Speaker 1: 0:04

Welcome to the Healthy Matters podcast with Dr. David Hilden, primary care physician and acute care hospitalist at Hennepin Healthcare in downtown Minneapolis, where we cover the latest in health healthcare and what matters to you. And now here's our host, Dr. David Hilden.

Speaker 2: 0:21

Hey everybody, it's Dr. David Hilden, your host of the Healthy Matters podcast. Today on episode six, we're gonna talk about recreational marijuana. To help me out, I have asked a repeat guest, Dr. Charlie Resnikoff, to join me. You may remember his name from episode four of the podcast last season. If not, I encourage you to go back and listen to that show because it's a great introduction to the field of addiction medicine. Today I've asked him to talk about another area of his expertise that mean marijuana. Many states now have legalized it, both for medicinal use as well as recreational use. Charlie, welcome back to the show.

Speaker 3: 0:56

I'm happy to be here excited to talk about this.

Speaker 2: 0:58

So tell us the current state of recreational marijuana, specifically in our state of Minnesota, but nationally. Where, where is it? Well,

Speaker 3: 1:06

Listeners might know or have heard that this summer a bill sort of snuck through the legislature and was signed into

Speaker 2: 1:15

Law here in Minnesota,

Speaker 3: 1:16

Here in Minnesota that allowed low dose hemp-based t hc. It acts just like recreational marijuana. It a, it behaves in the body just like that, but it's only low dose. And it is derived from hemp, which is related to marijuana, but not the same. And it has the active ingredient that is an I intoxicant, so that that is available now throughout Minnesota in a variety of retail stores. So that was a bit of an adjustment, but now the legislature is very heavily considering and they're looking at language and they're crafting language right now to legalize marijuana for recreational purposes in our state. And I think it is highly likely or almost certain that the bill will pass and be signed into law. And in the next couple years, we're gonna see a big change out there in Minnesota.

Speaker 2: 2:06

So many other states have done this either through their legislative process or by voter referenda. Yeah. Right. Yeah. How, how prominent is this? Is this a a, a natural progression in, in someday down the road, it's gonna be legal throughout our country? Good

Speaker 3: 2:22

Question. I think most people think that at some point in the future it will be legal federally throughout the country. Now we have many states where it's recreationally legal. It is a bit of a change. I think people notice the change, you know, walking through the city, you know, you'll smell it a lot more where people already smell it. Quite, huh?

Speaker 2: 2:41

You'll walk through Denver, Colorado. Oh yeah. You get stoned just walking down the street, the

Speaker 3: 2:45

Street<laugh>. I know. And the shops are everywhere, and it's more prominent in the culture. So yeah, I mean, for sure it is. It will be a noticeable change. It won't be a sort of cataclysmic change. I think life will go, go on mostly life will go on as normal, but it'll be a little, you know, a new, a new thing that we see every

Speaker 2: 3:05

Day for some people of, uh, maybe aer maybe it's generational, maybe it's not. Um, marijuana would've been like heroin or like other cocaine. Like I, what are you some drug addict. And now we're actually talking about making it legal for everybody. Yeah,

Speaker 3: 3:19

That's, that's my parents and maybe your

Speaker 2: 3:21

Parents' generation,

Speaker 3: 3:22

Maybe my, the silent generation, the, the generation that preceded the baby boomers, almost nobody used cannabis. My 80 year old parents still in 80 years have never used cannabis. However, from the baby boomers. And after that, those are all heavily exposed generations. Most people, baby boomer or younger have at least tried once or know many people who use cannabis. So it's generational.

Speaker 2: 3:44

I asked my, my son after, when he got back from a semester at college, he's in his early twenties, or he was at the time, I said, do many kids at college smoke? And he goes, oh yeah, they a lot to, and I said, really?

Speaker 3: 3:55

Yeah,

Speaker 2: 3:55

I thought kids weren't smoking cigarettes anymore, because that's what I meant. Oh, he didn't even, didn't even occur to him that I meant cigarettes. He goes, no, I don't know a single person who smokes cigarettes. They all smoke weed now. That's what, that's what they meant by smoking.

Speaker 3: 4:07

And now a lot of them aren't even smoking weed. They're vaping or eating edibles is, those are more common. There is some smoking still going on though. Okay.

Speaker 2: 4:15

So if all these laws are changing, there must be some positive benefits, either to individuals or to society. So I'd like to use this episode now from here on out talking first about the good. What are the good, what are the benefits of, of legalizing recreational marijuana? And then we're gonna shift after that to what's the downside? So what are the benefits either to an individual or to society at large to legalizing marijuana? Yeah,

Speaker 3: 4:39

It's funny, I, and you hear all these talking points about all the benefits, and some of them are true, and some of them are kind of, I think they're overstated. But I'll tell you what, the most important number one benefit is for the vast majority of people who use marijuana. It brings in pleasure and having some joy in your life. Whether that's, you know, right now we, we can drink a cocktail and nobody looks down upon us. Uh, and we get a little pleasure from that. And I think it's very reasonable that a lot of people are saying, I want to have a little safe pleasure in the privacy of my own home to be able to use this intoxicant. It's not that harmful. I use it appropriately. So I think the number one upside is for the vast majority of people, it's a relatively safe way to have a little bit of pleasure. And I, I'm not necessarily endorsing it, but I, I think that's the bottom line is that a lot of people just use it to relax.

Speaker 2: 5:30

You know, it's refreshing actually to hear a physician say that there's value to some enjoyment. You

Speaker 3: 5:36

Gotta find joy in life. And I think there, there are healthier ways to find joy, whether that be exercise or art. But, uh, this is a relatively safe way. It's a shortcut to joy, let's call it that. And, and that I'm quoting actually, Andrew, we, who's a, who's an MD who now sells herbs on the internet. But he originally was a cannabis researcher and he talked about, you know, how like little kids when they're, you know, maybe they're five years old, they'll spin around until they're dizzy. Yeah. And then they'll fall and they'll giggle.<laugh>. That's the childhood equivalent of becoming intoxicated as an adult. You've done something to yourself to make yourself dizzy and giddy. And then you giggle and fall.

Speaker 2: 6:12

It was fun for a while. It was fun

Speaker 3: 6:14

For a while, and you fall and you get back up and go on your day<laugh>. And that, that's the same thing adults do with a Manhattan, you know, or whatever. A glass of wine. Totally.

Speaker 2: 6:22

That makes perfect sense. Are there actual health benefits other than that, that sense of pleasure?

Speaker 3: 6:29

Good question. So a subset of people get good pain relief from it. So people suffering from pain, uh, some of them get some relief from cannabis and that could be really helpful and a preferable alternative to opioids. Some people with anxiety or trauma and insomnia. Um, the, what you're seeing a lot, and I've seen it in uh, literature, is that some people really find that cannabis helps them sleep and helps their sleep be less disturbed by nightmares or bad dreams. So I think some sleep, some anxiety level, some maybe helping cope with some past trauma they're struggling with. Those things I would say are benefits, nausea, you know, and, and it's

Speaker 2: 7:09

Cannabis cancer patients have known that for some time.

Speaker 3: 7:11

Oh yeah, yeah. HIV patients with their meds. Some of the h old HIV meds caused nausea and then they would find out that the cannabis helped them tolerate their medications. So there's some me, uh, nausea relief. Some pain relief. Yeah. I mean, I think those are the main things.

Speaker 2: 7:25

So there are some benefits to an individual as you've laid out. Are there benefits to our society?

Speaker 3: 7:31

Yeah, great question. I mean, I, this is something very front and center in Minnesota where the legislature is very keen on not incarcerating or penalizing people for small time drug possession or offenses. And those types of laws are unfortunately disproportionately applied to people of color. And so I think there's a lot of individuals incarcerated today for marijuana laws that probably needn't have been incarcerated and, you know, and it goes on their record and it affects their abil ability to get a job and all and housing and all the rest. So, so yeah. I mean that's a huge, uh, plus to society. That's a huge plus. Oh

Speaker 2: 8:07

Yeah. You look back on that. It's like what we're thinking, putting a bunch of people in jail. Yeah. It's

Speaker 3: 8:12

The, it's probably the most important, compelling reason to do it, in my opinion Yeah. Is to sort of write the ledger on all the wrongs we've done to certain people Yeah. Who use this drug. And then there will be some tax revenue. Uh, that's always nice for, uh, for the states.

Speaker 2: 8:26

Do states do that? They add some tax on? Oh yeah, you get it at a little, I suppose you get it at a little shop or something like Yeah. Like you see every other foot in Denver, Washington

Speaker 3: 8:34

State taxes is at 40% and that's a lot of tax revenue. And so our state is wrestling with what percentage tax to put it on. And that's smarter people than

Speaker 2: 8:44

Because I'll bet, I'll bet there's some disparities there too. Poorer folks can't, a sales tax is a bigger chunk of your money.

Speaker 3: 8:49

Exactly. So they wanna make it available to everyone in a fair sense. But they wouldn't mind the revenue either. So, so I think they're, they're figuring all that out. So tax revenue, criminal justice reform. And then also there is a black market right now. And what if, instead of having a bunch of drug dealers make money on a black market selling marijuana, it was through IIT channels. It was controlled, it was pure, it was secure.

Speaker 2: 9:13

So Charlie, uh, is what you're saying is that the, the drug supply will be regulated more for, for purity and such,

Speaker 3: 9:19

Right? Exactly. So you'll know what it is you're buying and what the potency is, and you'll have a much greater sense of what you're ingesting versus getting it on the black market.

Speaker 2: 9:28

But it's not a pharmaceutical type of regulation. No. This is still being sold in little shops No, in the street corner. Right.

Speaker 3: 9:34

That's that's true. But just imagine, if you will, if all alcohol consumed was moonshine made in someone's backyard at a, in a still in someone's backyard. Well that would be pretty dangerous cuz there's a lot of, you know, risk to that. And then finally there are reports, unconfirmed reports that sometimes marijuana is adulterated with fentanyl. Yeah, I've

Speaker 2: 9:51

Heard that.

Speaker 3: 9:51

Which is just terrifying. And if there's any chance that fentanyl is gonna get put in the marijuana supply, how fast can we legalize marijuana is what I would say, you know, to

Speaker 2: 10:01

Eliminate that

Speaker 3: 10:01

Risk. Oh, that the risk is just death. I mean it's, yeah, it would be a very bad situation if that became the norm that fentanyl was in marijuana. So those are all societal benefits. So

Speaker 2: 10:10

There really are some benefits. Yeah. There are some individual benefits, there are some societal benefits. We've covered the good when we come back. What are the downsides of recreational marijuana? Stay with us. We'll be right back.

Speaker 1: 10:23

You are listening to the Healthy Matters podcast with Dr. David Hilden. Got a question or comment for the doc. Email us at Healthy Matters hc m e d.org or give us a call at six one two eight seven three talk. That's 6 1 2 8 7 3 8 2 5 5. And now let's get back to more healthy conversation.

Speaker 2: 10:46

And we're back talking about recreational marijuana with Dr. Charlie Resnikoff. Okay, Charlie, we've covered the potential upsides. Let's turn to the downsides. What harms are possible both to an individual and to society of legalizing marijuana?

Speaker 3: 11:03

Yeah. Um, and I'm an addiction medicine doctor as you know. You know, and the listeners know. So I always think about those who are most vulnerable. So I do spend a lot of my energy worrying about the minority of people who will be vulnerable and harmed by this. And I think there are a couple groups to think about. People with addictions, people with serious mental health issues, adolescents and even college kids, a little young adults, adolescents and young adults and people driving a car. And we can start with people driving a car. Uh, there's

Speaker 2: 11:33

Is it dangerous?

Speaker 3: 11:34

Oh yeah, there's no doubt. It's, it's actually not hard to test whether someone gets intoxicated and drives worse. They put a bunch of orange cones in a parking lot, let you use your drug and test how well you drive the car. And turns out people knock over those cones more often when they've used cannabis. Uh, yeah. So it's really not hard to measure and there's a lot of concern that cannabis use, especially mixing cannabis with alcohol now

Speaker 2: 11:59

That is, that sounds scary. Yeah,

Speaker 3: 12:01

That's, that, that is way higher risk for an accident than either those drugs alone. You

Speaker 2: 12:07

Use the word intoxicated. Yeah. Most listeners I think would automatically assume intoxicated means alcohol. Is that the correct term to say? I use words like baited, stoned high. Yeah,<laugh>. I thought those probably aren't the actual

Speaker 3: 12:18

Terms. Well, yeah, I mean, you're right. I, I mean intoxicated or impaired. Impaired impaired would be, would be the two substance would would be the two words we would use to describe

Speaker 2: 12:27

It. Can you tell if someone is impaired while they're driving? There

Speaker 3: 12:30

Is no breathalyzer for cannabis or marijuana yet. And the drug screens or toxicology for marijuana are very imprecise in telling when you were intoxicated. So it's, it's pretty hard to tell whether the marijuana you used is causing or contributing to a car accident. That said, there are forensic experts that the police officer can call in a forensic expert to do an exam and to determine if you're intoxicated. But boy, it's not easy to

Speaker 2: 12:59

Tell. So that's one downside. Talk about the downside to young adults and adolescents.

Speaker 3: 13:05

Yeah, there was an interesting study at the University of Minnesota actually through Boynton Health, which is the clinic there. The

Speaker 2: 13:11

Student health center. Yeah, yeah. At

Speaker 3: 13:12

The, at the, at the University of Minnesota where they looked at marijuana use, how much you use and what is your grade point average. And it turns out whether you are male or female. And they only tested males and females. I know there are some people that don't identify with either gender, but between males and females, the more marijuana you used, the worse your GPA<laugh>.

Speaker 2: 13:34

So there's a whole bunch of parents right now going, see I told you kid. Yeah, you're gonna flunk your math test cuz you were high.

Speaker 3: 13:40

Yeah. And, and there is, um, a variety of studies in other settings and I think it's pretty well established now that especially heavy marijuana use in your adolescence or in your young adulthood worsens educational outcomes.

Speaker 2: 13:53

Do we know why that is? Is it, does it harm your neurologic networks or is it just that you're kind of sleepy?

Speaker 3: 13:59

Yeah, I mean, well and also memory, it affects memory. The cliche is, I forgot where I put my keys. You know, you'll hear the people who use marijuana, where'd I put my wallet? Where'd I put my keys? Wait, what was I gonna say? That's kind of the marijuana cliche. Um, well that if you're intoxicated on marijuana, it affects your ability to process and remember learning, learning is memory. I mean you can't learn without memory. And, and when they've studied this, they found that it takes three days off marijuana and then your memory comes back. You don't remember what you should have learned in class, but you regain the ability to learn again. So when you're using marijuana, it does impair your memory and therefore learning. But if you stop and then it takes three days, then you become a sharper student at that point.

Speaker 2: 14:43

So if you're using every day or every other day, you never have the chance.

Speaker 3: 14:46

Never clean out. Yeah. Yeah. And so, so that's an important aspect of marijuana is affecting learning in young adults.

Speaker 2: 14:52

Is it a myth or is it true that marijuana leads to apathy? Because I remember, think of the stereotypical person who's smoking a joint and they're kind of, you know, I don't care about the world. Is there any evidence that it kids or young adults are just, they don't seem to care as much about learning?

Speaker 3: 15:07

You know, the apathetic personality or apathy, everyone talks about it. It's kind of a non-medical thing that's hard to measure. But socioeconomic status, verbal iq, educational attainment, job satisfaction, those things have been measured and marijuana users have worse outcomes.

Speaker 2: 15:25

Now is there an amount of marijuana use in a teenager that doesn't lead to those negative outcomes?

Speaker 3: 15:31

Yeah, I mean it is dose dependent but in my world the most important question is daily use. So a daily user is gonna have all sorts of worse outcomes, learning and potentially mood and some other worse outcomes. So it's the daily users that get themselves into trouble and that's only a minority. There's a lot of intermittent, you know, weekend users, they're probably not getting into mm-hmm<affirmative> having these bad outcomes before

Speaker 2: 15:56

We leave adolescents and young adults. Is it a gateway drug to other drugs?

Speaker 3: 16:01

Hot topic? This is a debatable point. Uh, it is definitely associated with other drug use. There's no doubt that marijuana users are more likely to be using or to go on to use other drugs. Did the marijuana cause it or is it just an association? That's the eternal question. But for parents, it doesn't matter whether it's cause and effect. If your kid's smoking marijuana, it's worth, before you yell at them for smoking marijuana, take a breath and make sure you understand what else they might be using. Or another way to put it, if your kid's not smoking marijuana, they're unlikely to be using all the other drugs either. So it's kind of a, so you can cut either way. The association is important for parents. Did the marijuana cause it, I'll let someone else debate that point. So

Speaker 2: 16:50

We've talked about adolescents and young adults. We've talked about impairment while operating vehicles. Talk about the potential negative effects on your average adult who might smoke a joint every now and then. Are there any,

Speaker 3: 17:02

Well, I think it's really important for the average adult to consider set and setting meaning what is the setting, where am I, what's the context? Is this the appropriate time and place to be using cannabis? I shouldn't probably be doing it at a bar at midnight on Friday when I have to drive home in the privacy of my own home with trusted people around me. I don't need to go out and do anything. So that's the setting. And then the set is your mindset. You're in a good spot. You're not smoking marijuana cuz you're stressed out at work. If you're using it as that kind of coping mechanism, it probably doesn't help you at work the next day. And it's probably not the ideal way of doing it. So being mindful of set and setting I think minimizes the risks. If someone has an addictive history themselves, people can get addicted to marijuana. It's usually not a catastrophic addiction, but it's just becomes a thing you use every day, all day. And then maybe your spouse starts saying, geez, I really wish you'd stop doing that all the time. Why do you have to be stoned when we're having dinner together? Yeah. You know, like why we we're trying to go out and hang out with our friends and you gotta bring your cannabis along and vape in the back alley before we hang out with our friends. Your spouse is annoyed at you and maybe you find your using at work a little bit. Those sorts of troubles can happen in a minority of people. Again, it's not catastrophic, but it's a net negative on that person's life. So someone with an addictive history, I would say this is an addictive drug. Be careful.

Speaker 2: 18:26

Those are really insightful comments. So Charlie, that sounds not too dissimilar from alcohol. And you alluded to that earlier today. You, or at least you made an analogy about alcohol use. Could you put recreational marijuana use in that context and tell us how does it compare to alcohol use, which is legal in all states? And could you just compare it to alcohol use in this country?

Speaker 3: 18:48

Yeah, yeah. Alcohol is more a part of the, I mean 70% of us or more drink alcohol. It's a, it's very common. I intoxicant it's part of our culture. It's part of religious ceremonies and some of that is true to a much, much lesser extent to, uh, cannabis. It's much less pervasive in our culture. That's said alcohol has a dramatic negative health effect on our, our society. Like really bad. Our society pays a premium to drink alcohol in the form of healthcare expenditure, in the form of criminal justice issues. Violence happens because of alcohol. Alcohol is is a net drag on society. There's no doubt about it. And the magnitude of the cost to society that we drink alcohol. And I, and I drink alcohol myself. So, and I'm lucky to be able to do so in moderation. So I'm not hating on alcohol. But the cost to society of alcohol is almost certainly greater than what the cost of society will be for marijuana. Alcohol is an expensive vice, if you will. And uh, cannabis is, in my opinion, likely to be a little bit of a cost to society. But I don't think it'll be the scale of alcohol. Another way of saying it, if you go to our icu, our surgical icu, our trauma center, our burn center, our medical icu, there are a lot of people in those ICUs because of alcohol. There aren't that many people in those ICUs because of cannabis. Now on the other hand, if you go to the psychiatric icu, you're gonna see some people in the psychiatric ICU because of cannabis. Um, and so the psychiatrists are very intent on the harms of cannabis cuz they see it in, in their highest levels of their care. But by and large, alcohol creates more illness and harm than cannabis will. But we also have tobacco, which is outright just a poison. It's awful. So if tobacco's awful, it doesn't mean we have to legalize everything less awful than tobacco. Cause a lot of things would be legal

Speaker 2: 20:42

<laugh>. That all resonates with me, everything you just said. I, um, just got off a week in the hospital hospital caring for patients in the hospital. It's at a great number of my patients and alcohol related complications. Yeah, yeah. Many, many, many. And I, well it was just one week on service, but I didn't have a single one that had a mar a marijuana related illness. But then again, I don't work in the mental health

Speaker 3: 21:01

Ward and you certainly had people who used cannabis who came and that just was sort of incidental to their admission to the

Speaker 2: 21:07

Hospital. That's a really great perspective. Before we let you go, Charlie, could I get you to answer a few questions that have come up? First question, how will legalizing marijuana affect people who need to drug test for their jobs? Like say school bus drivers, right?

Speaker 3: 21:22

That is going to depend on the job. Each employer is gonna make a decision on this and it's hopefully going to be evidence-based based on do we want someone driving a bus on marijuana? Do we want a surgeon to be on marijuana? So each employer is gonna make their own decision. And

Speaker 2: 21:41

I'm gonna go with no and no on

Speaker 3: 21:42

This two I Yes. Yeah, I mean, yeah. And some employers are probably, you know, look, if you're a barista, they probably aren't that worried if their employee is using, you know, and that's nothing to say about the skill or the value of barista. I love my baristas, but it's gonna depend on the job and it's gonna, and so I what I counsel my patient, even with medical cannabis, talk to your employer and just, just have an honest, honest conversation. What's the expectation of me? What do you want to do? What's the testing protocol? So you are an informed employee.

Speaker 2: 22:12

Second question, is there a difference in those risks and benefits of eating cannabis versus smoking it?

Speaker 3: 22:20

So, yeah, I mean, it's hard. You know, an internist will never encourage smoking<laugh> and there is vaping. However, there was vaping associated lung injury that may, and that was a couple years ago, was, uh, in the news a lot and that was probably associated with vaping cannabis. Uh, that's a little less common now. So the good thing about inhaling a cannabis or marijuana product is you know how much you're using right away. So you tend not to use too much. Uh, use just what you need.

Speaker 2: 22:49

You mean you feel the effects right away. You

Speaker 3: 22:51

Feel the effects right away. So you don't use too much. The downside to eating cannabis is you sometimes you have to wait two to three hours before it has a full effect. And if you get impatient, you use more, you use extra. Now

Speaker 2: 23:05

This isn't doing anything. I'm have another one. And

Speaker 3: 23:07

Then it builds up and then two to three hours later you have a panic attack. And so the commonest thing, so eating cannabis is probably a safer way to go if you start low and go slow, start with a small dose and give it a couple hours to kick in. If you want something to kick in right away, you're gonna get yourself into trouble trying to eat enough cannabis to have a any feeling right away. So you gotta be careful about that. But if, if you can pace yourself and dose yourself appropriately, eating, um, eating is probably a healthier way to go with

Speaker 2: 23:36

This. Last question, and I don't mean to put you in the hot seat, but is the legalization of recreational marijuana in your opinion as an addiction medicine doctor, a net benefit or a net

Speaker 3: 23:46

Negative? Yeah, I mean, I, I think this is, um, probably going to be a small net negative for society. I think there'll be enough psychiatric harms and adolescent harms and motor vehicle accidents that it's gonna be a little bit of a drag on society. But I don't think it'll be nearly the negative of tobacco or alcohol. And I could be wrong on this. This is just, and I'm an addiction doc, so I definitely have my No, I appreciate

Speaker 2: 24:10

Your negative perspective. I think that's a good perspective.

Speaker 3: 24:12

Yeah. Yeah. I think it'll be a, a slight net negative, but I think, I think the vast majority of people who are basically average people are gonna either pay no mind to it at all or get a little bit of pleasure out of

Speaker 2: 24:23

It. This has been a great conversation. We've been talking to my friend and colleague, Dr. Charlie Resnikoff about recreational marijuana. I hope you've learned something on this show. If you want to hear Dr. Resn K's previous episode, go back to season one, episode four, where we talked about other issues with substance use disorders and addiction. Charlie, thanks for being on the show today. This has been a great conversation.

Speaker 3: 24:45

So much fun. Thank you

Speaker 2: 24:46

And thank you listeners for tuning into this episode. I hope you've enjoyed it and I hope you'll tune in for the next episode. And in the meantime, be healthy and be well.

Speaker 1: 24:55

Thanks for listening to the Healthy Matters podcast with Dr. David Hilden. To find out more about the Healthy Matters podcast or browse the archive, visit healthy matters.org. Got a question or a comment for the show, email us at Healthy Matters hc m e d.org or call 6 1 2 8 7 3 talk. There's also a link in the show notes. And finally, if you enjoy the show, please leave us a review and share the show with others. The Healthy Matters Podcast is made possible by Hennepin Healthcare in Minneapolis, Minnesota, and engineered and produced by John Lucas At Highball Executive producers are Jonathan Camino and Christine Hill. Please remember, we can only give general medical advice during this program, and every case is unique. We urge you to consult with your physician if you have a more serious or pressing health concern. Until next time, be healthy and be well.