1 August 2023
ROCHESTER Beginning Tuesday, Aug. 1, it is legal for adults age 21 and older to consume cannabis in Minnesota, the 23rd state to permit recreational use.
Cannabis has been available to some Minnesotans since July 1, 2015, when the state launched its Medical Cannabis Program. Patients can be prescribed cannabis for chronic pain, irritable bowl syndrome, seizures and 16 other medical conditions.
Minnesotans have also had access to food, drink, body care and supplement products that contain cannabidiol, CBD, which can be found in the cannabis sativa plant. CBD is FDA-approved as a treatment for epilepsy, according to Mayo Clinic.
Additionally, in July 2022, state law permitted the sale and consumption of edibles containing tetrahydrocannabinol, THC, derived from hemp, which is the same species though a different cultivar of cannabis plant but contains lower levels of THC, the compound that produces a high.
Despite its use in medicine, cannabis is a cause for concern for some clinicians, especially when they consider the developing brains of children and young adults. It is also an understudied substance, due in part to its federal classification as a Schedule 1 drug, limiting what we know, scientifically, about its potential benefits and harms on the human body.
“Cannabis is not one drug,” said Jacob Borodovsky, a senior research scientist at the Geisel School of Medicine at Dartmouth. “The cannabis plant itself, we’ve identified over 150 cannabinoid compounds that are present in the cannabis plant. THC and CBD are just two of those 150 or more identified compounds.”
So, what do we know about cannabis and its health impacts?
Marijuana as medicine
Dr. Dylan Zylla has been studying cannabis for more than a decade. As an oncologist and medical director of the HealthPartners Cancer Research Center, Zylla has observed how medical cannabis often administered as a pill can be used to treat pain and nausea caused by the patient’s cancer or their cancer treatment.
“It’s a medicine that has many potential benefits all in one,” Zylla said. “It helps with pain. Yes, it helps with nausea. Its biggest benefit, actually, is probably insomnia and sleep. It helps people sleep better, and when people sleep better, guess what? They feel better the next day, they have more energy … they emotionally feel a little bit stronger and more prepared to start the day.”
In a 2019 study that Zylla coauthored, he and his colleagues found that cancer patients enrolled in the state’s medical cannabis program had reduced symptoms such as anxiety, pain, fatigue, nausea and depression.
Mayo Clinic’s cannabis overview says the drug may have some benefit in treating glaucoma as well as muscle spasms and stiffness caused by multiple sclerosis.
Access to recreational cannabis may lead to higher enrollment in the state’s medical program, said Dr. Melanie Johnson, a medical cannabis certifying physician based in Zumbro Falls.
“Typically, recreational cannabis programs allow people to try cannabis for its pain control and mental health benefits without the commitment of medical cannabis certification,” Johnson said. “Once people experience the benefits, they usually choose to enter the medical cannabis program for the reliability of the products, variety of delivery methods and cost savings.”
Cautions and concerns about cannabis
An acute concern with cannabis is driving while high.
“If you consume cannabis by itself, you’re a worse driver,” Borodovsky said. “That is an incontrovertible fact. That has been established.”
Consuming alcohol and cannabis at the same time seems to multiply the impairing effects of both substances, Borodovsky added.
But when people are not behind the wheel, there are still some health impacts that individuals might weigh. In the context of medical cannabis, Johnson said certifying physicians will address patients’ side effects, potential interactions with other medications and their pre-existing health conditions.
“Medical cannabis is a safe and effective medication for the majority of people, however, there are some medical conditions that it can exacerbate,” Johnson said. “It decreases blood pressure and can make abnormal heart rhythms worse, so it should be used with caution in patients with heart problems.”
The American Heart Association reports that cannabis use is linked to increases in stroke, heart attack and heart arrhythmias, though the AHA notes that more studies are needed to measure short- and long-term impacts of cannabis on cardiovascular health.
In addition to cardiovascular concerns, Zylla said a history of mental illness needs to be considered when figuring out whether to prescribe cannabis to a patient.
“People with a history of schizophrenia or very uncontrolled mental health issues probably want to be careful with that,” Zylla said. “Sometimes it can trigger a psychosis episode I have not seen that happen. I think, generally, our patients seem to do OK with that, but that is a potential concern.”
“It’s very clear at this point that if you have some kind of schizophrenia-related disorder, THC will make your symptoms worse,” Borodovsky added. “But there’s still debate about anxiety and depression.”
The impact of cannabis on the brain, particularly in youth, is something Dr. George Realmuto is focused on. Realmuto is a retired psychiatrist, professor emeritus at the University of Minnesota Medical School and the former medical director of Child and Adolescent Behavioral Health Services in Willmar, Minnesota.
“I received referrals from Abbott Northwestern and Fairview to treat kids, adolescents, late adolescents who’ve used cannabis, and the psychosis did not clear up with the usual processes that psychiatrists use to treat psychosis,” Realmuto said.
Realmuto is a member of the Minnesota Psychiatric Society, which publicly stated during the 2023 Minnesota legislative session that it did not support the legalization of recreational cannabis. In the MPS’s position paper, the organization said it is “concerned (that) legalizing the recreational use of marijuana exposes teens and young adults (up to age 25) during a period of time where the brain is sensitive to developing addiction and exposure to addictive substances can permanently alter development of the brain.”
“The effect on adults with the brain that’s not forming new neural networks, it could be different than comparing it the brain that is still developing and forming new neural networks,” Realmuto said.
Realmuto cited a 2023 study in the Journal of the American Academy of Child & Adolescent Psychiatry that found that suicide mortality was increased among young women and teens, male and female, in states that had medical and/or recreational cannabis laws.
“That’s not going to be on the label,” Realmuto said of the study’s conclusions. “It’s not going to be on billboards, it’s not going to be at the dispensaries. … Higher suicide rate, you can’t ignore that.”
Substance use at the population level
The health impacts of cannabis can go beyond each individual’s experience. Borodovsky is an epidemiologist who studies substance use at the population level. Typically when U.S. states legalize recreational cannabis, uptake is slow, he said.
“A lot of it depends on like, well, have they started licensing dispensaries yet?” Borodovsky said. “It takes a while until you feel any effects and start to notice any effects of legalization.”
Minnesota does have a slow start in store. It is now legal to use cannabis without a prescription and grow your own plants, but for the foreseeable future, there is only one recreational dispensary in the state: NativeCare Anishinaabe Ganawenindiwin Dispensary, located on the Red Lake Reservation. Other licensed dispensaries in Minnesota aren’t expected to open until 2025, and in the meantime, several cities including Rochester have temporarily banned new cannabis businesses.
Something that could happen, Borodovsky said either with the start of recreational use or later on when dispensaries start popping up is an increase in emergency room visits.
“You’re going to see cases of extreme over-intoxication and adverse events,” he said. “I wouldn’t be surprised if your emergency rooms see a spike in over-intoxication due to cannabis edibles, and that’s why you want good regulation, packaging regulation.”
Whether increased cannabis use across Minnesota’s population will be good or bad for public health depends on a lot of factors, such as if the tax funds generated from cannabis sales go toward public health improvements.
“It depends, but in the big picture, cannabis is less harmful than alcohol and less harmful than opioids. It’s less harmful than tobacco,” Borodovsky said. “If people start substituting and stopping alcohol consumption, that’s a net positive, right?”
But the overall impacts of Minnesota’s recreational cannabis laws on statewide health trends won’t be immediately known.
“You’re not really going to know what the effects of your law are until 2033,” Borodovsky said. “It’s kind of a Wild West, and it’s a ‘swim at your own risk’ sort of thing.”
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