Medical Marijuana for Ohioans with Autism?

By Dr. Cindy Ripsin

Earlier this month, the Statehouse News Bureau reported the Ohio House passed a bipartisan bill to add autism spectrum disorder (ASD) to the list of twenty-five conditions for which medical marijuana can be used. It passed by a margin of seventy-three to thirteen. The bill now goes to the Ohio Senate for approval. However, even if the bill passes, there are many considerations families should consider before beginning that treatment. We hope the following information is helpful and encourage you to discuss any questions you may have with your family physician.  

Currently, the Food and Drug Administration (FDA), the division within the Federal government that regulates prescribed drugs, considers marijuana a Schedule I drug, which, by definition, means “no currently accepted medical use and a high potential for abuse.” This designation is actively being reconsidered as research about the potential benefits evolves. This website has information you might find helpful:  What You Need to Know (And What We’re Working to Find Out) About Products Containing Cannabis or Cannabis-derived Compounds, Including CBD | FDA.

Thirty-eight states, including Ohio, currently allow marijuana to be prescribed for a set of health conditions identified by each state. The following information may be helpful for you if ASD is added to the Ohio list of conditions: 

What is Marijuana? 

Marijuana, the common name for the cannabis plant, contains over 400 chemicals (grouped into cannabinoids, flavonoids, and terpenoids). Two chemicals in the cannabinoid group are most studied for their effects on physical and mental health conditions: 

Delta-9 tetrahydrocannabinol (THC): THC produces the “high” associated with marijuana, the so-called psychoactive (intoxicating) effect, and can also affect appetite, cognitive function, and memory, and can have effects on anxiety.    

Dronabinol (brand names include Marinol, Syndros) is a legally prescribed synthetic form (made in the laboratory) of THC that is FDA approved to increase appetite and decrease nausea and vomiting for people with cancer and other wasting syndromes such as late-stage AIDS.  

There are other non-FDA-approved synthetic chemicals that act on the same receptors in the brain as THC. Marketed as “synthetic THC” and sold in convenience stores and illegally sold on the street, these drugs are not actually synthetic THC. Kush, K2, and Spice are common names. Although it might seem that products legally purchased in a convenience store must be safe, when compared with synthetic THC, the intoxicating effects of these look-alike drugs are more intense, unpredictable, longer acting, and far more likely to cause hallucinations, seizures, and violent behavior (About synthetic cannabinoids | NCEH | CDC).   

Cannabidiol (CBD): CBD does not have the intoxicating effects of THC. Serotonin is one of the chemicals known to be disrupted in people who suffer from anxiety and depression. Early studies have shown that CBD can trigger certain receptors in the brain (for example, 5-hydroxytryptamine) to improve serotonin levels, similar to antianxiety and antidepressant prescription medications.  

Disruption of dopamine in the brain is seen in people with schizophrenia and other psychotic disorders. Early studies suggest that CBD might positively impact the dopamine system, potentially improving psychiatric symptoms associated with psychosis. 

Epidiolex is a legally prescribed FDA-approved form of CBD used to treat certain types of seizure disorders.   

Hemp is a species of cannabis plant that contains tiny amounts (less than 0.3%) of THC. CBD derived from hemp can be legally sold without a prescription in Ohio and is available in edibles, creams, salves, vapes, and other forms, and is often marketed to improve mood and sleep and decrease anxiety. One challenge when considering the use of nonprescription CBD is that the concentration of CBD can vary substantially from product to product and even within a product line (see below).   

What is the Ohio Medical Marijuana program? 

Marijuana is legal for recreational use in eighteen states, although not in Ohio. Sold legally and illegally for recreational use, the cannabis plants are bred with the goal of achieving high levels of THC content to maximize the “high” experienced by users. The content of THC has significantly increased in marijuana products since 1970 as its use as a recreational drug has increased. Obtaining this “high” is not the goal of Medical Marijuana programs; the concentration of THC in Medical Marijuana is regulated by law in all state programs (see below). 

The Ohio Board of Pharmacy regulates all the following: 

• Who can prescribe Medical Marijuana

  • Physicians must apply for and be approved for certification

• What conditions it can legally be used for

  • Voted on by state legislators when new conditions are requested by Ohio citizens

• How it can be used

  • It can be processed and sold as oils, tinctures, edibles, capsules, and vaporizing forms but not in a smokable form

• Who can sell it

  • Retailers are licensed and regulated, and they operate within dispensaries

• The testing process prior to distribution. Certified testers

  • Determine the safety of the material (lack of dangerous additives, lack of bacteria, fungi, and other harmful substances)

  • Determine the THC content of each sample. By Ohio law, each sample must be within 90-110% (49.5 mg to 60.5 mg) of the legal maximum of 55mg (70% by content ) of THC.

What is the evidence for using Cannabis products for ASD? 

The evidence is rapidly evolving on this important health topic. High-quality research is being conducted in medical centers around the world. You don’t need to be a researcher to stay well informed. Using this website (https://www.clinicaltrials.gov/ ) will help you stay up to date on the highest quality evidence. Use the search boxes to find information on your area of interest. For example, putting “autism,” “autism spectrum disorder” combined with “Cannabis” and “Cannabidiol” in the search boxes yields important details about ongoing trials. Here is a sample from a recent search: 

• Children’s Hospital of Philadelphia is conducting a three-part study, the first of which is a registry of children who are currently prescribed Medical Marijuana for ASD to understand the natural history for using this drug in this population. The second part will determine how Medical Marijuana acts within the bodies (pharmacokinetics and pharmacodynamics) in people with ASD, and finally, this information will be distributed in an organized manner. A registry is different than a clinical trial in that the researchers passively collect information about a particular topic that is already occurring instead of actively recruiting subjects and dispensing the drug of interest. However, registries can still provide very valuable information to help researchers plan controlled trials. 

• At least ten clinical trials studying the effects of CBD on children/adolescents and adults and at least one trial testing Medical Marijuana on children and adolescents with ASD are either just beginning, already underway or nearing completion. Most of these trials are well controlled, meaning they use a comparison group not taking the drug that closely resembles the group taking the drug, so it can be determined with confidence whether the effects seen were truly due to the drug or occurred by chance. 

Another high-quality resource free to the public is this website (PubMed (nih.gov). Using the search boxes as above will provide access to published research as well as summary articles on a wide range of topics. Many of the articles, although not all, are free to access online. Each article indicates in RED if there is a free copy available. Here are some examples: 

• This review article (Current state of evidence of cannabis utilization for treatment of autism spectrum disorders. BMC Psychiatry 2019) is primarily targeted to scientists and psychiatrists but provides plenty of information that non-scientists might find useful.  

• A recent case report (Journal of Autism and Developmental Disorders September 2021) describes three young adult men with ASD who developed psychosis after regular use of cannabis products: one using only CBD and two others using Medical Marijuana. None of these young men had psychosis prior to using cannabis products, and in each of these cases the psychosis continued after stopping cannabis. Case reports are not clinical trials but provide detailed information about a particular situation, in this case psychosis after using cannabis, that the authors believe requires further study. 

• In recreational users of cannabis without ASD, it has been determined (Schizophrenia Bulletin September 2016) that the chance of developing psychosis after heavy regular use is almost four times as high compared with people who have never used cannabis. This was a meta-analysis (a summary of many studies) that included over 66,000 individuals.  

• As part of a larger study funded by the National Institutes of Health (2018), researchers found that, after a single dose of CBD, brain imaging demonstrated some differences in certain parts of the brain (pre-frontal cortex) of people with ASD compared to those without ASD.  This suggests that drugs might act differently within the brains of people with ASD compared to people without ASD.

• Researchers (JAMA November 7th, 2017) testing the concentration of CBD in eighty-four products from thirty-one different manufacturers sold online found that only 22% of the products had the same concentration of CBD as stated on the label; 36% had less than what was labeled and 22% had more than stated on the label.   

• After alcohol and tobacco, cannabis use is the third most used recreational drug worldwide. Cannabis Use Disorder, like other substance use disorders, is defined as an inability to stop consumption even when it is causing harm. As recreational cannabis use has increased and the amount of THC in cannabis has also increased, Cannabis Use Disorder has come more often to the attention of the health care community. Stopping cannabis after regular use can trigger withdrawal symptoms, including abdominal cramping, sleeplessness, irritability, and cravings for the drug. Approximately 10% of regular users of cannabis (Cannabis Use and Cannabis Use Disorder, In Nature Reviews, Disease Primers February 25th, 2021) develop Cannabis Use Disorder.   

As Ohio moves toward allowing the use of Medical Marijuana for ASD, we can all monitor—transparently and under more controlled conditions—the benefits and side effects of cannabinoid products. Remember, always look to trusted resources to help you understand the crucial balance between benefits and risks so that you can, with the assistance of your physician, make the best possible choices.  

Dr. Cindy Ripsin is a board-certified family physician with over twenty years of experience caring for patients of all ages. She is the medical director for Boundless Health.