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*
A
s I sit here and read the latest report on smok-
ing 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 sub-
stances (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 medi-
cal 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 legal-
ization of recreational marijuana, despite the drug
still being classified as a Schedule I substance by the
federal government.2-4 This means that all pharma-
cists 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 mar-
ijuana 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
*
Director, Drug Information Center, College of Pharmacy, Washington State University, Spokane, Washington
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 antidepres-
sants, lithium, barbiturates, muscle relaxants, anti-
cholinergics, 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 adminis-
tration, 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, drowsi-
ness, 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 estab-
lished whether marijuana is associated with caus-
ing 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
Hospital Pharmacy 319
Editorial
will not be ingesting or smoking the drug as fre-
quently 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 infor-
mation 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 Preven-
tion and Health Promotion, Office on Smoking and Health;
2014.
2. Controlled Substances: by CSA Schedule. Drug Enforce-
ment 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 fed-
eral 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.
320 Volume 49, April 2014
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. Phar-
macotherapy. 2013;33(2):195-209.
7. Stout SM, Cimino NM. Exogenous cannabinoids as sub-
strates, 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 phar-
macist. Am J Health Syst Pharm 2007;64:1037-1044.
10. Research Monograph Series: Research findings on smok-
ing 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, Green-
land 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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