Marijuana has been around for thousands of years and has been used medicinally for various ailments since 2700 B.C. Up until the 1990s, the delta-9-tetrahydrocannabinol (THC) content in the plant was under 2%-3%. When Colorado legalized marijuana for medical use in 2000, the highest concentration of THC in the plant was 5% and there were no concentrated products like “wax,” “shatter,” or “dabs.” Over the last 20 years, without any state governmental regulation to limit potency, the industry has dramatically increased the concentration of THC to where the average in the plant is now 18.8%. They have also created a range of concentrates with the average THC potency of 69.4%, some up to 95% THC.
While there is evidence that components of marijuana can be beneficial for some medical conditions, the research supporting this has been done with THC concentrations less than 10% in the smoked plant. There is no validated research on the 18%-95% THC products available in dispensaries indicating they are efficacious for anything medical or safe for anyone. Despite the lack of research on concentrates, the 2019 Colorado Regulated Marijuana Market Update demonstrates an increasing amount of concentrates in both the medical and recreational market with a higher percentage for products labeled medicinal (34% vs 32%).
In January 2009, the medical marijuana registry in Colorado reported 5,051 patients with valid cards. In 2009, the Obama administration began relaxing enforcement of federal marijuana laws. As a result, applications for medical cards in Colorado increased dramatically and by December 2009 there were 41,039 patients with valid cards. This was also a time that the cannabis industry began creating solvent-based hash oils and by 2010 dispensaries were beginning to carry early versions of budder, saps, and waxes. In March 2010, there were 75,209 patients with valid cards, rising to 119,895 by January 2011.
The initial rules and regulations required that the recommending doctor have a bona fide physician-patient relationship and that the patient have a debilitating medical condition. However, in the fall of 2009 it was recognized, that although 900 doctors had written approval letters (7% of licensed MDs), just 15 doctors had written 72% of the forms, and five had written fully half. One doctor signed 3,500 letters in a two-day period. This resulted in new legislation further defining a bona fide relationship and limiting physicians authorized to approve cards to those with unrestricted medical and DEA licenses.
In 2012, Colorado legalized recreational marijuana as well, leading to a slow decline in medical marijuana applications for adults. However, children and adolescents younger than 21, who cannot legally buy as recreational users, can and do hold medical marijuana cards. State records show that, in November 2020, 131 children ages 0-10 years held cards; 140 were held by those 11-17; and 3,900 people ages 18-20 had cards, primarily for “severe pain.”
An 18-year-old adolescent in Colorado (whose brain is not yet fully developed and cannot purchase tobacco or alcohol legally) can obtain a medical marijuana card without parental knowledge or approval. The physician is not required to write a “prescription” with recommendations on the type of product, route of administration, amount used, frequency of use, and period of use. There is no requirement for follow-up appointments to determine whether the recommendation has been helpful or if there are side effects.
Even if the physician recommends the patient use something that is low in THC and higher in CBD, the patient can take the card to the dispensary and get anything they want or is recommended by the person selling the products, “budtenders” who have no requirements for any medical training. Patients can purchase twice as much in the medical (2 ounces per day) versus recreational dispensary (1 ounce per day) and it is less expensive because of lower tax. There is no tracking to see if someone is going from dispensary to dispensary and purchasing more product, a process known as looping.
As a psychiatrist, I have seen several young people in this age group, referred for problems with mood swings, anxiety, psychotic symptoms, and suicidal ideation. They report having a medical marijuana card but are usually unable to tell me the name of the doctor who gave them the card. I have looked at the cards and the recommending physicians name is not on the card. I guess the state wants to protect the identity of recommending doctors?
Invariably, these young people do not have what I would classify as a “debilitating” condition such as cancer. They are getting the cards for complaints of headache, sprained ankle, low back pain, or anxiety. They are using dab, wax, or shatter daily, multiple times a day or vaping products with 60% or more THC daily. When asked if a physician actually told them to use those products, often they say no, it is what the budtender recommended. Invariably, they have not had a follow-up appointment with the recommending physician until they need to renew the card the next year. Having viewed the medical record of one such 18-year-old (initial evaluation and follow-up evaluation one year later to renew the card), it was “bare bones” reporting and no indication that the physician knew their patient was using shatter 10 times a day and no questions whether the marijuana was helping their symptoms or not.
Because the cannabis industry has been allowed to label these concentrated products “medical,” people believe they are safe. Kids are increasingly using concentrates. The 2019 Health Kids Colorado Survey reported 10.2% of high school students are using dab and of those who admit to using marijuana, 52% report dabbing, a nearly 70% increase in only 2 years.
Many of these 18- to 20-year-old kids with medical marijuana cards are still in high school and become the supplier of concentrates for even younger kids. I am aware of several 14-year-old kids who are using concentrates obtained from an 18-year-old with a medical marijuana card. A mother of a 14-year-old confiscated a bag of shatter that is clearly from a dispensary.
The label indicates it is Scooby Snacks Shatter 1 gram, potency THC 75.7%, CBD 0%. The list of ingredients includes butane and propane, carcinogens, and there is a “disclaimer” in the industry’s own words: “There may be long term physical or mental health risks from use of marijuana including additional risks for women who are or may become pregnant or are breastfeeding. Use of marijuana may impair your ability to drive a car or operate machinery. This product was produced without regulatory oversight for health, safety, or efficacy.”
Such a package is available in both medical and recreational dispensaries in Colorado. If there is no regulatory oversight for health, safety, or efficacy – how can this be considered “medical”?
While we do not have research indicating these high potency THC products are safe and efficacious for any medical condition, we have multiple studies from around the world showing serious problems resulting from high potency THC including addiction, psychosis, depression, anxiety, sleep problems, suicide, and violence. Based on their experience, Dutch researchers have stated anything higher than 15% THC should be considered a hard drug, comparable to cocaine and ecstasy, and the Netherlands put a cap on potency at 15% THC.
Many states are looking to Colorado for guidance regarding rules and regulations for marijuana. Colorado needs to repair regulatory gaps that are affecting our most vulnerable citizens, including children, adolescents, young adults, and people with substance use disorders and mental health problems.
Libby Stuyt, MD, is an addiction psychiatrist in Colorado.