Waiting to Inhale: Hospitalists, Marijuana, and Legalization

by Dr. Jason Persoff MD, SFHM

Welcome to Friday night as a hospitalist in the ultimate Green State, Colorado: time to gear up for some marijuana-facilitated paranoia, memory loss, nausea and vomiting, and memory loss. I’m not a teetotaler but I do find the new surge in cases of preventable disease a bit disheartening if not occasionally humorous. Prior to this past year, it wasn’t uncommon for me to encounter an occasional marijuana medical problem, but since ringing in the New Year and the new law, it’s become a bit of a habit to admit folks with marijuana-associated illnesses.

Take Mr. L, my first marijuana-associated admission of the night. He presents for his 10th consecutive month of recurrent nausea and vomiting. Stating that these symptoms began roughly about the time that he had a stomach virus in January; his friends suggested a cure for his upset stomach: cue the marijuana. Since then, our gentleman has been suffering debilitating episodes of nausea and emesis. The only thing that stops it, he notes, is “weed”.

This phenomenon of marijuana hyperemesis syndrome (MHS) has resulted in a sharp uptick in cases over the past year. Our toxicologists have informed us that the prevalence of MHS has doubled since the new law went into effect, and my subjective experience is that every third shift I will be in the midst of some manifestation of marijuana misery. The hallmarks have become very familiar to our group: patients will sit under hot showers for hours at a time to quell the nausea and vomiting, which makes interviews more awkward, but the steam is a welcome diversion. Yet they still bristle at the suggestion that marijuana is the cause of their symptoms despite the fact that for many of them, our patient included, this problem with chronic nausea and vomiting started circa January 2014. It’s the classic “a bit of the hair of the dog that bit you” phenomenon akin to the alcoholic who states that alcohol is the only thing that makes his DTs better. and it’s equally problematic to achieve buy-in.

But it’s not always those who have toxicity that have stirred up a bit of ennui. We experienced the awkwardness of medicinal marijuana several years ago—try entering that into a medication list in your healthcare organization’s computerized health record. Ours allow us to add a “non-formulary medication”, but such oddities as dose and frequency border on comical. Are doses supposed to be in mg? Tokes? Inhalations? It’s a challenging discussion since anything we talk about is in terms that often leave me stymied. “Just a bong or two.” “A couple of hits.” “One or two edibles.” “I go for that super-concentrated stuff through an atomizer.” Take that computerized system! Oh, and when it comes to discharge medication reconciliation, should we check that box to “continue all outpatient medications?”

Now that we have fully legalized cannabis in the state, we now have a novel problem with documentation and coding. Courtesy of the Vox Populi, marijuana is no longer an “illicit drug”, but it’s not a medication either. I haven’t confirmed with our coders, but I’m not at all certain whether this can be a bullet point in the review of systems (Does it go under the dietary ROS? The pulmonary ROS?), or if it’s a separate problem in medical decision-making (After all, it’s also not necessarily a medical problem in a sense—or is it?).

Prior to enacting the new law, it was rare—if ever—that a patient came to the ER with acute marijuana intoxication. But now, we have a rise in marijuana intoxication: paranoia, akathisia, tachycardia, and nervousness are all consistent with an acute intoxication episode. In rare episodes, hallucinations and violence can occur. These hallucinations were contributory in the death of a young man in March 2014, when he leapt to his death from a balcony while having a violent reaction to edible pot. Edibles themselves pose a serious problem in that they triple the half-life of marijuana from 4 hours (inhaled) to 8 to 12 hours (eaten). Again, this rate is still far lower than the massive toll alcohol and firearms have in our day-to-day practice, but it is a new phenomenon that has prompted some debate on how best to label marijuana products in the state (see dosage conversation above).

Another weird irony is that there really hasn’t been stupendous research done on marijuana to-date because of the fact the Drug Enforcement Agency continues to list marijuana as a Class I drug. That prohibitive level of control means good case-control studies that could educate us clinicians even further about the potential benefits and other harms of marijuana are currently as common as trials on heroin or LSD. Read: not common at all. But those same researchers can venture out at lunch from a busy day of work, and conduct autonomous research of their own among the many dispensaries that have cropped up in Denver. It almost seems like a scenario created by The Simpsons’ writers.

So what changes once your state goes green? Beyond the amazing windfall into state coffers (to-date, Colorado has seen almost $50 million dollars of brand new tax dollars), inpatient medicine changes very little—our ED experience suggests an increase of maybe 1 to 2% of our admissions will be due to marijuana. Where it does change is in the openness of patients about their marijuana use with decriminalization leading to de-stigmatization. And while that is actually a positive thing overall, it is still sullied by the lack of good data to guide us in warning about dangers of regular consumption. Beyond the evidence of lowered IQs and the acute toxicities I’ve mentioned, I’m still limited to sounding like an after school special: smoking marijuana without filters may be harmful; it could lead to memory loss, your children may accidentally get into your marijuana-infused food and get stoned, etc. It’s just not that substantive: cue the need for the Feds to consider dropping marijuana down a few schedules so that we can begin to offer real information for patients to make real informed, consenting decisions.

Now if you want to come to the appropriately named “Mile High” city, use common sense: smoking marijuana in public places is a big no-no, and Denver police have been issuing 400% more public intoxication citations for marijuana since January 1, 2014. Despite the best efforts to convince the courts otherwise, there is ample data that stoned driving will result in a DWI (think: $10,000 court fees and loss of license as negative incentives), so nibble your Starbursts in the backseat of a cab. Last, if you do imbibe, and find yourself just a little jittery and nauseated, swing on by. We’ve still got plenty of beds available, and the night’s still young; I’m happy to chat with you through a wall of steam about what ails you.

Jason Persoff, MD, SFHM is an internationally renowned storm chaser, father of three, husband to an amazing lactation consultant and doula, erstwhile stand-up comedian, and contemporaneous Assistant Professor of Internal Medicine at the University of Colorado Hospital.  He is one of those weird guys who prefers being a nocturnist.  Each May he spends two weeks scouring the Great Plains using many of the same skills he uses in internal medicine—analyzing and interpreting subtle and system-wide weather physiology—to pursue severe thunderstorms and tornadoes.  He has appeared in many TV specials on The Weather Channel, Discovery Channel, and The Learning Channel, and several books.  After assisting in the Joplin tornado disaster, Dr. Persoff has begun to focus his efforts on developing mass casualty response plans for his hospital medicine group.