Bring on the Apothecaries

Left: Box of marijuana-infused “pot-tarts” from Pinterest Amanda Young; Right: Box of brand-name “pop tarts” from Darlene Michaud

With additional revenue earmarked for public schools, less money funneled into the illegal drug trade, and arrest rates on the decline, provincial marijuana legalization has proven one of the most successful experiments of the past decade. But the complexity of the issue became clear in 2014, when New York Times columnist Maureen Dowd chronicled a doomed escapade with the drug that began with pot-infused chocolate and ended with cascades of dread rushing through her veins. Feeling nothing after “nibbling off the end” of the candy bar, she had some more, and then more, until she unwittingly consumed a portion several times larger than recommended. An hour later, she began to feel it. “I felt a scary shudder go through my body and brain,” she wrote. “I barely made it from the desk to the bed, where I lay curled up in a hallucinatory state for the next eight hours. I was thirsty but couldn’t move to get water… I became convinced that I had died and no one was telling me.”

This begot scathing mockery from hipster outlets and soon-to-be defunct gossip hubs publishing ripostes like, “Maureen Dowd Freaked Out on Weed Chocolate Because She’s Stupid,” and “Maureen Dowd Is Very Bad at Getting High.” However funny, such reactions misunderstood the article, which was in no way a prohibitionist diatribe. In fact, she wrote a glowing follow-up about her smoke session with Willie Nelson just a few months later.

Rather, Dowd detailed her catatonic delirium to expose the lack of regulation and consumer education surrounding newly legal marijuana products. Media outlets have extensively documented the recent uptick in emergency room visits related to the over-consumption of marijuana, commonly referred to as “greening out,” especially as it pertains to marijuana-infused foods, or “edibles.” The reports suggest Dowd’s greenout was typical. Edibles take a while to activate because they must first be metabolized in the liver before reaching the brain, unlike smoked bud which travels straight from the lungs. And so, oblivious to the fact that edibles often take up to an hour to kick in, many novice users end up in the ER by first consuming a small amount and then having more when they don’t immediately feel the effect.

It’s easy to see how this kind of informational asymmetry could lead to a greenout. Dowd’s candy bar wrapper didn’t include recommended serving sizes, and her utter shock at the experience suggests she wasn’t properly educated about the potential for an adverse reaction. If Colorado had required manufacturers to include dosage recommendations and warnings about side effects, which range from heightened anxiety and paranoia to temporary depersonalization, on the label of their products, Dowd’s greenout may have been averted.

Legal states could prevent even more greenouts if they stepped up regulations for graphic design, since edible manufacturers often package products in wrappers or boxes almost indistinguishable from those of regular food. For some products, package designs are facsimiles of name brands aimed at young kids, which has led to cases of children, and sometimes adults, being hospitalized after unwittingly consuming large doses of THC from what looked like their favorite snacks. As Dowd wrote, “The caramel-chocolate flavored candy bar looked so innocent, like the Sky Bars I used to love as a child.”

These problems make sense. The legal marijuana industry has inherited a quaint lexicon from its years as an underground subculture, which, as the buzzwords in this article may demonstrate, can make it difficult for novice consumers to understand the products they purchase. Which is why the response to Dowd’s piece was so misguided. We would surely laugh at someone surprised they got sick after downing a dozen shots of vodka, but that’s because we were all taught the side effects of excessive drinking in school. Most Americans have never received a comprehensive drug education. They’ve been fed lies and told to stay away, and now that they’ve gotten the nod for marijuana, many are curious about trying a drug they know nothing about.

The biggest regulatory challenge, then, is bridging gaps in consumer education. Current approaches, which vary state by state, don’t go far enough. Only five states bar packaging with a likeness to products aimed at children and only two states require packaging to include a warning about potential side effects, which reads: “This product has not been analyzed or approved by the FDA. There is limited information on the side effects of using this product, and there may be associated health risks. Do not drive or operate machinery when under the influence of this product. KEEP THIS PRODUCT AWAY FROM CHILDREN.” Essentially, users may experience side effects, but manufacturers don’t know what they are or what may exacerbate potential risks. That all 29 legal states and the District of Columbia, which have legalized marijuana for either recreational or medicinal purposes, require manufacturers to label their products’ THC concentration and the minimum age for consumption on the package isn’t reassuring, either, since it’s hard to imagine that an inscription reading “9% THC” will guide a novice user or an inscription of the minimum age will deter children, especially those who don’t yet know how to read.

In the interest of protecting children, better packaging regulations should be a top priority in reform efforts. But for those of age, more distinctive graphic design and scrupulous labeling requirements can only do so much. Consumers in new markets cannot help but be uninformed, and without the help of trained professionals, people are destined to keep making the same mistakes. The solution is expertise. To adequately inform consumers, legal states should require dispensaries to employ on-site pharmacists well-versed in cannabis products and the ways the body may process them in combination with other drugs or conditions.

Currently, dispensaries in states without on-site pharmacist requirements employ “budtenders” to fulfill the pharmacist’s role. While budtending certification testing varies by state, it’s invariably easy to pass. (In some states, you can obtain a budtending certificate online.) Consequently, budtender education rarely surpasses the basics of the products sold at their respective stores. Dr. Allen Weiss, CEO of Naples’ NCH Healthcare System, made this point arguing against Florida’s medical marijuana law, Amendment 2. “The typical pharmacist spends five or more years in school, interns for more than 2,000 hours, must complete two intensive licensing exams, and spends 30 hours a year in continuing education,” he wrote. “[But] Amendment 2… will enable… individuals with no medical background, training or knowledge to recommend [and dispense marijuana].”

He’s right. If a customer asked about the effects of using marijuana while under the influence of a separate medication or intoxicant, or how marijuana might interact with a medical condition, a budtender would not be able to answer. This makes our current regulatory scheme untenable. Allowing the marijuana industry to prioritize profit over public health will endanger consumers and cause what has otherwise been a thriving experiment to lose credibility. Legal marijuana, medical or recreational, must be treated as a public health issue, which requires the involvement of medical professionals.

Poll data indicate that at least a plurality of Americans support on-site pharmacist requirements, which means that it would be an attainable goal if it were left up to states. The problem is that state-level requirements of this sort would be illegal under federal law due to the Drug Enforcement Administration’s classification of marijuana as a Schedule I Drug, which precludes medical professionals from writing or distributing prescriptions for marijuana. While the marijuana industry is technically violating federal law as it stands, dispensary owners have been shielded in recent years by the Cole Memo and the Rohrabacher-Farr Amendment, which bar the DEA from conducting raids of dispensaries or prosecuting proprietors acting in accordance with state laws.

Medical professionals don’t share these protections because they don’t work with dispensaries in a managerial capacity or possess the drug themselves. The handful of states with legislation stipulating on-site pharmacist requirements for dispensaries have tried to get around this by explicitly stating that physicians don’t “prescribe” the drug but “recommend” it, and that pharmacists don’t “distribute” the drug but “dispense” it. But these distinctions only exist on the state level, which offers no protection from federal prosecution. This has created a reluctance to implement on-site pharmacist requirements in legal states that don’t have them and an apprehension among pharmacists in legal states that do.

The most coherent way to protect pharmacists at the federal level is to reschedule marijuana. This will need to come in the form of federal legislation since the DEA’s dependency on the drug war gives it little has little reason to change its scheduling system, as its sclerotic refusal to reschedule the drug has displayed. Such legislation exists. Earlier this year, Representative Matt Geitz (R-FL) proposed House Resolution 2020, which would reclassify marijuana as a Schedule III drug and thereby allow medical professionals to prescribe and dispense the drug. If you’re interested in creating safer and more responsible legal marijuana industry, don’t hesitate to contact your representative.