The Dangers of Going to the Medical Cannabis Dispensary Without a Guide

Medical cannabis has been approved in many states as an adjunct therapy for the management of an array of medical conditions. In my experience, this has provided another treatment option for my patients with chronic pain, anxiety, insomnia, spasticity, and other painful conditions. It allows them to have another tool in their toolbox for use while they work on managing their own condition and optimizing their quality of life. Medical cannabis has become significantly more accessible to patients who could benefit from it, which is great progress. There are, however, dangers present for patients if they are not provided with education and direction from their doctors on what type of cannabis to try and what to expect during treatment. Though some dispensaries do have pharmacists who are able to provide some real clinical advice, many patients get their treatment recommendations from “budtenders”, or the employees who work at the dispensary who do not have a medical background. Nothing against budtenders, but some of my patients have had some very bad trips (literally and figuratively) from getting medical cannabis based on their recommendations.

I have seen many side effects and accidental intoxication from patients who did not consult with a pharmacist or other medical professional directly about their medical cannabis use. A particular patient story comes to mind that details the harm that could be caused if proper research and guidance is not performed. As you may or may not know, cannabis used for medicine comes in different forms: pills, flowers, tinctures, edibles, vapes and more. Because the delivery medium of medical cannabis varies, the time for the onset and duration of the drug effect and the impairment profile varies, too, depending on which type you use. My patient with fibromyalgia and anxiety, who was a first time user, was given pills containing 10 mg of THC, which is a dosing more appropriate for those who have been using medical cannabis for a period of time. The patient took her pills on Saturday afternoon, again on Sunday morning and again in the afternoon because she was not feeling any effects. Come Monday morning, she went to work where she was employed as a dispatch for a truck company. All of a sudden, the patient started feeling a bit uneasy. Her heart started pounding, and she started sweating profusely. She couldn't focus and began to feel very paranoid as worrisome thoughts set in. She thought “Oh my gosh, I’m very high, and I’m going to lose my job. Can everybody tell how impaired I am? Can they tell from my speech?.” This patient was having a very bad trip. She was more anxious than ever and felt like she was having a panic attack. She was able to get to her car and lay down for two hours for things to calm down.

These two hours were the most dreadful, longest hours of her life, she recalls. What happened here? This patient thought she was following the directions given on how to take her medical marijuana. This experience was a huge turn off for her, and she decided she would never use it again, even though she had few options for effective medications for her due to the side effects they would cause.

There are many lessons here to reflect on. First, the budtender did not take into account that this patient is not using cannabis for pain, but rather, was using it to manage her anxiety. Second, as her provider, I did write down exactly what I wanted her to get when she went to the dispensary (which was mostly CBD with a small amount of THC and terpenes to help with her anxiety), but this was substituted by the bud tender because they didn’t have what I recommended in stock. Third, this story emphasizes that it is important for patients to understand that “feeling something” should not be equated to cannabis working. A lot of my patients will say, “I didn’t feel anything when I took it, so I don’t think it’s working for me.” Most people know of the psychoactive properties of cannabis and expect that for it to be working, they have to feel “high”. This is far from the truth when we are using cannabis for medical purposes. Most of the medical benefits of cannabis can be achieved without any “high” or impairment. In fact, most patients seeking medical cannabis therapy in my practice do not want to get high. They are usually adults, who have failed conventional therapy and are looking for something that can help them improve their pain and still be able to function.

What happened in my patient case was a phenomenon called the first pass effect. When you take cannabis in forms such as via a pill or edible, it is metabolized through your liver. In the “first pass”, your liver then breaks down the 9-delta THC you have ingested into another molecule called 11-hydroxy THC. This intermediate compound can yield a strong sense of “being high”. The problem is that this conversion of THC to 11-hydroxy THC can take 4-6 hours and the drug effects can last for 24 hours. Because my patient took the pill and didn’t feel anything right away, she continued to take more. Her body was metabolizing the cannabis while she continued to take more, until 12 hours later, it all caught up to her, and she was so symptomatic she could not move and felt like she was floating.

These stories are very common in practice because most clinicians certifying patients for cannabis do not take the time to educate themselves on the proper dosing and titration of cannabis to prevent side effects. The patient is then left to the mercy of the budtender to advise them on dosing strategies, which we have learned, is not recommended.

Lessons Learned:

Go to a provider or doctor who understands and can educate you on what to get when you go to the cannabis dispensary.
If the dispensary offers you a “substitute” for what was recommended by your doctor, check with your doctor first to make sure it is similar, as there are many combinations of cannabis medicine out there.
Ask to speak to a pharmacist, especially during your first time going in, so they can provide clinically sound judgment with treatment recommendations.
Not “feeling something” doesn't mean your medical cannabis isn’t working, unless you are looking to get high.

Stay tuned, we will provide more blogs on the right cannabis to get for the next time you go to the dispensary.