Getting medical marijuana has never been easier in both Pennsylvania and New Jersey.
Telemedicine, online ordering, and home delivery — innovations spurred by the COVID-19 pandemic — have streamlined the process and encouraged more people than ever to explore whether cannabis might be a good health choice for them.
But patients new to the program face a bewildering array of cannabis products when they make their first foray into state-approved marijuana retailers, which in Pennsylvania are called dispensaries.
“Back in the day you got whatever your dealer had, and it was always “this is really good s—,” said one patient from West Chester, who started using cannabis to treat his depression in the 1970s. “Now there’s dozens — if not hundreds — of products and varieties.”
So how does a newbie decide which product — let alone how much of it — will be right for them?
Under state law, Pennsylvanians can obtain a doctor’s recommendation for marijuana if they have any one of 23 “serious qualifying conditions.” Those ailments range from chronic pain to anxiety, terminal illness to post-traumatic stress disorder.
Among the largest demographic venturing into the program are the elderly, who are using marijuana to treat chronic pain, anxiety, glaucoma, cancer, and other terminal illnesses.
They need guidance. Many are completely naive to the substance, having ignored the cannabis counterculture of the 1960s and 1970s.
“I see tons of geriatric patients who want to know how to make the first step,” said physician Sue Sisley, a cannabis researcher based in Arizona who consults as a medical director for several Pennsylvania medical marijuana companies including Whole Plants and Penn Health Group.
“Reliable information can be harder to obtain than the medicine itself,” Sisley said. “That’s because the federal government has impeded clinical research that would help us understand which strains, products, and dosages are best for which illnesses.”
But she notes that Canada and Israel are working with others in the U.S. to put the building blocks in place.
“Patients have to go on their own personal odyssey,” she said. “Everyone’s body chemistry is different, so it’s important for every patient to experiment until they find the right fit. No one fits a cookie-cutter algorithm.”
Physician Glenn Rosen of Parkside Family Medicine in Germantown sees a lot of value in medical marijuana but generally avoids recommending it to patients with severe psychological problems, such as extreme bipolar disorder or schizophrenia “because you could potentially induce a psychotic episode. I also don’t think you’d want someone who has mania to an extreme to be involved in the program.”
Rosen won’t recommend marijuana to younger patients who have early onset depression. And he screens for certain drug use.
“If anything, there are certain medications you’re trying to get people off. If someone is on a benzo[diazepine] or an opioid, your hope is to get them into the program and get them off those other drugs and get them on a medication that’s a lot safer.”
He is also cautious about recommending marijuana for teenagers due to potential effects on the developing brain. “No one can speak on any expert level on the long-term effects, but the same goes for Adderall or Ritalin.”
So generally start slow and try varieties of cannabis that have low levels of the psychoactive compound called THC, advises Sisley and other cannabis health experts.
“You don’t need a high-potency product,” said Ryan Goodchild, director of education at TerraVida Holistic Centers, a chain of marijuana dispensaries in Sellersville, Malvern, and Abington.
More nuanced products are favored by patients and consumers with years of cannabis experience.
Going for a cannabis variety with the highest percentage of THC can be akin to guzzling straight 151 proof rum. You’ll feel it, but it won’t necessarily feel good.
“My staff gets frustrated when people think THC is the be-all and end-all of good marijuana,” he said. “It’s not. It’s more complicated than that.”
There’s another myth that cannabis experts would like to dispel for both cannabis newcomers and old heads: the alleged effects of the varieties called “indica” and “sativa.”
“The rule of thumb used to be that indica was more relaxing and sativa more stimulating,” said Andrew Atterbury, chief pharmacist at Ethos Medical Marijuana Dispensaries in Philadelphia and Montgomeryville.
“The rhyme was that indica would put you ‘in da couch,’ ” Atterbury said. “But there’s been so much crossbreeding that those descriptions have become mostly useless. They primarily define the plant’s morphology or shape. Moving outside those categories can be more helpful.”
Finding the right ratio of THC to CBD is what patients need to determine first. CBD, also known as cannabidiol, is another compound found in marijuana.
THC is thought to block the perception of pain, Goodchild said, while CBD is believed to reduce inflammation and anxiety.
Some strains are turbocharged with extraordinary amounts of THC and have negligible amounts of CBD. Others offer a more balanced one-to-one ratio.
“Strain names can be worthless,” said Sisley, who serves as principal investigator at Scottsdale Research Institute.
“For instance, a strain called Blue Dream pulled from 10 different retail outlets can be wildly different because the genetics vary,” she said. “That’s why you want to stick with the biochemical profile of the material” noted on the label.
Every marijuana product sold in Pennsylvania and New Jersey is required to be labeled with the proportions of THC, CBD, and other notable molecular compounds.
A dispensary pharmacist, or a salesperson called a “budtender,” can help patients navigate those products.
Still, looking for the best strain may prove futile.
“The ’best strain’ may be the only strain that’s available at your local dispensary,” said Atterbury of Ethos. “It’s slowly getting better, but there remains a problem of supply meeting demand. So what we sell most is what we have available.”
Terpenes, dozens of molecules that give cannabis its distinctive rainbow of aromas, can boost efficacy through a phenomenon called “the entourage effect.”
Limonine, a terpene which carries a citrusy scent, is considered “energizing.” Myrcene, which produces a skunky or diesel odor, contributes to a more relaxing “couch-lock” feel.
To find the most effective product for them, patients should keep a journal, said Goodchild of TerraVida.
“Many of the strains have a strong effect on [disturbing] short-term memory, so it’s important to note how quickly they take effect, and how long they’re effective for,” he said. “Record how the strain affects you at different times of the day and how it affects your mood.”
Most important, start slow. Patients can choose products they can inhale — usually flower — an oil to place under the tongue, a pill, or salve. Buy — and try — small amounts first.
“Just because you’ve rolled a joint doesn’t mean you have to consume it all in one go,” she said. “Begin with one or two inhalations. And if you must drive, wait three or more hours before you get behind the wheel.”
Sisley recommends that concentrates — because they are extraordinarily potent — be used only by patients with a lot of cannabis experience.
If a patient consumes too much and starts to feel psychotic or paranoid, Sisley advises phoning a poison-control center.
“They’re accustomed to getting calls and can walk you through a negative experience,” Sisley said. “The paranoia usually lifts in 30 minutes.