A drive down I-35 and I-70 just before the midterm elections in November 2018 showed me that change was coming. Billboards for two different CBD oil dispensaries and two separate medical marijuana bills greeted me during my morning commute. With the passage of Amendment 2 legalizing medical marijuana in Missouri and with the Hemp Farming Act of 2018 set to legalize CBD oil nationally, now is a good time to review both the legal status and medical risks and benefits of marijuana, CBD, and similar products.
What’s the difference between marijuana and hemp?
Marijuana and hemp are actually two different varieties of the same plant species called Cannabis sativa. Just like dachshunds and greyhounds are both from the Canis species but were bred for different leg lengths, marijuana and hemp were also bred to emphasize different properties. Marijuana plants are cultivated for their flowers and THC content, while hemp is typically grown for its fibers and oils (and more recently, for its CBD content).
But wait, what are THC and CBD?
- THC (tetrahydrocannabinol) is the psychoactive compound found in cannabis plants that causes the ‘high’ that users associate with marijuana. For a plant or plant product to be defined as hemp (and not marijuana) the THC concentration has to be less than 0.3%.
- CBD (cannabidiol) is another chemical found in cannabis plants that has found use as a treatment for certain seizure disorders in children and has been suggested as a treatment for chronic pain and several other chronic conditions.
So what is the legal status of CBD and medical marijuana in Missouri?
Simply put, possession and use of marijuana for recreational purposes remains illegal.- CBD oil is currently in an a legal no-man’s-land in Missouri.
- Hemp production is legal in several states, but law enforcement interference in the transport between states and sale was essentially restricted by Congress in 2016 (The pending 2018 farm bill is expected to formally legalize hemp production nationally.)
- Amendment 2 legalized medical marijuana use in Missouri in several forms (such as capsules, oils, smoking, ointments, patches, or edible products) under supervision of a physician for a “qualifying medical condition.” That definition under the law is very broad.
A “qualifying medical condition” includes:
- Cancer
- Epilepsy
- Glaucoma
- Intractible migraines
- A chronic medical condition causing persistent pain or muscle spasms (such as Multiple sclerosis, Parkinson’s)
- Debilitating psychiatric disorders including PTSD (needs diagnosis by psychiatrist)
- HIV/AIDS
- A chronic medical condition that is normally treated with a prescription medication that could lead to physical or psychological dependence, when a physician determines that medical use of marijuana could be effective in treating that condition and would serve as a safer alternative to the prescription medication
- Any terminal illness [aka end-stage or incurable disease]
- In the professional judgment of a physician, any other chronic, debilitating or other medical condition, including, but not limited to, hepatitis C, amyotrophic lateral sclerosis, inflammatory bowel disease, Crohn’s disease, Huntington’s disease, autism, neuropathies, sickle cell anemia, agitation of Alzheimer’s disease, cachexia, and wasting syndrome.
As you can see, that leaves a lot of leeway for interpretation by a physician. Some might feel comfortable prescribing it for pain or other chronic illnesses, but others might leave that prescribing up to the specialist managing their patient’s condition (such as a neurologist managing epilepsy or Parkinson’s or their cancer doctor managing their cancer pain). Furthermore, with the availability of a few prescription medications that mimic the effects of CBD or THC and allow controlled dosing, some physicians might be more comfortable using a product with standardized and consistent dosing and FDA approval.
So what is the evidence for treatment with CBD and marijuana and what prescription alternatives exist?
Headlines such as “Research Shows CBD Benefits 50+ Conditions” are difficult to ignore. However, a closer look at many of the medical conditions listed show only a few studies performed on rats or mice or cells on petri dishes – not enough evidence to make any conclusions on how CBD treatment will affect humans. Other studies don’t include a placebo group or have a very small amount of people in the study which limit how useful the results are. A few areas that actually have been studied in-depth are seizures, nausea and poor appetite in cancer patients, and chronic pain.
Seizures (specifically the rare conditions Dravet Syndrome and Lennox Gastaut Syndrome) are one area in which CBD has been shown to provide some benefit. In fact, it has shown enough benefit for the FDA to approve cannabidiol for the treatment of this and a prescription form of CBD (Epidolex) has been approved. However, experts still recommend further research to determine the long-term side effects of this treatment and Epidolex/CBD is not recommended as a first-line treatment.
Marijuana and synthetic THC have also been evaluated as a treatment for nausea associated with chemotherapy as well as with poor appetite and weight loss associated with cancer or chronic disease. Two synthetic forms of THC (nabilone and dronabinol) have FDA approval for use in certain patient populations. Although these medications have been shown to have benefit similar to other anti-nausea medications, there is an increased risk of adverse events when compared to traditional anti-nausea medications. While dronabinol has been shown to help with weight loss associated with AIDS, studies show that both synthetic THC medications are less effective than another appetite stimulant (Megace) or placebo in cancer patients.
Some weak evidence exists that smoked or ingested cannabis can help with chronic neuropathic pain, although studies have yet to show evidence that this helps with other types of chronic pain. The use of cannabinoids wasn’t shown to provide a significant benefit over placebo in treating disease progression in multiple sclerosis but did show a small benefit in muscle stiffness and very small benefits in treating spasticity and pain.
What risks are associated with marijuana or CBD treatment?
Although there is evidence of benefit from marijuana or CBD in some conditions, any benefits need to be weighed against the risks of treatment.
- Short-term side effects of smoked marijuana include dizziness, dry mouth, paranoia, hallucination, and sleepiness.
- Long-term marijuana smoking is associated with cough, wheezing, and increased mucus production.
- The most common side effect of CBD is drowsiness, with fever, decreased appetite, diarrhea, vomiting, and elevation of the liver markers AST and ALT also reported.
- A potentially dangerous side-effect of CBD is how it interferes with the body’s enzymes that process certain medications, especially anti-seizure medications.
- For example, some children on anti-seizure medications given CBD in a research trial were found to have higher levels of the seizure medicine in their blood (despite no change in their dose of medicine) and more side effects from their medicine.
It is important to let your doctor know if you are taking CBD as it could require adjustment of medication doses or closer monitoring.
What do we know about cannabis use in kids?
The effects of marijuana on children’s developing brains are also very important to consider when discussing treatment with marijuana or CBD products.
- Regular cannabis use during the teenage years is associated with a lower IQ in adulthood.
- Some studies show a link between increased risk of psychosis or depression in teenage marijuana users.
- MRI scans of the brains of people who used marijuana regularly in the teen years show decreased brain volume in the parts of the brain responsible for memory, motivation, and emotional processing.
These findings show that the long-term risks of marijuana use in children need to be weighed against the possible benefits of that treatment (and also compared to risks and benefits of different treatments as well).
What does the passage of Missouri Amendment 2 mean for me?
Legalized medical marijuana is coming to Missouri, although the rollout will take several months to set up state-approved distributors and to finalize rules and regulations. This new law gives physicians much leeway in terms of which conditions they can recommend the use of medical marijuana for, but science is lagging behind the law.
There’s little to no quality scientific evidence of benefit for many of the conditions medical marijuana can be prescribed for. Similarly, there is little to no quality scientific evidence that CBD benefits many of the diseases that it is claimed to treat. Even in diseases in which CBD and marijuana have been more closely studied, often the studies don’t show much benefit compared to existing treatments, and medical marijuana and CBD are not recommended as first-line treatments.
It will be interesting to see what knowledge is gained in the coming years, but in the meantime, we must carefully consider the risks and benefits of CBD and marijuana and remain skeptical of many of the claimed benefits for certain diseases until more research is performed.
Additional Resources
- Here’s a series that provides a good overview on the scientific evidence on medical marijuana.
- An interesting, skeptical take on the lack of current evidence for CBD/marijuana as treatment for autism.
- One 60 person study was completed but without control group. The follow-up study with control group should be completed sometime in 2019.
- finance.yahoo.com article
- projectcbd.org article
- kansascity.com politics/government article
- kansascity.com health/fitness article
- globenewswire.com article
- cannabusiness.law article
- medium.com article