Psychosis, suicidal thoughts, scream-vomiting: Alarm sounded about high-potency THC products

Karen Randall, an emergency physician in Colorado, says “scromiting” cases were rare several years ago. Now she is seeing at least one per day.

Scromiting is shorthand for scream-vomiting, a condition that inflicts patients who use marijuana with high concentrations of tetrahydrocannabinol or THC, the psychoactive substance in cannabis.

The condition is much what it sounds like: screaming from nausea and vomiting at the same time.

“It’s a super huge issue,” said Dr. Randall, a practicing emergency medicine physician and vice president of case management at Southern Colorado Emergency Medicine Associates in Pueblo. Colorado became one of the first states to legalize recreational marijuana use more than a decade ago.

“They don’t necessarily have to be daily users. But they’re frequent users, and they’re using the high concentrate,” Dr. Randall said.

Weed is getting more potent as states rush to legalize it, raising fears that marijuana with little resemblance to Woodstock-era grass is causing psychosis, suicidal thoughts and other health problems despite the mainstream dogma that pot is harmless.

Mounting data and an eyebrow-raising report about schizophrenia rates in Denmark are ringing alarm bells in Washington and casting a harsh light on the relative lack of limits on how much THC can be put into cannabis products that are smoked, vaped or ingested.

“The higher the potency, the more addictive it is. It’s the addiction-for-profit model,” said Luke Niforatos, executive vice president of Smart Approaches to Marijuana, an organization that warns about the potential harm of marijuana use. “Once there was an industry producing and selling and manufacturing marijuana products, that’s when we saw potency start to skyrocket.”

Colorado and Washington in 2012 became the first states to legalize recreational marijuana. Since then, 19 states and the District of Columbia have joined them, though states have varying approaches to sales.

Now more people are using marijuana and doing so more frequently.

Data compiled by SAM shows that 52.5 million Americans used marijuana in 2021, up from 17.5 million in 1992. The number of Americans 12 and older reporting daily use increased from 6.2 million in 2009 to 13.8 million in 2019.

At the same time, the average potency of marijuana plant material has jumped from 1% to 3% in the 1970s to 18% to 23% today.

The amount of concentrates known as “shatter,” “budder” and “waxes” jumped during the legalization era from an average THC potency of 6.7% in 2008 to 55% by 2017. Some retailers advertise products containing as much as 99% THC, according to published medical articles.

Health officials in Washington state have reported a proliferation of highly concentrated THC products on the marketplace since legalization in 2012. Concentrates made up 35% of the cannabis market in the state by 2019, an increase from 9% in 2014.

As a result, modern users who vape or take other concentrates generally take in far more THC than people who used to pass around joints at parties.

“If you look at use now, you have your own vape pen, you don’t share and you’re using massive quantities,” Dr. Randall said.

The rush to legalize weed is challenging the “iron law of prohibition,” which argues that drugs increase in potency the more they are outlawed. This notion has an economic logic because “the greater the sanction risk, the more valuable it is to make things compact, which ought to favor potency,” said Jonathan Caulkins, a professor of operations research and public policy at Carnegie Mellon University.

“But folks who hate prohibition converted that to an ‘iron law’ just by wishing it to be so, and the facts clearly contradict it for cannabis,” he said. “It’s very clear that legalization has led to potencies that are much, much higher.”

Many politicians and industry players have pushed to loosen pot restrictions by saying the overhaul will advance social justice and equity without causing much societal harm. Yet a growing body of evidence is revealing a toll on public health.

A 2019 study published in The Lancet Psychiatry showed that European cities — London, Paris and Amsterdam — had higher rates of psychosis than other places analyzed. Highly potent weed, defined as at least 10% THC concentration, was more commonly available in those cities.

That same year, U.S. Surgeon General Jerome Adams warned that “the marijuana available today is much stronger than previous versions” and could be devastating for young users whose brains are still forming. His advisory said high doses of THC are more likely to produce anxiety, agitation, paranoia and psychosis.

“The psychosis, that’s so profoundly real,” said Dr. Randall, who is certified in cannabis science and medicine.

She said sufferers are in a wide range of ages, though the youngest she has seen was 7 years old.

“They’re very violent, very paranoid,” she said.

In February, the American Health Association said it surveyed more than 2,500 people ages 13-24 and found that 70% of the THC-only vapers and 60% of the nicotine-only vapers and dual vapers reported anxiety symptoms — worries, flashbacks, panic attacks and situational anxieties — within the prior week, compared with about 40% of participants who had never vaped.

More than 50% of people in all vaping groups reported having suicidal thoughts within the previous 12 months, compared with one-third of nonusers.

Last week, the National Institutes of Health released a study by its scientists and Danish partners. They found that young men who abuse marijuana are at a higher risk of developing schizophrenia. People with the disorder have difficulty participating in everyday activities.

The study examined data from health records spanning five decades and representing more than 6 million people in Denmark to explore the link between cannabis use disorder and schizophrenia. Scientists determined that 30% of cases of schizophrenia among men ages 21-30 might have been prevented by avoiding marijuana use.

The NIH said it is concerned about the emerging trend of high-THC products.

“As access to potent cannabis products continues to expand, it is crucial that we also expand prevention, screening, and treatment for people who may experience mental illnesses associated with cannabis use,” said Dr. Nora Volkow, director of the National Institute on Drug Abuse.

Laura Stack of Colorado said the Danish study didn’t surprise her.

Her son, Johnny, died of suicide by jumping from a six-floor building at age 19 after marijuana use, including vapes and highly concentrated “dabs,” made him “very paranoid and suspicious.”

“It’s not uncommon. It’s just something that hasn’t gotten a lot of play,” she said in a phone interview.

Ms. Stack launched a nonprofit, Johnny’s Ambassadors: Youth Marijuana Prevention, to speak at schools and warn other parents about the perils of marijuana use in young people.

She said the organization’s Parents of Children With Cannabis-Induced Psychosis support group has more than 600 parents, underscoring the issue’s prevalence.

Worries about scourges such as fentanyl often eclipse national conversations about the potential dangers of rampant marijuana use. Fentanyl kills more than 100,000 Americans per year, making it the No. 1 driver of overdoses in the U.S.

Ms. Stack said the parents she meets do not compare marijuana to fentanyl, though many view pot as benign.

“I ask them, ‘When’s the last time you used weed?’” she said. “It’s not even the same drug [anymore].”

A form of ingestion known as dabbing is generating the greatest alarm. The process involves concentrating THC into a solvent to resemble a sticky oil that is heated and inhaled.

“The kids use spoons, straws, nails. They steal their parents’ butane torch for the creme brulee from the kitchen,” Ms. Stack said. “You are high out of your mind. The kids get the serving size wrong all the time.”

Advocates for marijuana legalization point to studies that fail to find a causal link between cannabis use and conditions such as psychosis. They say acute cannabis-induced psychosis is rare or that people who experience it are either predisposed to psychosis or have preexisting psychiatric disorders.

The NORML Foundation, which advocates for the responsible use of marijuana by adults, said it does not support criminalizing products with high concentrations because that would drive the production and sale underground. It says regulators and concerned parties should provide the public with more comprehensive safety information about the effects of potent marijuana products while ensuring that products don’t get diverted to the youth market.

“Typically, when consumers encounter higher potency products, they ingest smaller quantities of them. There’s even a medical term for it: ‘self-titration,’” Paul Armentano, deputy director of NORML, wrote in a commentary for OtherWords, an editorial service published by the Institute for Policy Studies. “Second, higher potency THC products do not dominate state-legal markets. Retail sales records from these markets show that most consumers tend to prefer and to gravitate toward flower products of more moderate potency. Third, unlike alcohol, THC is incapable of causing lethal overdose, regardless of either its potency or the quantity consumed.”

Yet some experts warn that financial incentives will drive people into higher-strength products in greater numbers.

“Addicted customers are the most profitable customers. What stops this? Proper regulation. You can’t sell 50% ethanol content beer because the law says so. We have no such laws around cannabis. At the moment, it’s the job of states that have legalized to put those regulations in place,” said Keith Humphreys, a Stanford University professor who tracks drug issues. “So far, most of those supporting legalization at the federal level have shown little interest in regulating the industry at all. They want cannabis de-scheduled and don’t care much about regulating against risks.”

Only two states, Connecticut and Vermont, have capped THC content at 30% for cannabis flower and 60% for THC concentrates. Other states require warning labels for highly concentrated products.

“It’s still extremely high. But those two states have at least done something about it,” Mr. Niforatos said. “Most researchers agree it really needs to be more down to in the 15% range, 10% range — which, you know, that’s a complete non-starter for the marijuana industry.”

The Coalition for Cannabis Policy, Education, and Regulation, which includes tobacco turned cannabis giant Altria as a member, said high-THC levels are trending in regulated and illicit markets.

Evidence shows high-potency products interact with users differently than lower-potency products, and “there, of course, should be more study done here,” said CPEAR spokesman Chanse Jones.

CPEAR, which seeks a comprehensive federal regulatory framework for cannabis, said Congress should take a prominent role in crafting rules of the road for THC.

“This is clearly a place where federal prohibition hurts communities. [Lawmakers] can and should be helping lead this conversation and creating the product standards that keep people safe,” Mr. Jones said.

Mr. Niforatos said a nationwide education campaign about high-potency marijuana is needed because “nobody knows what’s out there.” He would also like the Department of Justice to clamp down on “extreme actors” in the high-THC markets, given that marijuana is still illegal at the federal level.

Pressed on marijuana policy, Attorney General Merrick Garland told the Senate Judiciary Committee in March that he is working on a department policy that would likely track with the Cole Memo. This Obama-era letter said the administration would not use federal resources to crack down on states that legalize marijuana use and put regulatory guardrails in place.

Mr. Garland said the Department of Health and Human Services “is working on the question of scientific analysis of marijuana.”

The NIH says the federal ban on marijuana as a Schedule I drug makes it hard for taxpayer-funded scientists to test and study highly potent pot products that are legally available in nearly a dozen states. Congress enacted a law last year to set up a registration process for marijuana research, but the NIH said significant legal and regulatory barriers remain.

“This makes it difficult for researchers to verify whether the claims being made by the companies selling these products are true, and prevents scientists from fully understanding the health effects, potential risks, and potential benefits of products containing cannabis,” the National Institute on Drug Abuse told The Washington Times.

Some states are resisting legalization. Missouri voters approved a state constitutional amendment in November to allow the recreational use of marijuana, but voters in Arkansas, Oklahoma, North Dakota and South Dakota have rejected similar measures.

Washington state lawmakers debated a pair of bills that would raise taxes or age limits on marijuana concentrates or more tightly regulate the concentrate market. Both bills died in committee.

Ms. Stack pointed to policy changes in Colorado that tightened the rules for medical patients ages 18-20, including purchase limits, and required young medical marijuana patients to get recommendations from two doctors. In the past, she said, high school seniors would rush out for medical cards once they turned 18 and often distributed products to younger students.

She said parents should forbid their children from using marijuana and keep close tabs on their smartphone usage, particularly at night, so they don’t order pot through social media apps.

“So many believe it is harmless, so I would tell them: Get educated,” she said. “With my son, there wasn’t a Johnny’s Ambassadors when this was happening. I had nowhere to go. No one believed me.”