When the Texas Medical Association Reference Committee on Science and Public Health solicited testimony this spring on policy proposing a closer eye on hemp-derived tetrahydrocannabinol (THC) isomers, it heard only one thing: “Support.”
The new policy was born from a rapidly growing, sometimes thorny retail cannabis landscape in Texas.
Medical marijuana is legal in Texas only through the state’s Compassionate Use Program. (See “Understanding CUP,” page 44.) But patients may see hemp-derived THC products as an alternative because they appear to be legal and more accessible – for now – despite significant questions surrounding their safety, says Jennifer Fan, MD, a palliative medicine physician in Temple.
“I feel very limited,” she said. “I have had patients buying a lot of things from local stores or off the streets, and I appreciate their honesty – I just can’t make a recommendation for them in those areas, because I can’t guarantee what’s in what they’re buying.”
Not only are hemp-derived THC products not required to have accurate, helpful labels but also the existing body of research on them, while growing, is insufficient to make clinical judgments. In fact, medical research on cannabis at all proves difficult.
Kimberson Tanco, MD, a palliative medicine physician at MD Anderson Cancer Center in Houston, keeps up with what he can. As part of a review group for the Multinational Association of Supportive Care in Cancer, Dr. Tanco has examined case studies and surveys that suggest potential guidelines. But in doing so, he’s learned the unique challenges cannabis research presents.
“Research – standardized, random, controlled trial, blinded research [on cannabis] – is very limited for numerous reasons,” Dr. Tanco said, citing not just the hoops researchers must navigate but also the very real issue of inconsistent products, given the general lack of regulation and oversight of the industry.
That is exactly what TMA hopes to address with the new policy – something Dr. Tanco is glad to see.
“We really need to [have more research]. That’s the only way we can really, truly have good recommendations,” he said. Even among physicians, “there’s kind of a skew between acceptance of cannabis products versus knowledge.”
A regulatory tangle
TMA’s House of Delegates adopted new policy in May that directs the association to encourage:
- Surveillance and research investigating health outcomes associated with the use of hemp-derived THC isomers, such as delta-8 THC;
- Appropriate laboratory testing of hemp-derived THC isomers; and
- State and federal labeling regulation of hemp-derived THC isomers to include total THC (and isomer) concentration, active ingredients, pharmaceutical properties, and accurate warning labels.
The legalized sale of hemp in Texas began with the 2019 legislative session. House Bill 1325 legalized the sale of the hemp plant, which has very little THC, and its derivatives, including hemp-derived THC isomers like delta-8 and delta-9, so long as consumable products contain less than 0.3% THC.
However, that decision is under scrutiny. In 2021, the Texas Department of State Health Services (DSHS) listed delta-8 as a Schedule I substance. Hemp retailers, pointing to bills outlining delta-8 as legal, sought and won an injunction against DSHS’ decision that so far has been upheld. At press time, products containing hemp-derived delta-8 and delta-9 isomers were legal for sale in Texas.
In studying the issue, the TMA Council on Science and Public Health expressed concern in a 2022 report that without established federal or state oversight, the hemp-derived THC market is opaque and potentially unsafe for customers. Products are frequently mislabeled; information listed on their packaging may not match the actual contents, raising issues with not just potency and consistency but also possible contamination with other drugs. The report also cited sweet or fruit-flavored products in packaging featuring bright colors and cartoon characters – attractive to children and adolescents.
The U.S. Food and Drug Administration has received reports of adverse events related to consumption of delta-8 products, including those in children necessitating emergency care. Additionally worrisome for medicine is that some retailers market their products as being helpful for symptoms of a wide range of conditions from chronic pain to cancer, the council report noted.
Open conversations
TMA’s new policy encourages patient protections at the point of sale by pushing for labeling regulations and laboratory testing. Some physicians say the stated goal of increased surveillance and research also can help them better care for patients who may be using hemp-derived THC products.
While Dr. Tanco says patients are generally honest about their habits, in his experience, they may not be used to discussing them with a physician.
“Our [practice’s] policy has never been to discontinue [use of cannabis products] or tell them to stop it. We try to understand why they’re using it and if it’s actually helping them or not. We try to be very inquisitive and also arm them with education” about side effects and interactions with other medications, for instance, he said. “They probably have never had any of those discussions in the past. They probably had more general information from friends, family, or whoever. They seem to appreciate it.”
Carlos Tirado, MD, an Austin psychiatrist, uses a similar approach.
“I first acknowledge that most patients who are using cannabis as medicine are seeking relief from physical and/or psychological suffering,” he wrote in an email to Texas Medicine. “I try to separate recreational use from medicinal use. If a patient is using medicinally, they believe cannabis is ameliorating a negative condition, and I ask them to specify the condition(s) they are trying to self-treat. I additionally ask if they find cannabis improves or worsens the condition [and] if they have any signs and symptoms of physiologic dependence.”
Involved, open conversations like this allow Dr. Tirado to use his judgment to determine if cannabis is interfering with treatment. He notes that in psychiatry, cannabis has only been approved by the Compassionate Use Program for medical treatment of post-traumatic stress disorder.
Dr. Fan adds that the average family physician or internist probably won’t see many patients who could benefit medically from cannabis.
This doesn’t rule out the chance that patients may use hemp-derived THC recreationally, which they’re even less likely to bring up to a physician.
Nevertheless, persistent social stigma puts the responsibility on physicians to ask first, she says.
“A lot of times when people come to me, they don’t want to bring up the topic,” Dr. Fan said. “It’s sort of a door-handle question. Patients are scared of being labeled as drug-seeking, and so if we don’t bring it up, sometimes they won’t.”
To be properly equipped to talk to patients about cannabis, Dr. Tanco encourages physicians to first learn the state’s related laws, and then read up in journals.
“It can help them when they get asked questions, either by their patients about potential use or when the patient is already using the product, so they can give an honest opinion about risk and benefits,” he said. “If the patient doesn’t stop using, at least [physicians] know what to monitor for.”
But the patient-physician relationship goes two ways, Dr. Fan adds. Especially when lacking resources and regulations, encouraging honesty may be the next best thing.
“The advice I would give goes back to the original principles of how we were trained to be a humanistic doctor: to listen to your patients,” she said. “Going back to that principle of listening to your patients is what will help guide a provider on what to do – not only in the big picture of caring for patients but also each individual, patient by patient.”