Chronic marijuana users who have severe dental anxiety may choose to work with oral healthcare professionals to ensure that their oral or inhalational sedation is not compromised by their marijuana use. In these cases, the patient should avoid topical and edible formulations of marijuana for at least 24 hours before the dental appointment (or longer if possible), in order to avoid the potentiated effects of this drug combination. In the case of chronic marijuana smokers, there is a greater concern as to the overall respiratory health of the patient, in which case nitrous oxide/oxygen inhalational sedation may in fact be contraindicated. One study found that smoking both tobacco and marijuana synergistically increased the risk of respiratory symptoms two and a half times over baseline, while the risk of developing chronic obstructive pulmonary disease (COPD) increased threefold (Tan et al., 2009). If the patient has COPD, nitrous oxide/oxygen inhalational sedation is contraindicated, and the OHCP is therefore left with oral Marijuana-herbal interactions Plants are made up of hundreds of different biochemical constituents. Used in whole form, whether decocted as tea or used as an extract or salve, the action of whole-plant therapies is complex when looked at through a reductionist lens. The chemical constituents in plants occur in very small amounts. Herbs, although they have healing properties and the ability to create change and can even cause chemical reactions in the body, are not like pharmaceutical drugs typically produced from one substance. They are much more complex. When people ingest, apply, or inhale herbs, they are taking in very small “doses” of particular substances that are in a natural, rather than synthetic, state and are in formulation, so to speak, as they occur in nature. The safe use of whole plants is related to the use of a plant in its complex natural state. Often, botanical science reveals that medicinal plants contain constituents in balance, with seemingly opposing actions. Plant pharmacology is replete with examples of such balance or contradiction. For example, the hypericin constituent in St. John’s wort ( Hypericum perforatum ) “induces the cytochrome P450 system (inducing CYP3A4 in hepatocyte cells) and at the same time contains the bioflavonoid quercetin, which is a 3A4 inhibitor” (Libster, 2002, p. 74). Likewise, as previously mentioned, Miller and colleagues (2018) report that, although the THC in cannabis lowers ocular pressure, CBD seems to have the opposite effect.
sedation as the pharmacological alternative (Donaldson et al.,2012). As is the case with the analgesics discussed previously, in patients who may concurrently take marijuana and another CNS depressant, monitoring for excessive sedation and somnolence during co-administration is advisable. A study of 138 tobacco smokers surveyed concerning their marijuana use found that anxiety sensitivity was related to marijuana use. In other words, users of marijuana seemed to experience anxiety more easily than they might when not using marijuana. The 25-item and 5-subscale Marijuana Motives Measure and the Anxiety Sensitivity Index-3 were the instruments employed in the study (Norberg et al., 2014). Healthcare professionals may want to consider helping anxiety- sensitive clients who use both marijuana and tobacco to choose alternative recreational behaviors that are associated with less health risk than smoking marijuana. However, when people decide to use a standardized extract of a single constituent of an herb, such as hypericin, much like a drug, or use an herb in a form that departs from traditional use, the historical safety record is no longer applicable. For example, if the safety record of traditional medicinal use of garlic is related to eating the fresh chopped bulb in food or as an infused oil, new safety data will have to be collected for use of powdered garlic tablets. Whereas safety “information” related to traditional use of herbs is shared through oral tradition (e.g., where and when to harvest, how to gather and prepare and apply, how much to take and when), biomedical use of herbs compels research and further gathering of population safety information about new forms of herbal remedies and applications. When herbs are used in the treatment of biomedically defined diseases, the same safety standards are followed as are employed with drugs. Marijuana has been used for centuries and is relatively safe when compared with other illicit drugs. However, when an herb’s constituents are removed and placed in pharmaceutical single-constituent drug form, a new history of use begins. Safety cannot be inferred for these or any whole-plant products that diverge from traditional use. Marijuana-based pharmaceuticals and innovative products such as cannabinoid-terpenoid synergy drugs require a clinical-trial evidence base. At this time, herbal medications are not part of the typical dental armamentarium, and herbal interactions with marijuana are not a specific current concern (Donaldson, 2016).
LEGAL ISSUES ASSOCIATED WITH MARIJUANA
Legal status of marijuana Marijuana is the most commonly used illicit drug in the United States. In one month in 2014, as reported by the Substance Abuse and Mental Health Services Administration (SAMHSA), more than 22 million people aged 12 years and older used marijuana. Among adolescents aged 12 to 17, 13%, or 3.3 million, had used marijuana (SAMHSA, 2022a), and according to the 2020 survey, 4.2 million people had disorders related to the use of marijuana (SAMHSA, 2022b). Now that the use of marijuana is becoming legal in some form in most states (as of June 14, 2022, 38 states have passed legislation broadly legalizing marijuana; other states have legalized CBD oil), healthcare professionals are well positioned to affect the choices communities make about the supply, distribution, prescription, and care of people using marijuana, as well as the regulatory developments surrounding marijuana’s future and its use and abuse. Worldwide, the growing development of marijuana-based medicines has led to greater discussion among prescribers, the public, and policy makers. Ethical principles in health care mandate a degree of separation between the prescribing of a drug and its supply, thus necessitating the need for independent channels of distribution.
In the case of marijuana, growers are engaged in distribution and quality control of supply, and marijuana dispensaries are being established in states where marijuana is legal. Should the federal prohibition on marijuana be lifted and medical marijuana be legalized, pharmacists may also be responsible for the handling, supply, counsel, and oversight of the safe use of the plant as well as its related products and drugs. The line between medicinal and recreational use of marijuana is often blurred. Greater awareness and education can clarify distinctions between these two purposes for using marijuana (Isaac et al., 2016). Marijuana’s legal status has often been contrasted with that of legal opioids, which have killed thousands more people than marijuana. States that have legalized marijuana have reported a substantial decline in opiate and pain medication prescription overdose rates (Schepker, 2016). Use of both illicit and prescription opioids has reached the status of a “public health emergency” (U.S. Department of Health and Human Services, 2017). This is not to say that there are not significant potential risks in the legalization of marijuana. A published review of drug policy publications suggests that it is plausible that legalizing recreational marijuana use in the United
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