"I have no personal experience with marijuana. But I do practice medicine in Colorado and given the state’s ongoing experiment with legal recreational marijuana, I am accumulating a significant amount of professional experience with the drug," writes Henry Rosevear, MD.
Unlike our current president who acknowledges experience with the drug and a certain past president who smoked but famously did not inhale (really?), I have no personal experience with marijuana. But I do practice medicine in Colorado and given the state’s ongoing experiment with legal recreational marijuana, I am accumulating a significant amount of professional experience with the drug.
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Let’s be honest, though, marijuana is not a new drug. The earliest reference I could find is from the Chinese emperor Shen Nung in 2737 B.C. (helps with gout). More recently, the Pew Research Center reported in 2015 that 49% of American adults have tried marijuana at some point and 12% of the population had used it in the last year. As a result, it is certainly possible that the only reason I have become aware of the influence of marijuana on urology is that it is much easier to talk about the drug in my office because it’s now legal.
On the other hand, the legalization of the drug certainly is leading to an increase in marijuana use in my state (we have gone from fourth place in regular marijuana use in 2011 before legalization to first in 2015, according to a survey by the U.S. Department of Health and Human Services. Thus, it’s possible I may be seeing connections to which I was previously oblivious.
Regardless, it has become obvious to me that marijuana is influencing how I practice medicine, and I thought it important to share some of my stories. The first time I found a connection between marijuana and urology was a year or two ago when a patient came back to my office a few hours after a vasectomy reporting that he had a seizure. I was a bit skeptical and after an exam, I sent him on his way home.
A few weeks later a second patient came back to my office with the same report. This case was different, as his wife who witnessed the event was a nurse on the floor at a local hospital. I trusted her, and she was confident it was a seizure. This case was also different because once I walked into the exam room, I was inundated with the very distinct, pungent smell of marijuana.
At this point, it’s worth noting that I offer my vasectomy patients a small cocktail of oral Valium and Percocet before the procedure. I don’t know if it does much for the actual procedure, but there is no doubt that it has a certain positive supratentorial effect.
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Since I am giving narcotics and benzodiazepines, I always tell the patient to avoid alcohol for a few hours after the procedure, and it turns out that both of the patients in question had done exactly what I asked them to do. Instead of having a beer to celebrate after their vasectomy, they smoked up. Since that event, I have started instructing everyone to also avoid marijuana for a day or so and have had no further problems.
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Interestingly, my next medical experience with marijuana also had to do with fertility. A man in his 20s came to me with complaints of infertility. He and his twenty-something wife had been attempting to conceive for about a year with no success. Her OB had done an exhaustive evaluation before having my patient submit a semen sample for analysis. (Does anyone else think it’s a waste to do a million-dollar OB evaluation before you have the guy simply produce a sample?)
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Regardless, my patient’s sample showed abnormal morphology, decreased counts, and low motility. My first thought was a varicocele, but the exam was normal. The only risk factor I could identify was near daily use of marijuana (by both the husband and wife). After a long conversation, I convinced the couple to try a marijuana holiday and 4 months later we rechecked the semen analysis and while not perfectly normal, it was vastly improved. A few months later I received a phone call informing me that they were pregnant.
The endocrine effects of marijuana are well documented. Cannabinoid is known to bind to a cannabinoid receptor near the hypothalamus, leading to suppression of gonadal steroids and thyroid hormone. Luckily for my patient, the effects were reversible, although the long-term use of marijuana on male fertility is unclear.
The last and by far most common way that the increase in marijuana use is affecting my practice is through its effects on anesthesia. Cannabis potentiates the hypnotic and sedative effects of CNS depressants such as benzodiazepines, opiates, barbiturates, and phenothiazines. It also uniquely can lead to significant oropharyngitis and uvular edema, which can lead to airway obstruction surrounding general anesthesia. Most of my anesthesiologists prefer to delay surgery for at least 3 to 4 hours after smoking to minimize this.
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And yes, I encounter patients who state that their stone pain was so bad that even smoking marijuana didn’t help. Welcome to Colorado. There also appears to be a dose-dependent cardiovascular effect of anesthesia and cannabis use. At low to moderate doses, there is increased sympathetic activity, leading to tachycardia and increased cardiac output. At high doses, there is increased parasympathetic activity, leading to bradycardia.
Next: "Why hasn’t there been more research into the substance?"
I have also observed an increased risk of psychiatric side effects during both induction and emergence. Lastly, patients who use marijuana on a regular basis can pose pain control issues after surgery, as the typical dose of narcotics does not affect them in the expected way. Often I have found simply discharging them and letting them start using marijuana again at home is more effective than increasing narcotic dosage in house. With that in mind, I frequently tell patients who use marijuana that pain control will be an issue and, for the most part, they have understood.
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This raises the question, if this small-town plumber has readily identified interactions between marijuana and medicine, why hasn’t there been more research into the substance? The first problem is that marijuana is still classified by the Drug Enforcement Administration as a Schedule 1 drug, meaning that it has “no currently accepted medical use and a very high potential for abuse.” This means that in order to officially study the drug, a research would have to apply to the DEA for a license, an onerous process as you might imagine.
Further, let’s assume a researcher does get permission from the DEA. The next step is to find research money, which either means going through their own university and potentially dealing with controversial publicity or getting funding from the National Institute on Drug Abuse (NIDA), which specializes in research on Schedule 1 drugs. Unfortunately, NIDA’s mandate from Congress states that it is to “only study substances of abuse as substances of abuse,” which clearly poses problems for someone researching the potential positive effects of marijuana.
While the policy decisions regarding the further legalization of marijuana are well above my pay grade, I think it is important for those of us in the trenches of medicine to share experiences like mine so that we better understand the effects of this drug on our practice. I would also love to see more consistency in the policies governing marijuana, as it seems silly to allow legal widespread use of the substance without at the same time legalizing research on exactly what the drug does. Again, this is just one small-town plumber’s opinion.
Marijuana isn’t going anywhere, so the best we can do is better understand it so we can continue to treat out patients well! If you have experience with the drug in your practice, please let me know! If we really want to broaden urologist’s knowledge of the drug, maybe the AUA should hold its next conference in Denver.
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