Is CBD Psychoactive?

By Roger Chriss, PNN Columnist

The CBD boom is making Dutch Tulip Mania seem dull. CBD water is becoming a thing, and Ben & Jerry’s may soon introduce a CBD-infused ice cream. Basically, CBD is in everything.

The boom is built on the assumption that CBD, the cannabis cannabinoid known as cannabidiol, is not psychoactive. The FDA isn’t so sure and the DEA demurs, putting the CBD-based seizure drug Epidiolex into Schedule V last year.

So is CBD psychoactive? The answer hinges on the definition of the term psychoactive.

According to the World Health Organization: "Psychoactive substances are substances that, when taken in or administered into one's system, affect mental processes, e.g. cognition or affect.”

The National Institute on Drug Abuse explains psychoactive drugs this way: “Drugs in this category act on the central nervous system and alter its normal, everyday activity, causing changes in mood, awareness, and behavior.”

The term “psychotropic” is used with a similar meaning. MedicineNet states that a psychotropic drug is “any drug capable of affecting the mind, emotions, and behavior.”

But does CBD affect mental states, alter everyday activity, or change mood, awareness, or behavior?

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The FDA last year approved Epidiolex -- the first CBD-based medication -- for the treatment of two rare and severe forms of childhood epilepsy, Lennox-Gastaut syndrome and Dravet syndrome. CBD potentially has many other uses, including neurological conditions such as Alzheimer’s and dementia, and neuropsychiatric illness such as autism, ADHD, and PTSD.  It could also be beneficial for anorexia, anxiety, and mood disorders.

Purveyors of commercial CBD products go further, claiming that CBD may help with insomnia, social anxiety, and panic attacks. Although most product labels avoid specific claims of treatment efficacy to avoid FDA scrutiny, clear statements of possible benefits are easy to find online.

The FDA recently sent a warning letter to a New Jersey company for claiming that CBD can treat anxiety, depression, PTSD, schizophrenia, psychosis and obsessive compulsive disorder.

In order for CBD to do even half of this, it would have to have an effect on mental states, mood and awareness. In other words, CBD could not do what its proponents claim without being psychoactive, at least in the narrow, technical sense of the term.

Dose Matters

But details matter here. First, psychoactive does not mean intoxicating, hallucinogenic or dissociative. And many prescription drugs have benefits precisely because they are psychoactive. Even caffeine is arguably psychoactive, though only very weakly.

Second, dose matters. The pharmaceutical Epidiolex is administered in doses that have 10 to 100 times more CBD than a typical over-the-counter or commercial CBD product. So CBD may be psychoactive in therapeutic doses, but not in “commercial” doses. Of course, this assumes the product actually contains CBD, which in practice is not necessarily the case.

Third, route of administration matters. CBD is only weakly bioavailable and unstable in light or temperature extremes. A clear bottle of CBD water or CBD bath oil could easily lose much of the CBD it may contain, and the remaining CBD may not even be absorbed. And if the CBD is applied to non-vascularized tissue, as is the case with CBD mascara, then it cannot be psychoactive because of a lack of blood vessels for transport to the brain.

Thus, whether or not CBD is psychoactive depends on the amount and method that CBD is introduced to the human body. Since most of the claims from proponents remain unverified and in many cases untested even in animals, it could be premature to state that CBD is psychoactive in a specific way.

On the other hand, the existing work on CBD argues for calling CBD psychoactive. Recent findings by Yasmin Hurd showed that CBD, specifically Epidiolex, reduces cravings in people addicted to heroin. Ongoing research is demonstrating possible benefits of CBD for seizure disorders in humans and even in dogs.

Project CBD noted in 2016 that “as our scientific understanding and therapeutic experience deepens, the description of CBD as non-psychoactive may fall by the wayside.”

For now, it would be reasonable to say that CBD is probably “weakly psychoactive” at commercial doses but more “strongly psychoactive” at therapeutic doses. As more studies are completed on what CBD actually does, the pharmacological description of CBD can be updated accordingly.

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Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

House Panel Seeks Clinical Trials of Kratom

By Pat Anson, PNN Editor

At a time when several states and cities have banned kratom, a powerful congressional committee is recommending that the herbal supplement be studied in clinical trials because of its “potential promising results” in treating chronic pain.

In a report to Congress, the House Appropriations Committee recommends that the National Institutes of Health (NIH) conduct research on whether kratom can be used as an alternative to opioids in treating pain.

“The Committee requests that NIH expand research on all health impacts of kratom, including its constituent compounds, mitragynine, and 7-hydroxymitragynine. The Committee is aware of the potential promising results of kratom for acute and chronic pain patients who seek safer alternatives to sometimes dangerously addictive and potentially deadly prescription opioids.”

The committee also recommended that the Agency for Healthcare Research and Quality (AHRQ) spend $3 million on clinical trials of kratom and cannabidiol (CBD) as alternatives for treating pain, and that the trials be conducted in “geographic regions hardest hit by the opioids crisis.”

The panel said it was concerned that the continuing classification of cannabis as a Schedule I controlled substance was stifling research “at a time when we need as much information as possible about these drugs.”

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“The Committee notes that little research has been done to date on natural products that are used by many to treat pain in place of opioids. These natural plants and substances include kratom and cannabidiol (CBD). Given the wide availability and increased use of these substances, it is imperative to know more about potential risks or benefits, and whether or not they can have a role in finding new and effective non-opioid methods to treat pain.”

The committee said the current state of pain management in the U.S. is “often inadequate for many patients” and that additional treatments were needed. It asked that Congress be given an update on the development of non-opioid chronic pain therapies in the next fiscal year.

To be clear, the 346-page report by the House committee is an ambitious “wish list” of hundreds of various projects that may or may not be included in a final congressional spending bill.  But the inclusion of funding for kratom research is significant, given the campaign against kratom by some public health offiicials.

Kratom comes from the leaves of a tree that grows in southeast Asia, where it has been used for centuries as a natural stimulant and pain reliever. In recent years millions of Americans have discovered kratom and use it as a daily treatment for pain, addiction, depression and anxiety.  

Although kratom is not an opioid, health officials have warned that it has “opioid-like” qualities, can be addictive and is not approved for any medical condition. Last month the CDC said kratom was listed as the cause of death in at least 91 overdoses and the FDA said it discovered dangerous levels of heavy metals in dozens of kratom products.

Kratom has been banned in 6 states and dozens of counties and cities have enacted or are considering their own bans. Last year, the Department of Health and Human Services (HHS) recommended to the DEA that kratom be classified as a Schedule I substance – which would effectively ban it nationwide.

Ironically, HHS oversees both the NIH and AHRQ, the same agencies the House Appropriations Committee wants to fund for kratom research.   

Using Cannabis and Opioids Together May Not Be Such a Great Idea

By Roger Chriss, PNN Columnist

The opioid-sparing effect of cannabis is routinely touted as a reason for marijuana legalization. The hope is that cannabis combined with opioid medication will produce equal analgesia at lower opioid doses, thus reducing the risks associated with opioid therapy.

But evidence in favor of the opioid-sparing effect is largely pre-clinical and often involves animals or healthy volunteers, not the real world conditions that pain patients live with.

A recent study on rhesus monkeys, for example, at the University of Texas found that combining cannabinoids with morphine did not significantly increase the impulsivity or memory impairment of the monkeys.

A 2018 study by Ziva Cooper and colleagues on healthy cannabis smokers concluded that cannabis enhances the analgesic effect of oxycodone, suggesting there is a synergy between the two.

And a 2017 systematic review of over two dozen studies in the journal Neuropsychopharmacology reported “robust evidence of the opioid-sparing effect of cannabinoids.”

But evidence against the opioid-sparing effect of cannabis is mounting, based on clinical findings in real-world chronic pain patients.

Andrew Rogers of the University of Houston reported at the 2019 American Pain Society Scientific Meeting that chronic pain patients who used both prescription opioids and recreational marijuana showed higher levels of anxiety, depression and substance abuse problems than those who used opioids alone. There was no difference between the two groups in pain levels.

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"The things psychologists would be most worried about were worse, but the thing patients were using the cannabis to hopefully help with — namely pain — was no different,” Rogers told MedPageToday. "Co-use of substances generally leads to worse outcomes. As you pour on more substances to regulate anxiety and depression, symptoms can go up."

A large Australian study in The Lancet Public Health found that cannabis use was common in patients with chronic non-cancer pain who were prescribed opioids, but “there was no evidence that cannabis use reduced pain severity or interference or exerted an opioid-sparing effect.”

This research, known as the Australia POINT study, followed over 1,500 chronic pain patients for almost four years. Although its methodology has limitations, it is one of the largest long-term studies of opioids and cannabis under real-world conditions.

“At each assessment, participants who were using cannabis reported greater pain and anxiety, were coping less well with their pain, and reported that pain was interfering more in their life, compared to those not using cannabis,” said lead author Gabrielle Campbell, PhD, of the University of New South Wales.

In other words, the opioid-sparing effect of cannabis seems not to work well in the real world, despite its apparent success under laboratory conditions. There are several possible factors at work.

First, laboratory conditions are artificial. Studies often use lab animals or healthy human volunteers. But people with chronic health conditions may be different. Or perhaps people who are experienced with cannabis and willing to spend a day in a laboratory being subjected to painful stimuli are different.

Second, laboratory studies are often short term, but chronic pain is long term. The cumulative risks of opioids and cannabis, as well as the complex interactions between them, may take time to unfold and discover. It is possible that an initial opioid-sparing benefit washes away quickly and is replaced by nontrivial risks.

Third, real-world studies emphasize patient outcomes, a factor that laboratory work cannot assess. Because outcomes are so important, studies that focus on them must be given greater weight. 

More research will be needed to sort out the effects of combining cannabis and opioids in chronic pain management. But at present, clinical studies point to more risks and harms than benefits. Perhaps a subset of patients or a particular combination of a specific opioid and cannabis preparation will change this. Or perhaps combining cannabis and opioids is not such a great idea. 

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Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

CVS Begins Selling Cannabis Products

By Pat Anson, PNN Editor

You may not be able to get your opioid prescription filled at a CVS pharmacy, but you can stock up on medical marijuana. The nation’s largest drug store chain has begun selling cannabis-based products in eight states, despite lingering concerns about their effectiveness and legal status.

The move was announced by cannabis retailer Curaleaf Holdings, which carries a line of cannabis lotions, tinctures, edibles and lozenges that CVS started carrying in its stores last week. The CBD products are being sold over-the-counter without a prescription.

(Update: Walgreens has also announced plans to sell CBD products in 1,500 of its stores.)

CBD stands for cannabidiol, a chemical compound in marijuana that does not produce euphoria but is believed to reduce symptoms of chronic pain and other health conditions.  

“We have partnered with CBD product manufacturers that are complying with applicable laws and that meet CVS’s high standards for quality,” a CVS spokesman said in an email to MarketWatch.  

CVS said that it was selling CBD products in Alabama, California, Colorado, Illinois, Indiana, Kentucky, Maryland and Tennessee. Curaleaf executives said CVS would eventually carry its products in 800 stores in ten states.

“We’re going to walk slowly, but this is something we think our customers will be looking for,” CVS Health CEO Larry Merlo told CNBC.

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‘Treated Like Criminal’ at CVS

The move is somewhat puzzling for CVS, which was one of the first pharmacy chains to crackdown on opioid prescriptions due to concerns about addiction and overdose. In 2017, CVS began restricting initial opioid prescriptions to 7 days’ supply and aligned its polices with the CDC opioid guideline.

Pain sufferers now complain they’re treated like drug addicts by CVS pharmacists.

“I submit to monthly drug tests and do everything I am supposed to do and I am treated like a criminal at the doctor and CVS pharmacy. My two pills a day barely touches the pain, but I need to work,” one patient recently told us.

“Some pharmacies, such as CVS, have taken it upon themselves to deny my prescriptions that I have been having filled there for 15 years. They first took it upon themselves to adjust my dosage. I didn’t realize that pharmacist were allowed to change a prescription,” said another patient.

“Why does CVS, a drug store that sells NSAIDs without restriction, have control of how I treat my patient?” asked one practitioner.

Although most Americans now support the use of medical marijuana and it is legal in dozens of states, the safety, effectiveness and legality of CBD is still very much up in the air.  Marijuana remains classified as a Schedule I controlled substance by the DEA, alongside heroin and LSD.

“Societies have jumped far, far ahead of science,” Dr. Margaret Haney, a professor of neurobiology at Columbia University Medical Center, told NBC News. “So it’s showing up in lotions and pretty much any form of product one can use. There’s a lot of different ways one could use CBD, but the ways we have studied CBD is much more limited.”

According to MarketWatch, Curaleaf only list its shares on the Canadian Securities Exchange because major exchanges in the U.S. and Canada will not list shares of marijuana companies due to their hazy legal status.

Study: THC More Effective Than CBD in Treating Pain

By Pat Anson, PNN Editor

The psychoactive ingredient in marijuana -- tetrahydrocannabinol (THC) – is more effective than cannabidiol (CBD) in treating chronic pain and other medical conditions, according to a new study that challenges the widespread belief that THC is harmful and has limited value in medical cannabis products.

Researchers at the University of New Mexico used the Releaf App, a mobile software program, to analyze self-reported data from over 3,300 people who logged their responses in nearly 20,000 user sessions to a variety of cannabis products, including natural dried flower, edibles, tinctures and ointments.

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Dried flower was the most commonly used product and was generally associated with greater pain relief than other cannabis products, regardless of the amount of THC.

"Despite the conventional wisdom, both in the popular press and much of the scientific community that only CBD has medical benefits while THC merely makes one high, our results suggest that THC may be more important than CBD in generating therapeutic benefits,” said Jacob Miguel Vigil, PhD, a professor in UNM’s Department of Psychology.

“In our study, CBD appears to have little effect at all, while THC generates measurable improvements in symptom relief. These findings justify the immediate de-scheduling of all types of cannabis, in addition to hemp, so that cannabis with THC can be more widely accessible for pharmaceutical use by the general public.”

Hemp is a strain of marijuana that was legalized by Congress in the 2018 Farm Bill. It has very low levels of THC, but is being grown commercially as a source for CBD.

UNM researchers found that indica strains of cannabis were more effective than sativa strains in treating pain and insomnia. Both strains have substantially higher levels of THC than hemp, but are illegal Schedule I controlled substances under federal law.

“Only THC potency levels showed independent associations with symptom relief and experiences of both positive and negative side effects, with higher levels (of THC) resulting in larger effects,” Vigil said.

Researchers say the relative weakness of CBD in treating symptoms may be due to inaccurate labeling of CBD content in cannabis products, which is a widespread industry problem. It’s also possible that THC simply heightens the experience or awareness of symptom relief.

Vigil published his findings in the journal Scientific Reports. Three of his co-authors developed the Releaf App, which has collected information from cannabis users since 2016. The app is an important data source for researchers, who are currently limited in conducting clinical studies of cannabis because of federal regulations.

Two previous studies by Vigil using data from the Releaf App found that cannabis provides significant relief from a wide range of symptoms associated with chronic pain, including insomnia, seizures, depression, anxiety and fatigue.

CBD Is Now Regulated and That May Be a Good Thing

By Roger Chriss, PNN Columnist

The legal status of cannabidiol (CBD) is changing. Once classified exclusively as a Schedule I drug under the Controlled Substances Act, CBD is now legal under federal law. And this means regulation.

The 2018 Farm Bill removed hemp from Schedule I. Hemp is a strain of marijuana with very low levels of THC, but high amounts of CBD.  This has opened the door to a legal market for CBD products, including food and supplements. But there’s a catch. The FDA has strict regulations about CBD being used in dietary supplements or promoted as medical treatments.

“It’s unlawful under the FD&C Act (Federal Food, Drug, and Cosmetic Act) to introduce food containing added CBD or THC into interstate commerce, or to market CBD or THC products as, or in, dietary supplements, regardless of whether the substances are hemp-derived,” FDA commissioner Scott Gottlieb, MD, said in a December 2018 statement.

“Among other things, the FDA requires a cannabis product (hemp-derived or otherwise) that is marketed with a claim of therapeutic benefit, or with any other disease claim, to be approved by the FDA for its intended use before it may be introduced into interstate commerce. This is the same standard to which we hold any product marketed as a drug for human or animal use.”

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 The FDA has a FAQ page about cannabis that answers some basic questions:

"Can products that contain THC or cannabidiol (CBD) be sold as dietary supplements? A. No."

"Is it legal, in interstate commerce, to sell a food to which THC or CBD has been added? A. No."

The FDA has reason to be concerned. Product quality for CBD products is iffy at best. An investigation by the NBC affiliate in Miami (see “Patients Are Being Duped”) found that 20 of 35 CBD products tested had less than half the amount of CBD advertised on the label. Some samples had no CBD at all.

Other recent analyses have found THC, pesticides, synthetic cannabinoids and toxic solvents in CBD products.

Moreover, a lack of regulatory oversight has led to an abundance of false, misleading or unsubstantiated claims. A recent review of CBD in the Journal of Clinical Pharmacology found that “CBD has been touted for many ailments for which it has not been studied, and in those diseases with evaluable human data, it generally has weak or very weak evidence.”

There is a lot of research on CBD going back years. The FDA’s approval of the CBD-based drug Epidiolex for rare childhood seizure disorders and a 2018 review that found potential for treating multiple sclerosis symptoms are important indicators of CBD’s medical value. At the same time, researchers have found no benefit in treating spinal cord injury, Crohn’s disease and osteoarthritis.

Yet CBD is now being widely promoted as a wellness product, and added to everything from coffee and pastries to bath oils and mascara. So it is not surprising that the FDA is concerned that people may be duped or put at risk.

The FDA is not alone in this. The New York City Department of Health has banned CBD products from being sold in bars and restaurants. Maine, New York, and Ohio are also banning CBD edibles.

For medically complicated people with chronic illness, regulation could be beneficial. At present these patients face significant risks with CBD products. Tainted CBD may cause unexpected allergic reactions or drug interactions. And contaminated CBD could trigger a positive result on a urine drug test, a common part of pain management amid the opioid crisis. Regulatory oversight could help reduce these risks. 

The legal and regulatory landscape surrounding CBD is shifting quickly. The FDA and state government agencies are watching closely and starting to intervene. This may flush out bad actors in the CBD marketplace and improve product quality and reliability. A stable marketplace with reliable products may be a net gain for the people who stand to benefit the most from CBD.

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Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

‘Cannabis Tourism’ Linked to More Fatal Accidents

By Pat Anson, PNN Editor

Has marijuana legalization made driving more dangerous?  There have been conflicting claims over the years that states where cannabis is legal have more car crashes. And one recent study found that over half of medical cannabis users drive while impaired.

A new study adds a little more clarity to the issue.

Researchers at Monash University in Australia looked at traffic fatalities in three U.S. states where recreational cannabis was legalized (Colorado, Washington and Oregon), and in eight neighboring states and British Columbia.

They found there was an average of one additional traffic fatality for every million residents. That may not sound like much, but when you consider there were 27 million people in the affected areas, it adds up to 170 additional deaths in the first six months after legalization.

Many of the additional deaths were attributed to “cannabis tourism” in which people in neighboring states and provinces purchased recreational cannabis in legalized states and then drove home while under the influence.

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"The results suggest that legalizing the sale of cannabis for recreational use can lead to a temporary increase in traffic fatalities in legalizing states. This spills over into neighboring jurisdictions through cross-border sales, trafficking, or cannabis tourists driving back to their state of residence while impaired,” says lead author Tyler Lane, PhD, a postdoctoral research Fellow at Monash.

"Our findings suggest that policymakers should consult with neighboring jurisdictions when liberalizing cannabis policy to mitigate any deleterious effects."

Because the increase in fatalities was temporary, Lane believes it could be due to an initial “celebratory response to legalization” that contributes to cannabis tourism. His study was published in the journal Addiction.

Fatalities Drop in Medical Cannabis States

While fatalities rose in states with recreational cannabis, Lane notes that previous research has found a decrease in traffic fatalities in states that legalized medical marijuana. That may be because patients may be substituting cannabis for alcohol and other controlled substances used to relieve symptoms.

“There seem to be differences between medicinal and recreational user consumption patterns. Medicinal users have a tendency to substitute, but recreational users are more likely to treat alcohol and cannabis as complements and use them together,” Lane said in an email to PNN. 

“Because marijuana on its own is less impairing than alcohol, and combined used is much more impairing than either in isolation, it suggests that when people substitute alcohol for cannabis (in the medicinal use context), they will still be impaired, but to a much lower degree than if they were still using alcohol.” 

This “harm reduction role” of medical cannabis was noted in a 2016 Canadian study that found patients reduced their use of alcohol, illicit drugs and prescription drugs when cannabis was taken for medical reasons. 

Medical marijuana is currently legal in 33 states and Washington DC, and ten states allow its recreational use.

What Should You ‘Tell Your Children’ About Marijuana?

By Roger Chriss, PNN Columnist

Depending on your point of view, the new book “Tell Your Children: The Truth About Marijuana, Mental Illness, and Violence” is either a welcome cautionary tale about cannabis or a reincarnation of the infamous movie Reefer Madness.

Author Alex Berenson, a novelist and former reporter for The New York Times, is clearly no fan of cannabis legalization and the growing hype over its medical use.  

“Marijuana is not medicine. Marijuana and THC-extract products — whether eaten or smoked — are intoxicants and mild pain relievers, like alcohol,” he writes. “Marijuana in the United States has become increasingly dangerous to mental health in the last fifteen years, as millions more people consume higher-potency cannabis more frequently.”

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Berenson argues that cannabis causes paranoia and psychosis, with more use leading to greater mental health issues and even violence.

He uses a combination of history and statistics as evidence, often with lurid reporting about cannabis and violent crime in the U.S. and Britain from over a century ago. Berenson describes incidents of psychotic breaks, murderous episodes, and heinous acts of violence that read a bit too much like true crime stories.

“Marijuana causes paranoia and psychosis. Psychosis causes violence. The obvious implication is that marijuana causes violence,” he writes, without offering any evidence linking the two.

Berenson then gives a brief history on the promotion of cannabis in the modern era by groups such as NORML, the Drug Policy Alliance and the magazine High Times. He emphasizes that the cannabis of the 1960s and ‘70s was “near beer” compared to the cannabis of today.

Berenson builds his case on the work of Swedish physician Sven Andréasson, who in the 1980s used data from the Swedish military draft to investigate the connection between cannabis and schizophrenia. Andréasson found that the use of cannabis was strongly correlated with schizophrenia and that the risk was dose-related.

To bolster his argument, Berenson draws on the work of Phil Silva in the Dunedin Multidisciplinary Health and Development Study; Robin Murray at the Institute of Psychiatry in London; and the 2017 National Academies report on cannabis.

The cannabis-schizophrenia connection has been overlooked, in part because of limited data. In Washington state, for example, where recreational cannabis was legalized in 2014, the state health department doesn’t even keep track of schizophrenia cases.

Berenson says legalizing cannabis for medical use is a cagey strategy to protect recreational users and gain public support for full legalization, because it “encourages voters to think of marijuana as something other than an intoxicant.”

“Medical marijuana is a way of protecting a subset of society from arrest,” he wrote, adding that “marijuana simply wasn’t a strong enough painkiller to be effective for most people who truly needed opiates.”

He even suggests cannabis legalization may be exacerbating the opioid crisis.

“What’s gone unnoticed in the discussion over state-by-state changes is the striking correlation between the opiate epidemic and cannabis use at the national level,” he said. “The direct economic benefits of legalization also appear to be vastly overrated.”

Berenson concludes with an ironic argument for more research: “The government should drop its barriers to researching cannabis for medical purposes. The reason is not that marijuana is likely to prove a miracle cure for cancer — or anything else. It’s precisely the opposite. Let’s put unfounded claims to rest, permanently.”

There are reasons to be skeptical of Berenson’s conclusions. He points to a lack of data on trends in serious mental illness as hiding the impact of cannabis on schizophrenia rates. But the lack of data means we don’t really know what is happening. Trends are further obscured by changes in diagnostic criteria, reporting requirements and treatment availability. All of this needs to be carefully teased out in regard to cannabis as a factor in schizophrenia.

Similarly, Berenson recognizes that no research proves cannabis causes psychosis and violence. He points out that such research is not ethically acceptable. But there are other ways to establish causation, including prospective longitudinal studies and natural social experiments such as Canadian legalization. In other words, Berenson may be able to claim he is right some day, but not yet.

Lastly, Berenson ignores the issue of scale. Even if the psychotic breaks and criminal acts he describes are attributable to cannabis, they are still very rare compared to the scale of cannabis use. He needs to establish a base rate and then show that increasing levels of cannabis use are associated with rising rates of psychosis and violent crime. That work remains to be done.

“Tell Your Children” is useful but could have been better. Berenson overreaches in his conclusions and omits important considerations. But he raises relevant questions about the potential mental health risks and social implications of cannabis. “Tell Your Children” may not be essential reading, but for people who are interested in the possible risks of cannabis, it is certainly worth reading.

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Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Survey: Most Medical Cannabis Users Drive While High

By Pat Anson, PNN Editor, and Shefali Luthra, Kaiser Health News

With medical marijuana now legal in nearly three dozen states – and ten allowing its recreational use – state governments face two difficult questions: Are more people driving under the influence of marijuana? And at what point are they too impaired to drive?

The answer to the first question is troubling and the second one is elusive. 

According to a new survey, over half the people who take medical cannabis for chronic pain say they've driven under the influence of cannabis within two hours of using it.  And one in five say they've driven while “very high.”

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Researchers at the University of Michigan Addiction Center surveyed 790 Michigan adults who sought medical cannabis certification for chronic pain in 2014 and 2015. The researchers asked about their driving habits over the past six months.

Fifty-six percent reported driving within two hours of using cannabis, 51% said they drove while a "little high" and 21% reported driving while "very high."

"We want people to know that they should ideally wait several hours to operate a vehicle after using cannabis, regardless of whether it is for medical use or not," said Erin Bonar, PhD, a psychiatry professor, clinical psychologist and lead author of the study published in the journal Drug & Alcohol Dependence. "The safest strategy is to not drive at all on the day you used marijuana."

The survey found that patients with higher pain levels were less likely to to drive while impaired. But Bonar says the overall risk of impairment could be higher for chronic pain patients who use medical marijuana daily and have trace amounts of tetrahydrocannabinol (THC) lingering in their system. THC is marijuana’s main psychoactive ingredient.

"When it comes to driving, we haven't yet figured out the best way to know how impaired marijuana users are at any given time," she says. “It's hard to quantify because there is a lot of variation in marijuana dosing, THC potency, and route of administration. We also don't have specific guidelines yet about when exactly it would be safe to operate a vehicle.

"We also need clearer guidelines about marijuana dosing and side effects with an understanding of how individual differences in things like sex and body weight interact as well."

The study was funded by the National Institute on Drug Abuse.

Measuring Impairment

Brain scientists, pharmacologists and law enforcement are still learning how measure if and to what extent marijuana causes impairment.

Blood and urine tests can detect marijuana use, but because traces of the drug stay in the human body for a long time, those tests can’t specify whether the use occurred earlier that day or that month. They also don’t indicate the level at which a driver would be considered under the influence.

“It’s a really hard problem,” said Keith Humphreys, PhD, a psychiatry professor and drug policy expert at Stanford University in California, the first state to legalize medical marijuana and where recreational cannabis use among adults became legal in 2016. “We don’t really have good evidence — even if we know someone has been using — what their level of impairment is.”

For alcohol, there is a clear, national standard for impairment. If your blood alcohol content is 0.08 percent or higher, you’re considered cognitively impaired at a level that is unsafe to drive.

Extensive research supports this determination, and the clarity makes enforcement of drunk driving laws easier.

Setting a marijuana-related impairment level is a murkier proposition. And states that have legalized cannabis have to figure it out, experts said.

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“You can’t legalize a substance and not have a coherent policy for controlling driving under the influence of that substance,” said Steven Davenport, an assistant policy researcher at the nonprofit Rand Corp., who specializes in marijuana research.

With marijuana going mainstream around the country, regulators are “playing catch-up,” according to Thomas Marcotte, a psychiatry professor at the University of California-San Diego and one of a number of academics who is researching driving while high.

States have put forth a bevy of approaches. At least five outlaw driving if someone’s blood level of THC exceeds a certain amount. Colorado, where voters approved recreational marijuana in 2012, has this type of driving law on the books. But it took three years to pass amid fiery debate and deems “intoxicated” any driver who tests higher than 5 nanograms of THC per milliliter of blood.

Rhode Island, Pennsylvania and Indiana are among states that forbid driving at any THC level.

Still others say drivers should be penalized only if they are impaired by THC -- a standard that sounds reasonable but quickly gets difficult to measure or even define.

None of these approaches offers an ideal solution, experts say. “We’re still definitely evaluating which policies are the most effective,” said Ann Kitch, who tracks the marijuana and driving issue for the National Conference of State Legislatures.

States that set a THC-level standard confront weak technology and limited science. THC testing is imprecise at best, since the chemical can stay in someone’s bloodstream for weeks after it was ingested. Someone could legally smoke a joint and still have THC appear in blood or urine samples long after the high passes.

There’s general agreement that driving while high is bad, but there’s no linear relationship between THC levels and the degree of impairment. States that have picked a number to reflect when THC in the bloodstream becomes a hazard have “made it up,” argued Humphreys.

“The ones who wrote [a number] into legislation felt they had to say something,” he said. But “we don’t know what would be the analogy. Is the legal amount [of THC] equal to a beer? Is that how impaired you are? Is it a six-pack?”

Roadside testing for THC is also logistically difficult. Blood and urine samples need to be collected by a medical professional and analyzed in a lab.

In Canada, where recreational cannabis was legalized last year, law enforcement will test drivers with a saliva test called the Dräger DrugTest 5000. But that isn’t perfect, either.

Some private companies are trying to develop a sort of breathalyzer for marijuana. But Jonathan Caulkins, a drug policy researcher at Carnegie Mellon University, said, “There are fundamental issues with the chemistry and pharmacokinetics. It’s really hard to have an objective, easy-to-administer roadside test.”

Until a reliable system is found, states are relying on law enforcement to make a subjective assessment of whether someone’s driving appears impaired by marijuana.

In California, every CHP officer learns to administer field sobriety tests — undergoing an extra 16 hours of training to recognize the influence of different drugs, including marijuana. Because medical marijuana has been legal there since 1996, officers are “very used” to recognizing its influence, says Glenn Glazer, the state’s coordinator for its drug recognition expert training program.

That kind of training is taking off in other states, too. Lobbying groups such as Mothers Against Drunk Driving are pushing for more law enforcement training to help officers assess whether a driver is impaired.

In the meantime, the public health threat is real. States with legalized cannabis appear to have more car crashes, though the relationship is muddled.

“This is going to be a headache of an issue for a decade,” Caulkins said.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

How Chronic Pain Led Me to Illegal Drugs

(Editor's note: This column was written by someone I've known for several years and consider a friend. The author is intelligent, college educated and works full time. They also have a progressive and incurable chronic pain condition. Like a growing number of pain patients who are undertreated or have lost access to pain care, my friend has turned to illegal drugs for pain relief. For obvious reasons, we are not disclosing the author's name.) 

For me, it started with borrowing a couple hydrocodone pills from my uncle, who’d just had surgery and didn’t finish his prescription.  

Technically illegal? Yes. Illegal illegal? Not really. That’s what I told myself.

I run out of pain pills early every month — because they are prescribed to take one every six hours and only last about three. So I was happy to have a few more to get through those last few days before my refill.  

I always need more though, because the pain is always there. So I started to swap pills with my cousin, who also has chronic pain.  “Here, take 10 of mine today,” I’d offer.  

Then a few days later, I’d go back with, “Okay, now I need to borrow some pills from you. Maybe just five to get me through until my next refill?”  

I know she would never consider those drug deals. She would never consider herself a dealer. She goes to church for goodness sake. 

Eventually, I started to pay a little cash for 5mg pills from a friend of a friend, because it seems only fair to give him something in return.

I guess that’s about as “drug deal” as drug deals get. Here is money for you in exchange for drugs for me. There’s no way to really argue that.   

But it still didn’t feel like a drug deal. He’s doing me a favor, so I’m doing him a favor. We’re working professionals. We’re not meeting in a dark alley. Nobody has a gun on them. We’re just helping each other.

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Then I started buying marijuana to see if it would help with the pain.  I felt like marijuana was easier to get than my monthly pain pill prescription. And as long as I had the money, I could get as much as I wanted.  

I bought it from an old high school friend, who has a quiet house in the country and always invites me over for dinner. It felt more like buying homemade jewelry than buying homemade drugs. And she’d send me home with marijuana edibles that didn’t seem all that different than any other muffins my friends would bake for me.  

Recreational marijuana isn’t legal where I live, but it is in a lot of other places, so it’s still easy to justify this one to myself. My state is just a little behind. We’ll catch up. And soon buying an eighth won’t be much different than buying a pack of cigarettes.  

The marijuana doesn’t help me much other than putting me to sleep, so I hardly ever buy it. But if it did work — if it helped anywhere close to the way hydrocodone does — I would become a regular customer.  

Since I didn’t like it or use that much, I ended up selling some leftover marijuana to a friend’s uncle. That’s about when I officially became a dealer myself, I suppose.  

And now, I’m regularly buying extra hydrocodone from the local drug dealer. I meet up with him in the alley behind his apartment. He does not make drug dealing look glamorous. He never has enough money for his phone bill, he always needs a ride, and I’m pretty sure he uses the money I give him to buy heroin.  

I tell myself that most people would do what I was doing if they were enduring the kind of daily, debilitating chronic pain that I have. It’s either this or suicide.  

I try to get my doctor to increase my prescription and hold my breath every time they drug test me. So far, I’ve always passed. And so far, my prescription has yet to last me until the end of the month.  

All these illegal drugs get expensive. $10 for one 10mg hydrocodone. You can whip through $300 a week easily. Hydrocodone is more expensive than heroin and even harder to get.  

Sometimes I wonder if I should just take the leap and buy $20 worth of heroin, which would be more potent than $400 worth of hydrocodone pills. I know where I can get it now, thanks to my new connections to the local dealer.  

But so far, I’ve resisted. Not worth the possible side effects. Not worth the hassle. And not worth the potential legal issues. If I buy hydrocodone, I can slip them into one of my pill bottles with a legitimate label and the cops would have a hard time proving they weren’t mine. Heroin is a little more difficult to hide. 

I know some heroin users and they aren’t like the ones in the movies. They aren’t shooting up in dark alleys. They’re doing it in the morning to combat chronic pain. They’re doing it so they can go to work. They’re doing it because their legitimate doctor cut them off. They’re doing it so they can live their lives.  

And that’s what I'm doing, too. I bought 10 hydrocodone this morning, because I needed something to get me through the work day. Without opioid pain medication, I wouldn’t even be able to check my emails.  

I don’t know what the solution is, but I do know that when you’re in pain, you’ll do anything to make it stop. And as long as the only way to make it stop comes down to buying illegal drugs or killing myself, I’ll keep choosing illegal drugs — and pray that it doesn’t lead to me accidentally killing myself.  

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.