What type of shields are the cannabis industry using to protect the public when dueling with a two-headed dragon? On one hand, patients seeking to address serious medical symptoms require an attentive understanding of product information while adult-use consumers have a more casual, but increasingly educated relationship with cannabis. We’ve talked about education and intent, but viewing cannabis from a policy maker’s perspective is incredibly difficult.
Mimicking the pharmaceutical industry is the easiest place to start when we hear the word “medicine” but cannabinoids like THC and CBD participate in a unique biological network known as the endocannabinoid system (ECS). The ECS affects every single bodily function from eating to memory to reproduction and is still not fully understood due to barriers of research. Schedule I substances are incredibly difficult to study, and research has not been able to stay on par with the flourishing availability of cannabis products nationwide. What types of measures can policy makers enact to ensure access to cannabis products are safe for both medical and adult-use populations?
The lowest hanging fruit would be to place potency caps on products to prevent negative unintended side effects, right? Not necessarily!
Pharmacokinetics, or how a drug interacts with the body, play an important role in understanding why cannabis must be treated as a distinctive form of healthcare. Pharmaceutical medications usually display a monophasic or linear dose-dependent response: if the dose is increased, the effects will increase as well. For example, patients taking opiates for pain or statins for cholesterol may find that when their target goals are not being met, the physician’s first reaction is to increase the dosage of the medication in hopes of increasing the efficacy.
Cannabinoid pharmacokinetics have displayed a biphasic dose response in experimental models and in clinical practice. This means that at some point, increasing the dose will not equate to a more effective response. In this randomized controlled trial, patients using 20mg of dronabinol (a semi-synthetic analog of THC) did not experience more pain relief than the group using 10mg in the same trial.
The difficult part of this conversation is that this “sweet spot” of an effective dose is unique to every single patient. In my experience servicing patients of the NJ Medical Marijuana Program, I’ve witnessed patients use 2.5mg of THC orally as well as another patient using 150+mg of THC inhaled as their respective base-line effective doses. Both of these patients had chronic pain listed as their qualifying condition.
The collision of cannabis and healthcare requires taking a bottom-up approach where patients must be diligent in their self-discovery of what product and potency works for their medical condition. Until health insurance companies begin covering medical cannabis products, patients will continue paying out of pocket for their medicine that can be extremely costly. Placing potency caps on products may lead to an additional financial burden for the patients that require a higher effective dose.
From a public health perspective, my opinion is that restricting product access or potencies will not correlate with reduced amounts of unintended side effects. Efforts should be focused on ensuring processors and manufacturers produce standardized, uniform labels prominently displaying both active and inert ingredients, precise concentrations and potencies, and clear serving sizes. Every single pharmaceutical medication sent to the pharmacy has a physical package insert containing this information as well as publicly available online. I believe having a centralized data base for cannabis products, where the public can access this information would be a great resource in building consumer confidence. To avoid potential issues with minors, packaging should be child-resistant and avoid imagery that might be seemingly attractive to that population. Lastly, dispensary staff should be required to undergo baseline training highlighting the importance of patient education, responsible cannabis consumption, as well as the technical ability to interpret and translate package labels into recommendations for their patients.
What other measures can be used to protect public health and ensure safety for both the medical community and adult-use consumers? Let’s continue the conversation.