As the author of Cannabis for Chronic Pain, Boulder-based Dr. Rav Ivker is among the country's best-known and most respected advocates on behalf of medical marijuana. But he's wary about weed consumption in a number of circumstances, warns that pot addiction is real, and is so against the consumption of powerful concentrates that he supports banning them.
"I think they should be illegal," says Ivker, who practices at Fully Alive Medical Center. "In fact, I hope they become illegal. The only thing they're good for is getting really high. But they're high-risk, and there's really no benefit from them."
Although many proponents have argued for ages that marijuana isn't addictive, studies conducted by the National Institute on Drug Abuse maintain that 9 percent of users will become dependent — and that number rises to 17 percent for those who began consuming cannabis while in their teens.
Ivker believes these figures, which were given new life in recent weeks thanks to a widely syndicated Washington Post story. "I address them in my book," he points out. "I have the exact same statistics. So this is real."
Moreover, Ivker feels the addiction problem has been exacerbated by the introduction of "high-potency marijuana products, including concentrates — the shatter and the wax. These can contain from 80 to even 95 percent THC."
In his view, the argument that marijuana isn't addictive "goes back to maybe a decade or two ago, when the highest potency marijuana flower probably contained 5 percent or maybe 10 percent THC. But today — and we're talking about just the marijuana flower — the highest sativa strains can contain 25 to 30 percent THC. That's what most people are smoking. And what they're dabbing can be two or three times more potent than that."
The people "who are most attracted to these products happen to be adolescents and young adults — people in their twenties," Ivker continues. "And even more concerning than the addiction problem is the fact that our brains are still developing until we're in our mid-to-late twenties. The THC affects brain function and can create a higher risk of schizophrenia, and that's really awful. We're definitely seeing an increase in the number of young people developing schizophrenia from the daily use of cannabis. I think that's the greatest health risk of all, and one common denominator is that people who are at the highest risk for developing schizophrenia began using daily before the age of eighteen."
He stresses that he hasn't developed doubts about the medical efficacy of marijuana. "I advocate for cannabis as a medicine for treating chronic pain. That's the title of my book, and Fully Alive is predominantly a chronic-pain practice, a holistic medical practice. The vast majority of my patients have chronic pain and are using medical marijuana to treat their problem, along with other modalities. And because I teach my patients how to use cannabis appropriately as a medicine, I don't see the addiction problem among my patient population."
Still, Ivker advises younger patients, who make up between 5 and 10 percent of the folks he sees regularly, "to avoid using cannabis on a daily basis unless they absolutely need it for pain relief. And in those cases, I often recommend topicals — creams and salves that have proven to be highly effective. Many of these young people have chronic pain as a result of sports-related injuries — snowboarding, mountain biking — and also automobile accidents. And they can get two to three hours of relief without getting high from a topical."
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The doctor also uses "a fair amount of CBD, which is not psychoactive and is an excellent analgesic and anti-inflammatory. Most people with chronic pain have some degree of inflammation, and CBD along with a topical is excellent as pain relief with no downside whatsoever. There's no psychoactive effect, no addiction problem, so you can use it multiple times a day — and that's what I've been doing with the younger patients, and some older patients as well. The strongest pain-relieving combination is a one-to-one ratio of CBD and THC, but in the most severe cases, you can add more CBD by itself. It's really a remarkable medicine. I've been a family doctor for 46 years, and I've never seen a medicine as effective for pain without any downside."
As for marijuana's addictive qualities, Ivker urges that they be put into context: "Marijuana, like any substance or behavior that affects the reward system of the brain, has the potential for dependence and possible addiction — and that includes food, sex and even television. THC releases dopamine in the brain, and dopamine is the neuro-transmitter that causes us to have feelings of pleasure, just like food, sex and TV do. And it's the vulnerable individual that can lead to problem use, dependence and possible addiction. A patient's mental-health history, such as a diagnosis of depression, anxiety or mood disorder, or a family history of addiction, can serve as a warning that marijuana could be a potential problem. So, really, it's not the drug, but the user of the drug that is the major contributor to addiction — and rather than emphasize the dangers of marijuana, I would focus on the the mental-health history of the user and the risks of concentrates."
With that in mind, Ivker notes, "I strongly advise my younger patients to stay away from concentrates. A lot of them say they have friends who are dabbing on a daily basis. But when I warn them about the dangers, they often tell me that they're going to let their friends know."
He adds: "They don't hear about the risks in dispensaries. They're not informing people about that. A lot of them think it's totally safe, and most of them are not even aware of the addiction problem, let alone the schizophrenia problem. But it's well known within the addiction-medicine community that this is a problem, and it's important that we let people know about it."