Breaking down the myths about medicinal marijuana, an interview with Dr. Joseph M. Pierre

It has been portrayed as the most dangerous substance in the world (as if cocaine hasn’t been around for over a century, huh?), just as it has been praised to be the medicine of the era. The truth is, in spite of what people may say, this green leaf (which in my personal opinion, looks very cute) is neither the end of the world nor the miraculous cure to all of mankind’s diseases. However, it’s undeniable that cannabis does have effects that deserve to be studied by science in general and by medicine in particular, since it can not only be just a palliative for pain anymore, but an effective way to treat an illness.

Of course, this is not an encouragement for all the people reading to sit around waiting for 4:20. Marijuana’s effects, good or bad, are still relatively unexplored, and therefore it’s necessary to hope for more investigation, now that the stigma around it is not as strong as it was before.

So, the thing is, marijuana, in addition to be used for relaxation and recreational purposes, may have a positive impact in children who suffer from epileptic disorders. This has been going around for a while now, however, it’s safe to say not all the info is completely true, and it is no reason to start praising on marijuana.

Joseph M. Pierre, M.D., is a Health Sciences Clinical Professor in the Department of Psychiatry and Biobehavioral Sciences at UCLA, Associate Director of Residency Education, Semel Institute of Neuroscience, and VA Greater Los Angeles Healthcare System. He runs the blog Psych Unseen at Psychology Today, where he has been recently posting about these topics. And now he’s going to talk to us about it.

1) How has your work in neuropsychiatry led you to study the usage and effects of marijuana in children?

For the past 20 years, I’ve worked as a psychiatrist specializing in the treatment of schizophrenia and other psychotic disorders with an interest in co-occurring substance use disorders and substance-induced psychotic disorders.  During this time, much has been learned about the potential negative impact of marijuana on psychotic symptoms -whereas marijuana was previously thought to have little potential to cause psychosis, research has now shown that cannabis as a risk factor for the development of psychosis and that increasingly potent forms of cannabis carry greater risk.

My Psych Unseen blog at Psychology Today is intended for general readers – a recent 3-part series called “A parent’s guide to modern marijuana” was written to provide parents with an update of new information regarding the effects of marijuana in children.

 2) Let’s begin by asking the question everyone wants to know: what are the risks and consequences (long term or short term) of marijuana’s consumption known to this day? Can marijuana cause addiction (physiological or psychological)?

There’s little question now that some people can develop
psychological and/or physiologic dependence on cannabis. It’s estimated that among regular users of cannabis, about 20% will become “addicted.” Beyond addiction and psychosis, we still have much to learn about psychiatric and medical consequences of marijuana use, but for people with existing mental health issues, there’s little to no evidence that using marijuana is a good idea. And of course, marijuana clearly causes cognitive impairment in the short-term -as one author put it, “that’s the primary reason for its use!” Being “high” might feel good, but it’s clear that using marijuana can impair performance when it matters, whether driving a car or taking a test.

3) What is THC and CBD? Would you explain where the phrase “today’s marijuana is not your parents marijuana” comes from?

Marijuana contains hundreds of “phytocannabinoids,” or chemical compounds unique to the plant. The two most prevalent and well-understood are delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is generally thought to be responsible for the euphoric properties (the “high”) associated with using marijuana and also appears to be responsible for marijuana’s analgesic potential (the ability to decrease pain).  Cannabidiol may have a variety of health benefits, but in comparison to THC is usually contained in only very small amounts within marijuana used for recreational purposes.

The phrase “not your parents’ marijuana” refers to the fact that the THC content of marijuana purchased “on the street” or in medical marijuana dispensaries in states where it is legal contains on average about 5-10 times as much THC as did marijuana sold in the 1970s and 1980s. This significant increase in “potency” has been a consumer-driven change giving users a more intense high and “more bang for their buck,” but the availability of high-potency cannabis has generated concerns about an increased risk of potential side effects and health risks.

4) What is “spice”?

Starting in around the 1970s, researchers have been trying to understand what marijuana does inside the human body and brain. That understanding was furthered by the laboratory development of “synthetic cannabinoids” that interact with the “endocannabinoid” system in the human body.  About a decade ago, some of these synthetic cannabinoids began to find their way into herbal products that were marketed as alternatives to cannabis sold under brand names like “Spice.”

With widespread availability of these products, particularly among young people in search of a “legal high,” reports began to emerge of users developing serious health problems requiring emergency room (ER) care. Some of the more common problems have been agitation, aggression, psychosis, nausea and vomiting, a rapid heartbeat, and seizures.

Although it is now illegal to sell or purchase the synthetic cannabinoids found in Spice products based on these health concerns, there are hundreds of synthetic cannabinoids and new ones keep appearing that continue to thwart efforts to legislate them out of existence.

5) Does the higher concentration of THC increase the risks of smoking marijuana? 

Although much remains to be learned about the effects of increasing cannabis potency (defined by its THC content), the available evidence does suggest that it increases the risk of addiction, psychosis, cognitive impairment, and structural brain changes in the brain.  While it’s possible to decrease the amount of cannabis one uses in order to compensate for increasing potency, it appears that most people don’t adequately adjust the dose resulting in more THC consumption overall. This is analogous to the increased amount of alcohol in hard liquor compared to beer where the former is often specifically used to get more drunk.

6) Following this, how come “marijuana” has been acknowledged to work as a treatment for epileptic disorders?

To be clear, there’s little to no evidence that marijuana itself is a treatment for epilepsy and some evidence suggests that THC might worsen or cause seizures. In contrast, there’s mounting evidence that cannabidiol (CBD) may have the ability to help with very severe and difficult-to-treat seizure disorders in children. As a result, some states have legalized the use of high-CBD marijuana products (usually sold as “CBD oil”) for children with epilepsy.

7) What is Epidiolex, and how is it different from other high-CBD products?

Epidiolex is a pure-CBD medication made by GW Pharmaceuticals that has been granted “orphan drug” status by the FDA, meaning that it has not yet been approved, but is available within designated treatment centers to children with treatment resistant epilepsy. As a pharmaceutical grade product, Epidiolex is a reliably pure form of cannabidiol -in contrast, cannabis and high-CBD products sold in dispensaries or as dietary supplements are not subject to the same purification standards and have been found to have unreliable quantities of THC and CBD.

8) Since caregiver’s statements may not be exactly accurate, it has been said that the effectiveness of using high-CBD products may be more of a placebo than an actual treatment. Would you care to elaborate?

Reports by parents and other caregivers about improvements in seizure frequency when taking CBD products has not been well-correlated with objective evidence of seizure activity as measured by electroencephalogram (EEG). It therefore appears that such reports are subject to placebo effects (reports biased by the hope of a response as opposed to a true response). As a result, caregiver reports must be taken with a grain of salt and do not represent the kind of objectively reliable outcome data that is required in clinical trials for medications.

9) Beyond caregiver’s statements, is there any evidence to support this kind of treatment?

Just this past month, a “double-blind placebo controlled trial” was published comparing Epidiolex to placebo in children with Dravet syndrome, a very severe and potentially lethal form of childhood epilepsy.  In that trial, children treated with Epidiolex had significantly fewer caregiver-reported seizures than did those treated with placebo. This study therefore provides important evidence that CBD may represent a breakthrough in the treatment of some forms of treatment-resistant childhood epilepsy.

10) Has Epidiolex proven not to be a placebo, however?

Without objective EEG findings, it remains possible that some of the observed benefits from Epidiolex might represent a placebo effect. However, because Epidiolex was compared to placebo under blinded conditions (meaning that parents/caregivers were not aware whether their children were being treated with Epidiolex or placebo), we can be confident that the observed reductions in seizure frequency beyond those observed on placebo were specific to medication treatment.

11) Has there been any side effects of using this new drug?

Sedation/somnolence, diarrhea, and loss of appetite were the most commonly reported side effect of Epidiolex.

12) It’s clear that there’s a lot more research to do, and that it’s way too early to jump into conclusions. Nonetheless, do you have any advice for those parents considering the use of a cannabinoid based treatment?

It’s important to avoid jumping to the conclusion that the encouraging results of a small study in children with a specific form of treatment-resistant epilepsy can be extended to other kinds of seizure disorders. It may be, for example, that the benefit of CBD in seizure disorders is restricted to Dravet syndrome or other very rare forms of epilepsy.

Many of the more common seizure disorders do respond well to FDA-approved medications. Therefore, those medications should remain “first line” treatments under the care of a doctor, with children who do not respond well to conventional therapies referred to specialty care. Research with Epidiolex in other forms of epilepsy is ongoing and some children might be eligible to participate in a clinical trial with their parents’ consent.

As for other cannabis or cannabinoid use in children with seizure disorders, this is not something a responsible physician can recommend in the absence of better data regarding efficacy and safety and without reason to be confident in the labeling of available products with regard to their THC and CBD content. Although pro-marijuana supporters like to tout the health benefits of cannabis as a natural product and based on the “entourage effect” (which suggests that the many different phytocannabinoids in cannabis all contribute to therapeutic effects), there’s no evidence to support those claims and sufficient cause for concern. Just because

the FDA -approved medication digoxin has been shown to be effective for heart failure doesn’t mean that people should be smoking foxglove joints or eating nightshade brownies- in fact, that’s a very bad idea.