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Mixing Marijuana with Other Drugs

Disclaimer: AspenRidge Recovery does NOT endorse the use of any mind-altering substances, including cannabis. We know that marijuana is an addictive substance that can cause significant problems in the lives of many individuals and families. If you or someone you know is struggling with marijuana addiction, contact us directly at (855) 281-5588. Please understand the risks associated with mixing marijuana with other drugs. Read more below.

Mixing Marijuana with Other Drugs: What You Need to Know

Our advice to those who struggle with addiction is always to abstain from the use of habit-forming substances. However, because weed is readily available to residents of Colorado and other states, we believe it is our duty to provide relevant health considerations and educate you about marijuana drug interactions.

Considering there’s a lot of buzz surrounding the potential benefits of medical marijuana, it can be easy to assume that this drug is safer than others. However, there are many risks that come with marijuana use, particularly when used in combination with other prescription medications or with illicit substances. Mixing marijuana with other drugs, in fact, can be risky and even

Weed – Colorado Legalization & Nationwide Use

Without question, the United States has seen a profound shift in drug policy in the past decade. Colorado was the first to legalize marijuana in the U.S. with Amendment 64 passed in 2012. Since then, a number of other states have followed suit, making it legal and accessible for recreational and medicinal use. Nevertheless, pot is still illegal in most states. Users caught in possession of the drug can be ordered to pay hefty fines or spend time in jail. Still, millions of Americans are daily users and rely on this substance to get through the day.

As more studies are conducted with respect to pot use nationwide, the more is understood about risks involved in mixing marijuana with other drugs. There’s some indication that cannabis interacts negatively with other substances, such as alcohol, for example. We’re taking a closer look.

How does cannabis interact with other drugs?

Although most people would probably rank weed pretty low on the totem pole in terms of danger, combining it with other substances can have negative consequences. In this article, we will talk about what happens when mixing marijuana with other drugs, such as:

  • alcohol
  • prescription drugs
  • illegal substances.

But, first – let’s answer some of the most commonly asked questions about cannabis. We will be talking about naturally grown cannabis – NOT dabbing or synthetic marijuana.

We offer marijuana addiction programs for Colorado residents. Our compassionate staff offers supportive services for a variety of substance addiction and we provide a dual-diagnosis approach to the treatment of ongoing substance misuse, abuse, and addiction.

1. Can Marijuana Kill You?

The potency of the weed available for sale on both the black market and in legal dispensaries around the country is significantly higher than it was decades ago.

Unfortunately, the potency of marijuana can create issues for users. In fact, many described the sensation of feeling like they’re dying. A weed induced panic attack can sometimes cause a feeling of impending death.

When cannabis contains high levels of THC (the active ingredient in pot that gives you a buzz), it can cause a feeling of overwhelming anxiety, which can generate a feeling of extreme panic. In this frenzied state, many people will think, “Uh-oh. Can marijuana kill you?” The answer is no. While ingesting high levels of THC can cause a user to FEEL like they are going to die, the feeling quickly passes.

Still, there are both short and long term adverse side effects of marijuana use. It has been known to cause impaired judgment and motor skills, and there are increased risks of use when mixing marijuana with other drugs.

2. Is Marijuana a Depressant?

Many people who come to us for addiction treatment ask us, “Is weed a depressant?” The drug actually falls into three categories. Weed can be classified as a:

  • depressant
  • stimulant
  • hallucinogen.

This is because cannabis affects everybody in unique ways and various types of pot generates different kinds of effects. When some people get stoned, they feel relaxed and sleepy.

Some immediate side effects include and experienced:

  • loss of motor skills
  • poor coordination
  • lowered blood pressure
  • short-term memory loss.

In this way, cannabis is a depressant for many users. However, you might be surprised to learn that for many, weed is a stimulant. When most people think of stimulants, they think of cocaine or methamphetamines. These drugs make the user feel super “speedy.” Pot doesn’t deliver this type of extreme mental or physical stimulation. Nevertheless, it can cause someone to experience an increase in:

  • heart rate
  • raised blood pressure
  • anxiety
  • paranoia
  • amped energy
  • a jolt of motivation.

Finally, weed can be hallucinogenic. While a user won’t experience extreme hallucinations like they would if they took LSD or DMT, they can have auditory, visual, or sensory hallucinations. (For example, someone who is high on weed might think their cat is telepathically communicating with them). So, there you have it. Clear as mud, right? Whether weed is a depressant, stimulant, or hallucinogen depends on your own body chemistry and the type of cannabis you are using.

3. How Does Marijuana Affect The Brain?

In order to understand why mixing marijuana with other drugs is not a good idea, it helps to first understand how cannabis affects your brain. Essentially, when you use cannabis in any form, the drug activates tiny little spots on the cells in your brain. These are called “cannabinoid receptors.” Those little receptors are there to receive endocannabinoids, which are neurotransmitters that our system produces naturally to help our body and brain communicate with each other.

When someone uses weed, however, the drug generates “phytocannabinoids” (THC, CBD, and others) in their body that jump in and take the place of the naturally-produced cannabinoids. Some effects of the drug, like euphoria or decreased pain, can be attributed to the fact that these new cannabinoids alter the way the body and brain are communicating with each other.

Combining weed with other drugs, however, can alter this process, making things a bit more complicated. Marijuana drug interactions can cause phytocannabinoid production to increase at an unsafe rate, making it difficult for the user to function properly.

4. Can You Become Addicted to Weed?

Without a doubt, absolutely, no question about it – you CAN become addicted to marijuana. Most regular pot users will laugh at this assertion. They will say they can quit anytime, but they don’t want to. They will say they enjoy the way green makes them feel and that they have no intention of stopping. They will say weed is a natural substance that grows from the earth and that it completely harmless. Most people who use bud regularly refuse to even consider the possibility that they might be addicted. Here’s the thing. Heroin is also a natural substance that grows from the earth. Those who chase the dragon offer up the same explanations for their habit – they can quit anytime they want, they don’t want to quit, they like the way the drug makes them feel, etc. No one questions if heroin is addictive, yet users will insist they aren’t hooked! The same is true for regular cannabis users.

The Straight Scoop On Marijuana Drug Interactions

Now that we have answered some of the most commonly asked questions about weed, let’s talk about mixing marijuana with other drugs.

Most pot users completely downplay the powerful effect this drug has on the brain and body. In recent years especially, we have been taught that weed is relatively safe – especially when compared to alcohol, cocaine, heroin, crystal meth, and other addictive drugs. Like any psychoactive drug, pot can interact with other psychoactive chemicals in a way that produces less than desirable results.

As weed becomes increasingly more accessible, it is helpful to know about marijuana drug interactions. That way, if you or someone you care about chooses to partake of this substance, you’ll be able to do so in the safest and most responsible manner possible.

Mixing Marijuana and Depressants

Many people mix marijuana with depressant drugs like alcohol, barbiturates, and benzodiazepines (like Xanax) because they like the way it makes them feel. This can be dangerous.

Here is a quick study in pharmacology. Depressants are drugs that inhibit the central nervous system (CNS) functioning and cause breathing and blood pressure to slow down. Many depressants also increase the production of the neurotransmitter known as gamma-aminobutyric acid (GABA). GABA carries messages between cells. Increased GABA activity reduces brain function. This leads to drowsiness, increased relaxation, and deep sleep.

Mixing marijuana with other drugs like depressants can cause the heart rate to decrease to a very low rate. It can also inhibit the user’s basic motor skills, making it difficult for them to think clearly, speak, or react appropriately to things around them. More importantly, mixing weed with depressants can be fatal or cause serious health complications. This may sound extreme, but many people who have gone to the emergency room because they have stopped breathing tested positive for marijuana and depressants. This is not a coincidence.

Mixing Marijuana and Alcohol

Let’s talk about mixing marijuana and alcohol for a minute. These are the two most commonly used drugs in America.

Getting “crossfaded” is very common among pot users. People say they like the buzz caused by the effects of booze and pot. The risks can be significant. For starters, the combination of weed and alcohol is known to increase the effects of each drug. Users who mix the two become drunk and stoned much quicker and with greater intensity. Exaggerated effects of THC can cause those terrifying weed-induced panic attacks, as well. It can also cause:

  • extreme paranoia
  • frightening hallucinations
  • disorienting short-term memory loss
  • complete disconnection from reality.

Exaggerated effects of alcohol can lead to blurred vision, complete loss of motor skills, slurred speech, nausea, vomiting, and other unpleasant consequences. Put these two together – and it’s a recipe for disaster. If your goal is to get high and drunk at the same time by mixing alcohol and marijuana, just know going in that you might be in over your head.

Excessive drinking becomes problematic when done in combination with cannabis because weed prevents you from vomiting. While you might become nauseous, you may not be able to throw up. Usually, when someone drinks too much, they throw up, which helps flush all the alcohol out of the system. However; pot can prevent this from happening. As a result, drinking alcohol and using cannabis at the same time leads to an increased risk of alcohol poisoning – which almost guarantees a hospital visit. According to US News at least 2,200 people die every year from alcohol poisoning. Many of them were drunk AND stoned. Also, It should go without saying that no one should ever drive or operate heavy machinery while they are under the influence of green and alcohol. It is particularly important for those who use a combination of marijuana and alcohol to stay far away from the driver’s seat of a car.

Mixing Marijuana and Prescription Medicine

Millions of Americans are prescribed benzodiazepines like Xanax, Valium, and Klonopin for anxiety, insomnia, and other health conditions. By themselves, these anti-anxiety medications are dangerous. They are not only highly addictive, but they also deliver a powerful sedative effect many. If you combine benzos and weed, you are looking for trouble. Remember, we told you that Xanax and other benzos are depressants. You should never mix depressants and cannabis. They can significantly reduce heart rate and blood pressure and lead to coma or death. Another thing you should know about mixing marijuana and benzos is that you are likely to wake up in the morning (if you are lucky enough to make it home safe) with absolutely no recollection of how you got there.

Benzodiazepines are notorious for affecting memory and causing blackouts. Bud is also associated with short-term memory loss. When you mix these two substances, you are likely to walk around in a mental fog that will prevent your brain from creating new memories. This increases the likelihood that you will put yourself in dangerous situations that could result in you getting robbed, assaulted, or something much worse.

Mixing Marijuana And Suboxone

What about mixing marijuana with other drugs like suboxone? This synthetic compound, which can be found in many opioid replacement therapy drugs like Suboxone and Subutex, has a sedating effect much like marijuana. Buprenorphine is often prescribed to those who are dependent on opioid drugs like heroin, Oxycodone, or Fentanyl. It helps fight off cravings and withdrawal symptoms. Therefore, it is likely that someone who is prescribed the drug would not want to mix it with an addictive substance like cannabis in the first place. However, those who are considering using bud while on Suboxone, Subutex, or another drug containing buprenorphine should seriously consider the safety risks. The problems with mixing marijuana and buprenorphine stem from the fact that the opioid replacement drug has strong depressant effects. Upon taking a prescribed dose of drugs like Suboxone, the user’s central nervous system will begin to slow down. Because marijuana can also act as a depressant, using the two drugs in combination can lead to respiratory depression and death. Also, it is important to note that combining marijuana and Suboxone or other opioid replacement therapies can render buprenorphine ineffective. This means that cravings for opioids and withdrawal symptoms will eventually kick in, which can lead to a relapse.

Can You Mix Marijuana And Antidepressants?

Mixing marijuana with other drugs like antidepressants are, also, a no.

Most drugs don’t mix with antidepressants. Pot is no exception. Antidepressants are prescribed to treat psychiatric conditions like

  • anxiety
  • depression
  • PTSD
  • other mental disorders.

Many people use green while taking their antidepressants to self-medicate in an attempt to find relief from their mental health issues. This is not the solution. In fact, mixing marijuana and antidepressants can actually make things much worse. For example, cannabis causes many people to experience anxiety. Those who have Generalized Anxiety Disorder or other similar conditions can actually feel more anxiety when they use pot. Medications like Prozac, Lexapro, and Zoloft are commonly prescribed to treat anxiety. Combining these antidepressants with marijuana can counteract the meds and enhance anxious thoughts and feelings. Some studies have shown that chronic cannabis use can lead to depression. This is ironic because many people think getting high makes their condition better. The problem is, the drug wears off and feelings of despair return. Then, the user uses more pot to feel better. It can become a vicious cycle. Wellbutrin, Celexa, and Paxil are often prescribed for the treatment of depression.

Mixing weed and these antidepressants prevent the medications from working properly. Some Doctors Won’t Prescribe Antidepressants to Marijuana Users It is important to mention that taking antidepressants and weed together makes it almost impossible for your doctor to help you get better. When you are under the care of a psychiatrist, they monitor your progress and determine if the medication you have been prescribed is working. If you are using marijuana and antidepressants at the same time, there is no way to figure out which substance is causing what specific effect. Medication adjustments and changes are basically out of the question because they are completely counterproductive. Many doctors won’t even treat you if you are mixing these two substances.

Different Types of Antidepressants and Marijuana Drug Interactions

There are three different types of antidepressants that may interact with cannabis in negative ways – SSRIs, SNRIs, and MAOIs. Mixing different antidepressants with weed can produce varied side effects and problems. Let’s talk about these. Selective Serotonin Reuptake Inhibitors, also known as SSRIs, are the most commonly prescribed type of antidepressant. Drugs like Lexapro, Zoloft, Prozac, Wellbutrin and Paxil are examples. These help to treat depression other mental health conditions by increasing the amount of serotonin released in the body. Serotonin is a natural feel-good neurotransmitter. It promotes feelings of wellness and contentment.

Studies have shown that weed also helps release serotonin in the brain. For this reason, mixing marijuana and Prozac, combining weed and Wellbutrin, or doing pot with other antidepressants can have dire consequences. Specifically, too much serotonin can lead to Serotonin Syndrome. This occurs when the brain can’t handle the quantity of the chemical it’s been tasked to process. People who have Serotonin Syndrome will experience a variety of symptoms that range from mild to severe. These include agitation, restlessness, mental confusion, rapid heartrate, high blood pressure, sweats, vomiting, and diarrhea. Also, be warned: using marijuana and SSRIs can lead to life-threatening conditions like high fever, seizures, shock, irregular heartbeat, and unconsciousness. On another note, many people take the antidepressant Wellbutrin to help fight cravings for harmful substances. It is sometimes prescribed to people who are quitting smoking or in recovery from heroin addiction.

Mixing marijuana and Wellbutrin, like other SSRIs, is not a good idea for the reasons we have explained. Effexor is a Serotonin and Norepinephrine Reuptake Inhibitor (SNRI). Other SNRIs include Cymbalta and Pristiq. These antidepressants work in very much the same way that SSRIs do. People who are prescribed SNRIs should not mix them with cannabis. THC and CBD (two of the major compounds in pot) and SNRIs can have an effect on the way serotonin is regulated in the brain. The combination of them can produce unpredictable results. Those who are prescribed to an SNRI and throw cannabis into the mix might find themselves feeling extremely disoriented. They are also subject to developing Serotonin Syndrome. MAOIs: Although Monoamine Oxidase Inhibitors (MAOIs) like Nardil are not prescribed very much these days (most patients who would have been prescribed them receive SSRIs or SNRIs instead), those who do take these drugs shouldn’t smoke pot. MAOIs interact with marijuana in a way that heightens the sedative qualities of cannabis to an unsafe level.

Be Aware of Cannabis Drug Interactions and Stay Safe

Truth be told, we think it’s a good idea to stay away from weed altogether. The stuff is addictive and it can cause some significant health problems. If you want to be healthy and avoid many of the problems that can come from getting high, your best bet is to find other pleasurable activities to engage in. But, as we have said – you are going to use the stuff until you are ready to quit. We respect that. Nevertheless, as cannabis becomes more commonly used in Colorado and elsewhere, we can all benefit from increased awareness of marijuana drug interactions. The effects of weed do not pose the kind of immediate health threats that other drugs do. However, when combined with incompatible substances, pot can be quite dangerous. Those who do choose to use weed should carefully take inventory of what else they put into their bodies. If you’re going to get high, please be safe. Think twice about mixing marijuana with alcohol and other drugs.

Mixing marijuana with other drugs carries serious health effects. Learn more about how cannabis interacts with other drugs here.

Serotonin Syndrome versus Cannabis Toxicity in the Emergency Department

Jacob W. Baltz

* CoxHealth System, Department of Emergency Medicine, Springfield, Missouri

Lamanh T. Le

† CoxHealth System, Department of Pharmacy, Springfield, Missouri

Abstract

As more states legalize marijuana, the potential of marijuana abuse could lead to an increase in the number of emergency department (ED) visits. We describe two patients who presented to the ED with dilated pupils, rigidity in both lower extremities, and clonus in both feet after inhaling the vapor of a highly potent form of marijuana. Serotonin syndrome diagnosis was initially considered in the differential diagnosis. Ultimately, high-potency marijuana abuse was the final diagnosis. Therefore, marijuana toxicity should be considered in ED patients who present with signs and symptoms similar to that of serotonin syndrome.

INTRODUCTION

As the legalization of cannabis becomes prevalent in the United States, effects from its abuse will result in an increase in emergency department (ED) visits.1 We have witnessed a growing trend in our community ED among adolescents abusing a highly potent form of marijuana, butane hash oil (BHO). BHO is a concentrated form of tetrahydrocannabinol (THC) that is created by using liquid butane as a solvent to extract THC from marijuana plants. As butane is highly flammable, reports of burns and explosions have been reported from the synthesis and use of BHO. A popular trend called “dabbing” involves heating the concentrated oil and inhaling the resultant vapors. These vapors contain very high concentrations of THC, as high as 90% pure. Adolescents may use e-cigarette devices to abuse BHO as a delivery device. Such devices are easily concealed and produce almost no odor, thus leading to the potential for abuse at school and in the home.2,3

Previous case reports have shown BHO abuse may lead to agitation along with neurotoxicity and cardiotoxicity.3,4 Since THC may activate serotonin receptors and inhibit serotonin reuptake, its abuse in high concentrations may mimic serotonin syndrome.5 We present two cases of adolescents with recent “dabbing” use who exhibited signs and symptoms of serotonin syndrome.

CASE REPORT

Case 1

A 17-year-old female presented to a large community ED by emergency medical services (EMS) from her home for a possible seizure. EMS providers had witnessed agitation, altered mental status, tachycardia, muscle stiffness and tremors in the limbs, and administered 10 milligrams (mg) of midazolam intranasally. History was obtained from the EMS providers and the patient’s parents who were present in the room. The patient had been taking sertraline 50 mg daily and had also been prescribed a short course of cyclobenzaprine 5 mg every eight hours, as needed, for “muscle aches.” According to the parents, the patient had taken “a few” but stopped the cyclobenzaprine as it was not effective. No history of drug overdose or recent illness was obtained.

Upon arrival to the ED, the patient was obtunded (likely secondary to benzodiazepine), but would occasionally follow commands. Her Glasgow Coma Score was eight, scoring two points for eye-opening response, two points for verbal response, and four points for motor response. Vital signs revealed blood pressure of 135/81 millimeters of mercury (mmHg), pulse 124 beats per minute (bpm), rectal temperature of 99.6 degrees Fahrenheit (F), and 97% pulse oximetry on room air. Physical exam revealed dilated pupils of six millimeters (mm), normal neck exam, normal lung sounds, a soft and non-tender abdomen, and normal heart sounds. A neurological exam revealed rigidity in both lower extremities with a sparing of rigidity in the arms. Deep tendon reflexes showed sustained clonus in both feet, and the presence of hyper-reflexivity in the patella tendons bilaterally but with normal reflexes in the upper extremities.

Lab results showed a normal complete blood count, normal creatine kinase, normal comprehensive metabolic profile, normal arterial blood gas, normal prolactin level, and a urine drug screen positive for THC. Electrocardiogram showed sinus tachycardia, and a non-contrasted head computed tomography was normal. Serotonin syndrome was considered in the differential diagnosis. After pediatric critical care and pediatric neurology consultation, one oral dose of cyprohepatidine 4 mg was administered. The patient was admitted to the pediatric intensive care unit. Magnetic resonance imaging of the brain was normal, and an electroencephalogram showed no epileptic activity. The patient rapidly improved and was discharged the following day. Prior to discharge, the patient admitted to “dabbing” about 30 minutes prior to arrival to the hospital. The same patient returned to the ED the following night with a similar presentation, once again associated with dabbing.

Case 2

A 16-year-old male took “a hit from a dab pen” while on the bus to school. He developed altered mental status and was transported to the ED. On arrival he was mildly obtunded, Glasgow Coma Score was 13 (three for eye-opening response, four verbal response, and six motor response). Vital signs were recorded as blood pressure 152/86 mmHg, pulse 116 bpm, oral temperature 98.6° F and 100% pulse oximetry on room air. Physical exam showed dilated pupils to five mm, tachycardia, and rigidity of the lower extremities with non-sustained clonus in the legs bilaterally. Lab results were normal with the exception of a drug screen positive for THC. This patient slowly improved over six hours of observation in the ED and was discharged home.

DISCUSSION

Psychotic states, cardiac toxicity, and neurotoxicity have been reported as clinical sequelae of THC-induced toxicity.4,6 Our cases show additional harmful side effects of highly concentrated THC when abused by adolescents in its vapor, or “dabbing” form. Although the cases did not show all of the hallmarks of a true serotonin syndrome, some overlap existed in physical exam findings. Serotonin syndrome may show vital sign abnormalities such as tachycardia, hypertension, and hyperthermia. Physical exam findings of serotonin syndrome may reveal agitation, ocular clonus, dilated pupils, tremor, deep tendon hyper-reflexia, muscle clonus, dry mucus membranes, and flushed skin with diaphoresis.7

The most striking exam finding in these two ED patients was the lower extremity rigidity with hyper-reflexivity. Animal studies have demonstrated that potent cannabinoid receptor agonists may activate the serotonin receptors (5-hydroxytryptamine1A and 5-hydroxytryptamine2A), and THC inhibits serotonin re-uptake.5, 8 Therefore, it is likely that emergency physicians may see some of the hallmarks of serotonin syndrome in “dabbing” users.

CPC-EM Capsule

What do we already know about this clinical entity?

Serotonin syndrome and marijuana abuse are recognizable conditions encountered in the practice of emergency medicine.

What makes this presentation of disease reportable?

We report two cases of high-potency marijuana abuse that mimicked serotonin syndrome.

What is the major learning point?

When encountering potential serotonin syndrome, a thorough social history and drug testing may be needed to rule out a disease mimic.

How might this improve emergency medicine practice?

As legalized marijuana becomes more prevalent, emergency physicians should be aware of this disease mimic.

CONCLUSION

Medical marijuana and cannabidiol have been used and proved to be medically safe and effective; however, as marijuana use grows there is increased access of cannabinol products, including high-concentrate THCs. Our cases reflect that adolescents who abuse THC by heating and then inhaling the concentrated vapor, can present with signs and symptoms that mimic serotonin syndrome. For that reason, high-potency marijuana abuse should be considered when encountering young adults in the ED with these exam findings.

Footnotes

Section Editor: Rick A. McPheeters, DO

Full text available through open access at http://escholarship.org/uc/uciem_cpcem

Documented patient informed consent and/or Institutional Review Board approval has been obtained and filed for publication of this case report.

Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.

Serotonin Syndrome versus Cannabis Toxicity in the Emergency Department Jacob W. Baltz * CoxHealth System, Department of Emergency Medicine, Springfield, Missouri Lamanh T. Le †