re seeing a patient, comes to you and says, “I’ve heard all these things. Here’s all these studies.” And, I guess it’s, the hypothetical is hard because there’s physical symptoms or physical conditions and sort of psychological symptoms, but what would that conversation sort of sound like between you and a patient who is seeking that medication?
Brant Hager: You know, it would sound a lot like the conversation we’re having right now. Probably not getting as much in the weeds in terms of the depth of the evidence based and so on. It would probably… usually when I have these conversations, because I have these conversations with patients all the time. Usually, it starts off with a discussion about, you know, what we know about the benefits of individual cannabinoids and what we know about the benefits of the cannabis whole plant, preparations for, or the preparations that are available, not whole plant, for specific medical conditions. What we know about risks from the clinical trials and what we know about risk from the epidemiologic standpoint that I was sharing with you before. And then an assessment of what their experiences with cannabis in their lives. What their experience has been like, in the past. Whether they’re experiencing any the adverse effects that have been demonstrated from these clinical trials or these epidemiologically-observed adverse effects. What adverse effects to watch out for. An agreement to collaborate closely on strain selection and on monitoring for adverse effects. An agreement to watch out for the development of a cannabis use disorder. So, it’s basically, it’s not dissimilar to risk benefit discussions with any other treatment. It’s just, also has a twist to it because of the lack of good information.
Megan Kamerick: Is it your fear that people might be using cannabis for everything… that, it’s the qualifying conditions that are on the New Mexico medical cannabis program and they might be using it for something that we don’t have robust clinical data for? And, I mean, maybe it works, maybe it doesn’t. But, they’re then not pursuing another more efficacious treatment for what they’re dealing with?
Brant Hager: Sometimes I see that. Sometimes I see, sort of, moving towards cannabis and not exploring the treatments that have more robust evidence for it. And people have different reasons for doing that. I certainly don’t begrudge somebody their choice to move in that direction. I think, say for example, somebody comes in with opioid use disorder. Let’s take an example for something that has a really robust evidence base for four different types of treatments. And somebody comes in for opioid-use disorder and request medical cannabis diagnostic certification for opioid-use disorder. And say, over time, the concern is that cannabis alone is not likely to abate the opioid-use disorder in a way that leads to opioid decreases and reduction of harm and reduction of overdose risk. I don’t know of any clinical trials that have demonstrated that cannabis will reduce the risk of say opioid overdose death. And so, in that circumstance, there could be a concern if somebody’s like, well, no, I just want to treat with cannabis and, you know, I don’t want to pursue medication-assisted treatment. Now we work, in psychiatry and medicine in general, we work all the time with people’s ambivalence as towards different treatments. Right? And that’s part of our job, is to help educate and help motivate and help people move towards different types of treatments. So that’s, sort of, a high-profile example. One of the things that concerns me is that, the functional way that I’ve seen a number of people interact, psychologically speaking, with the medical cannabis program, is there sometimes can be a thought like, well, here’s the list of certifying conditions. The state has certified these, or has, sort of, said these are qualifying conditions. Therefore, there must be good evidence for this. There can be an assumption that because they’re included that there is as robust evidence as there is for any other treatment that we suggest. So, some of the functionalities are concerning as well.
Andy Lyman: I’ve got a question for you, and I apologize because I’m probably going to make you sort of defend the, just psychiatrists across the globe, but as I talk to folks, I hear, sort of, these… the sentiment of, sort of, distrust for psychiatrists or other sort of doctors, who they sort of perceive might be getting funding by quote, big pharma. And, I know in your case working for UNM, and again, last disclaimer here, that you’re not speaking for UNM, but I’m pretty sure UNM has some pretty staunch guidelines as far as taking money from companies.
Brant Hager: Yeah, yeah, yeah.
Andy Lyman: But, what do you have to say about that in general, for maybe a private practice psychiatrist. Does that cloud their judgment?
Brant Hager: Well, I think it’s a very reasonable concern to express. You know, my medical school and the current university that I work for and, of course, I’m not speaking on their behalf, is, both of them have very strict rules about the influence of pharmaceutical companies in education and in practice, in clinical practice. Now, it’s no, it’s no secret that most of the large randomized clinical trials are being run by pharmaceutical companies who have a financial stake in pursuing efficacy and in pursuing profit. That’s the reason why pharmaceutical companies are in business, in addition to desires to help people in advanced therapeutics. And one of the rhetorical questions that comes to mind to me is to say, if we are asking pharmaceutical companies to foot the bill for, not all, but many of these large clinical trials, why don’t we ask people who stand to benefit financially from medical cannabis to also foot the bill for large clinical trials? And what would, you know, wouldn’t we know more about that? And I see… I think that that could be very beneficial. I know the governor has, I don’t know if she initiated this, or she certainly proposed the formation of a, like a research fund. I’m not sure… I didn’t quite catch whether or not it got approved. Do you all know?
Andy Lyman: I’m not sure about that. I couldn’t say.
Brant Hager: Yeah. Um, so, yes. I think it’s a very reasonable criticism of medicine in general, is that you know, a lot of the influence in the medical literature is being driven by pharmaceutical companies. Now, that being said, if you look, for example, in the herbal medicine literature, you can see tremendous numbers of examples of good, well run, randomized clinical trials of fairly good size, using different herbal preparations, some of which are funded by the preparer of the herbal preparation, but some of which are just funded by academic centers. And, if other areas of herbal medicine can commit to going forward with this, it would seem to me that we might want to ask the medical cannabis industry to commit to going forward with this as well.
Andy Lyman: I think we are… do you have another question, Megan?
Megan Kamerick: I was just… I didn’t know if you saw it. There was a question I saw from someone on Facebook that I… from Almay, who’s interested in learning more about what scientific evidence do we have about the positive and negative effects of specific terpenes or how they may have very different effects?
Brant Hager: Yeah. Yeah, that one is, I mean, there’s a huge potential for exploring all of these individual terpenes. There’s some really interesting information about linalool and anxiety. Linalool is the terpene that is also found in lavender and there’s some interesting information about Lymonene and its attenuation of some of the adverse effects of cannabis intoxication. Those are the two that are coming to mind just right off the top of my head. But yeah, there’s huge, huge open questions. And just to highlight the impact of the terpenes in this. So, there’s a there’s a clinical trial that’s about to come out. They’ve sort of hinted at the results in a previous publication. This clinical trial looked at cannabis, various cannabis preparations in about 80 veterans with PTSD. And they took a look at high THC, high CBD cannabis, high THC, low CBD cannabis and then high CBD, low THC cannabis and then what they call placebo cannabis, which was low THC, low CBD. And over the course of the, I think it was a five-week study they, they saw no differences in terms of PTSD improvements between the groups. All the groups, I think improved, but no differences. So, this really opens a question about, like if there’s a benefit in PTSD, what’s driving it? Is it THC? Is it CBD? Is it the terpenes? Is it the flavonoids? We don’t know. And these are really important questions.
Megan Kamerick: Well, do you… as you know, we’re going to be debating legalization in the next legislative session. Do you have a stance, whether we should move forward legalizing recreational or should we be thinking… things that we should be thinking about in that legislation?
Brant Hager: Well, I think, certainly, paying attention to some of the known risks would be important. For example, paying attention to the impact that it may have on traffic safety and traffic fatalities. How do we mitigate that? Because it’s something that we’ve observed epidemiological from other places that have legalized cannabis for recreational use. How do we, how do we help people who are at high risk for developing schizophrenia or other psychotic disorders? How do we help them to make choices for themselves, but also choices based upon information about the risks and the benefits of recreational cannabis use? I think, mostly, taking a harm reduction approach, I think, is important. I think the cannabis legalization is probably inexorable. I mean, that’s been the movements throughout the country. And it just continues to increase. I think it’s inexorable. So, I think it’s more about how do we do it safely?
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Andy Lyman: To wrap things up… just to, you know, this was a little extra for “growing forward,” the podcast collaboration between New Mexico PBS and New Mexico Political Report. We just spent time talking to Dr. Brant Hager, psychiatrist in New Mexico. So, thank you dr. Hager for joining us and giving us your vast knowledge.
Brant Hager: Yeah. Thank you both.
Megan Kamerick: Yeah, it was really interesting. Thank you very much.
Brant Hager: Yeah, you’re welcome.
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