I would like to thank Dr. Bier for writing the article “Cannabis: An Old Medicine Without a Package Insert,” which was written in response to the article I published, “Dangers of Marijuana Experienced Firsthand.”

The article he wrote supporting using marijuana for medicinal purposes needs to be viewed from several important contexts. Dr. Bier is the CEO of Green Well, a marijuana-based business, and has been quoted in the San Antonio Express-News speaking about the financial prospects of marketing marijuana.¹ He did not disclose this significant conflict of interest. His article illustrates what we encounter here in Colorado; statements regarding cannabis often do not include financial disclosures. He also does not practice where recreational marijuana is legal and has limited exposure to what we are experiencing in emergency departments in the “Napa Valley of Cannabis,” as Pueblo, Colorado, has been called.

The dangers marijuana presents to our patients are very real. The experiences I shared are supported by a large body of recent literature, including the review by the National Academy of Sciences, Engineering, and Medicine, which Dr. Bier referenced. These dangers include increased risk of developing psychosis, schizophrenia, social anxiety disorders, and depression; increased risk of suicide; impairments in cognitive domains of learning, memory, and attention; problem cannabis use; increased abuse of other substances (including opiates); pediatric exposures and overdoses; motor vehicle accidents; and increased risk of heart attacks, strokes, and poor respiratory outcomes with smoked cannabis.^2–6

It is important going forward that we define what we are speaking about in regard to cannabis. High-THC smoked cannabis is different from cannabidiol (CBD) oil.

I am in favor of using CBD (or other parts of the cannabis plant) as medicine, provided peer-reviewed studies with low risk of bias show benefit over existing medications and the risk/benefit ratio is favorable to its use. In that circumstance, it should not have any stigma different from any other effective medication. However, we should not be ignorant of the other possible effects and should not justify abusing marijuana and calling it medicine.

Brad Roberts, MD
Pueblo, Colorado

References

1. O‘Hare P. The ‘green rush’. San Antonio Express-News. June 5, 2016.
2. National Academies of Sciences, Engineering, and Medicine. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National Academies Press; 2017.
3. Hill KP. Cannabis use and risk for substance use disorders and mood or anxiety disorders. JAMA. 2017;317(10):1070-1071.
4. Olfson M, Wall MM, Liu S, et al. Cannabis use and risk of prescription opioid use disorder in the United States [published online ahead of print Sept. 26, 2017]. Am J Psychiatry.
5. The health and social effects of non-medical cannabis use. World Health Organization website. Accessed Dec. 8, 2017.
6. Wilson M, Gogulski HY, Cuttler C, et al. Cannabis use moderates the relationship between pain and negative affect in adults with opioid use disorder. Addict Behav. 2018;77:225-231.