Hosp Pharm 2014;49(4):319–320 2014 © Thomas Land Publishers, Inc. www.hospital-pharmacy.com doi: 10.1310/hpj4904-319

Editorial Legalization of Recreational and Medical Marijuana: What We Don’t Know Danial E. Baker, PharmD, FASHP, FASCP*

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s I sit here and read the latest report on smoking from the Surgeon General’s office, I can’t help but wonder what the next few decades will reveal about the effects of smoking various other substances (eg, marijuana, cocaine, methamphetamine, bath salts). January 2014 marked the 50th year of the Surgeon General’s Advisory Committee report on the health impact of smoking.1 This report highlighted the potential health risks associated with smoking and the progress that had been made to reduce tobacco use and its impact on disease and death. Our country is starting on a different path related to the smoking and ingestion of marijuana for medical and recreational purposes. The medical use of marijuana has been legally accepted within various states, but not at the federal level. During the past year, several states (eg, Colorado and Washington) have begun the implementation process for the legalization of recreational marijuana, despite the drug still being classified as a Schedule I substance by the federal government.2-4 This means that all pharmacists need to be aware of the local, state, and federal laws that apply to marijuana use in their practice location, so they can help patients understand their legal risk if they choose to use marijuana for medical or recreational reasons. This change in the public’s attitude toward the use of marijuana raises many questions: • What are the drug–drug interactions associated with more frequent use of marijuana? • What are the health consequences of smoking marijuana on pulmonary disease and cancer? • Will there be a Surgeon General’s report on the health consequences of marijuana use in 10, 25, or 50 years? Drug–drug interactions are a concern with all drugs, but they can pose a potential risk when patients do not report all the drugs they are using during a *

medication history. Marijuana is one substance that is not commonly reported by patients. They may not report it even when its legal status changes. Potential drug interactions with marijuana include antidepressants, lithium, barbiturates, muscle relaxants, anticholinergics, cocaine, disulfiram, naltrexone, ethanol, protease inhibitors, sildenafil, theophylline, warfarin, opioids, and central nervous system depressants.5-7 Some of the drug interactions are pharmacokinetic and others result in pharmacologic changes. It may be worthwhile for pharmacists to check whether their drug interaction software program can detect any of these potential drug interactions or even recognizes marijuana as a drug. Marijuana is used and produced in many ways. It is estimated that marijuana contains more than 460 active chemicals and over 60 unique cannabinoids. The concentration of the various ingredients varies from plant to plant and batch to batch and will also differ based on where the plants were grown. Routes of administration (eg, dried and smoked, cooked in food, inhaled through a vaporizer, or applied as a topical balm) will influence the rate and amount of drug absorbed.6,8-10 Patients may observe differences between the various products or routes of administration, and they should be aware of this possibility. Like all other drugs, marijuana use is associated with adverse reactions. These include altered central nervous system responsiveness, dry mouth, drowsiness, sedation, blurred vision, dry eyes, reddening of the conjunctiva, mydriasis, photophobia, changes in psychological function, dyspnea, vomiting, and weight gain.7,9,11 It has not been adequately established whether marijuana is associated with causing chronic bronchitis symptoms and large airway inflammation and cancer, especially lung cancer, but these effects are thought to be possible.12-15 Will there be a Surgeon General’s report on the health consequences of marijuana use in 10, 25, or 50 years? It is unlikely, because the majority of patients

Director, Drug Information Center, College of Pharmacy, Washington State University, Spokane, Washington

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will not be ingesting or smoking the drug as frequently as cigarettes, but you never know. Pharmacists should consider all of these issues in their evaluation of patients’ medication profiles and in answering patients’ questions related to drug–drug interactions and the medical consequences of using marijuana for recreational or medicinal purposes. When obtaining medication histories, pharmacists should ask all patients whether they use marijuana and, if so, how often and by what route. This information should be entered into the patients’ records so it can be screened by the drug interaction program for potential interactions with other medications. Without this type of screening and record keeping, we are doing our patients a disservice. REFERENCES 1. US Department of Health and Human Services. The Health Consequences of Smoking – 50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014. 2. Controlled Substances: by CSA Schedule. Drug Enforcement Agency. US Department of Justice. December 2, 2013. http://www.deadiversion.usdoj.gov/schedules/orangebook/e_ cs_sched.pdf. Accessed January 27, 2014. 3. Room R. Legalizing a market for cannabis for pleasure: Colorado, Washington, Uruguay and beyond [published online ahead of print November 3, 2013]. Addiction. doi: 10.1111/ add.12355. 4. Eddy M. Medical marijuana: Review and analysis of federal and state policies (RL33211). CRS Report for Congress. Congressional Research Service. April 2, 2010. https://www. fas.org/sgp/crs/misc/RL33211.pdf. Accessed January 24, 2014.

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5. Lindsey WT, Stewart D, Childress D. Drug interactions between common illicit drugs and prescription therapies. Am J Drug Alcohol Abuse. 2012:38(4):334-343. 6. Borgelt LM, Franson KL, Nussbaum AM, Wang GS. The pharmacologic and clinical effects of medical cannabis. Pharmacotherapy. 2013;33(2):195-209. 7. Stout SM, Cimino NM. Exogenous cannabinoids as substrates, inhibitors, and inducers of human drug metabolizing enzymes: A systematic review [published online ahead of print October 25, 2013]. Drug Metab Rev. 8. Grinspoon L. On the pharmaceuticalization of marijuana. Int J Drug Policy. 2001;12:377-383. 9. Seamon MJ, Fass JA, Maniscalco-Feichtl M, Abu-Shraie NA. Medical marijuana and the developing role of the pharmacist. Am J Health Syst Pharm 2007;64:1037-1044. 10. Research Monograph Series: Research findings on smoking of abused substances. National Institute of Drug Abuse. 1999. http://archives.drugabuse.gov/pdf/monographs/99.pdf. Accessed January 29, 2014. 11. Wang T, Collet JP, Shapiro S, Ware MA. Adverse effects of medical cannabinoids: A systematic review. CMAJ. 2008;178(13):1669-1678. 12. Hashibe M, Straif K, Tashkin DP, Morgenstern H, Greenland S, Zhang ZF. Epidemiologic review of marijuana use and cancer risk. Alcohol. 2005;35:265-275. 13. Cannabis and Cannabinoids. National Cancer Institute. November 21, 2013. http://www.cancer.gov/cancertopics/pdq/ cam/cannabis/healthprofessional/page5.Accessed January 27, 2014. 14. Joshi M, Joshi A, Bartter T. Marijuana and lung disease [published online ahead of print December 30, 2013]. Curr Opin Pulm Med. 15. Callaghan RC, Allebeck P, Sidorchuk A. Marijuana use and risk of lung cancer: A 40-year cohort study. Cancer Causes Control. 2013;24(10):1811-1820. J

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