The Cannabis Industry: A Medical Perspective
Standing Up for Health and Safety
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The cannabis industry has experienced exponential growth in recent years. Due to legislative changes, this growth brings new opportunities and challenges, particularly in occupational health and safety. As cannabis becomes legalized for both medical and adult use, locally and globally, OHS regulations specific to the industry are emerging. This article explores the OHS considerations within the cannabis industry, aiming to shed light on best practices, regulations, and the importance of prioritizing the well-being of workers and the need for standards.
REGULATORY HISTORY In the United States, the Marijuana Tax Act of 1937 made the possession or transfer of cannabis illegal under federal law, except for medical or industrial uses. In 1969, the Supreme Court ruled that the Marijuana Tax Act was unconstitutional because it violated the Fifth Amendment privileges against self-incrimination. The following year, Congress repealed it and passed the Controlled Substances Act. The CSA placed cannabis under federal law as a Schedule 1 drug, which identifies drugs that have no medical use and the potential for abuse. Yet the U.S. has multiple patents on the plant.
California became the first state to allow legal access to cannabis for medical purposes with the Compassionate Use Act of 1996. In 2012, Colorado and Washington became the first states to legalize the adult use and sale of cannabis. Since then, 24 states along with Washington, D.C., and Guam have legalized adult use of cannabis.
Despite the trend toward legalization, disparities exist in OHS regulations, and compliance with standards varies. Cannabis is still illegal on the federal level, yet OSHA has the authority to check cannabis work sites and companies for workplace violations. The environments that fall under OSHA’s jurisdiction include agricultural processing, manufacturing, cultivation, retail, and cannabis testing laboratories.
The cannabis industry is evolving quickly from illicit operations to culturally normalized establishments. Both illicit and legal markets affect the health and safety of cannabis workers. OHS regulations apply on a state-by-state basis where cannabis is legal, but cannabis remains on the Drug Enforcement Agency’s Schedule 1 drug list.
OHS ISSUES Fatalities, injuries, and illnesses can be prevented and mitigated by early detection of acute and chronic medical conditions. In areas that have decriminalized cannabis, both legal and illicit businesses still operate with substandard working conditions. The most recent fatality in the cannabis industry provides an opportunity for healthcare providers and individuals to address occupational and environmental exposures.
In January 2022, a 27-year-old flower production technician suffered a fatal asthma attack while working at an indoor cannabis cultivation and processing facility in Massachusetts. The worker had started at the facility seven months earlier. During her three months as a flower production technician, the worker’s duties included processing and handling whole and ground cannabis flower buds. Her death was determined to be caused by occupational asthma due to exposure to ground cannabis.
A report on the investigation of the worker’s death was prepared by the Fatality Assessment and Control Evaluation program of the Massachusetts Department of Public Health. The report included six recommendations for cannabis employers, equipment manufacturers, and the state’s Cannabis Control Commission to improve the health and safety of cannabis industry workers: 1. Assess and control hazardous materials, including asthmagens. 2. Train all workers on hazardous materials. 3. Develop and implement a comprehensive safety and health program. 4. Implement a medical surveillance program to monitor worker health. 5. Apply prevention through design concepts for equipment. 6. Cannabis industry licensing agencies in Massachusetts should consider how to further support health and safety.
PROTECTING CANNABIS WORKERS In areas where cannabis is illegal, growers have tried to avoid detection by cultivating it in spaces with little to no ventilation, which can present health hazards. But even legal operations may be run by people who don’t know how to ensure that their workplaces are safe, healthy environments.
Workers in the cannabis industry are exposed to known and unknown hazards. Each exposure presents distinct OHS challenges that demand tailored solutions. But the tasks of cannabis workers and the hazards they face are the same as those in other agricultural production, manufacturing, retail, and delivery businesses. We don’t have to recreate the wheel; we just need to add another spoke.
In the cannabis industry, occupational and environmental exposures can vary with job duties, so assessing potential exposures and implementing appropriate surveillance programs are critical for applying controls. Table 1 lists some common job titles and related duties for cannabis workers.
Table 1. Common Job Titles for Cannabis Workers
Click or tap on the table to open a larger version in your browser.
HEALTHCARE PROVIDERS During my family practice residency at the Medical University of South Carolina in Charleston, I worked with people of all ages, from conception to grave. I saw cases of children with lead toxicity, asthma, and common respiratory illnesses, and adults with work injuries and illnesses. A pediatrician at MUSC, Dr. Stanley Schumann, taught me the importance of addressing occupational exposures and how to incorporate them into a detailed history using the mnemonic “WHACS”: • What do you do? • How do you do it? • Any concerns about any of your exposures on or off the job? • Coworkers or others exposed? • Satisfied with your job?
Dr. Schumann and several MUSC colleagues later published a paper about WHACS in the Journal of Occupational and Environmental Medicine.
My growing interest in the association of environmental and occupational exposures to injuries and illnesses led me to the Harvard School of Public Health in 1998. There, I did my second residency in occupational and environmental medicine (OEM), obtaining a master’s in public health and a fellowship in heavy metals. OEM is the prevention and management of occupational and environmental injuries, illnesses, and disability and the promotion of health and productivity for workers, their families, and communities. A subspecialty of preventive medicine, OEM includes individual patient care, population health management, and public health.
As a physician, I teach WHACS to my colleagues and patients and incorporate it into my practice. I use the mnemonic to establish a detailed patient history. I try to find out if the worker has any concerns, including barriers to returning to work such as violence or mental stress. If there are exposures and illness, I make an effort to understand the patient’s work. I also try to see the patient over time and with family in case decontamination practices at work are not effective. The goal is to ensure family members are not subject to exposure to hazards that the worker may inadvertently bring home on clothing or equipment.
Even a family doctor untrained in occupational health can impact potential workplace exposures of employed patients by using a different mnemonic, “STAMP”: • Shortness of breath? Using anything? Over-the-counter meds or someone else’s inhaler? • Tiredness or fatigue? • Allergies, including skin or upper respiratory tract symptoms? • Medical conditions, either previous or existing? Heart or lung conditions? • Pulmonary conditions?
The fatality at the Massachusetts facility is a reminder that any breathing or lung problem is a critical indicator for allergies. Even skin symptoms like rashes are a sign of increased risk of allergic reaction and sensitization. Sensitivity happens over time; what seems like just a slight irritation has the potential to become anaphylaxis, a life-threatening allergic reaction.
Asthma related to occupational exposures is prevalent: according to NIOSH, approximately 17 percent of all adult-onset asthma cases are related to occupational exposures, and workplace conditions aggravate asthma for approximately one-quarter to two-thirds (22–58 percent) of asthmatic adults. We have evidence that cannabis dust is a potential respiratory sensitizer. Recognition and control of contaminants at their source can mitigate occupational exposures and potential health outcomes. Medical and workplace intervention is necessary to educate workers and increase awareness of respiratory illness and the risk factors.
CALL TO ACTION In the early 20th century, Massachusetts was the first state to take significant steps to define the nation’s safety and health legislation. Unfortunately, it is also where the first death of a cannabis worker from occupational asthma occurred. While progress has been made in OHS for cannabis workers, we need to be vigilant in identifying and addressing new hazards and challenges.
It is time to stand up for the safety and health of the workers in the cannabis industry and prioritize creating a safe work environment. We have an opportunity to prevent injury and illness and set a better course for the future of the cannabis industry locally and globally. The AIHA Cannabis Industry Health and Safety Committee is creating a guidance document that will discuss the hazards, controls, and practices within different segments of the cannabis industry. The committee’s goal is to identify the hazards that are both unique and inherent to the cannabis industry and recommend best controls, standards, and practices designed to protect workers from those hazards. The proposed audience will be OHS professionals and cannabis facility operators. In the meantime, a wealth of existing safety standards can be applied to current hazards, including federal OSHA standards.
The cannabis industry and the medical profession need to join forces to build on past learnings, apply existing standards to known hazards, and commit to the health and safety of workers and the workplace. Pre-employment medical assessments are a great way to collaborate on illness prevention. Healthcare providers can establish a baseline for workers’ health, particularly associated with blood count; vital signs; metabolic function; heavy metals in urine; lung function; chest x-rays; hearing; vision; skin abnormalities; or pre-existing health conditions, including cancer, allergies, autoimmune diseases, and mental health issues. More of this information may be collected when an employee is assigned a respirator; OSHA provides a respirator medical evaluation questionnaire (PDF).
Workplaces can easily promote worker self-monitoring using these instruments or apps now available on smartphones or health and fitness trackers: • peak flow meter for lung function • scale for weight fluctuations • thermometer • blood pressure monitor • pulse oximeter
Workers should be encouraged to visit a health professional when their results are outside of normal ranges.
Another element that could have prevented the fatality in Massachusetts was a first-aid protocol. A workplace with potential allergens, asthmagens, or sensitizers needs: • a trained first-aid resource • an adequate first-aid kit with an epinephrine autoinjector, medical-grade oxygen, and blood glucose meter • an AED (automated external defibrillator) • ready access to emergency personnel
The death of a worker is a profoundly distressing event for everyone involved, and it requires a comprehensive and compassionate response from employers and authorities. It reinforces the importance of maintaining a strong focus on occupational health and safety to prevent accidents and protect the well-being of workers in all industries. Promoting a safety culture, providing ongoing training, and involving employees and subject matter experts in developing, implementing, and improving safety programs are integral to maintaining a healthy and safe workplace in the cannabis industry. Regular hazard assessments and adjustments to safety measures based on evolving industry standards and regulatory requirements are essential for ensuring long-term employee well-being.
DR. UMA DHANABALAN, MD, MPH, FAAFP, MRO, CMS, is founder and CEO of Global Heath & Hygiene Solutions LLC and an independent practitioner at Uplifting Health & Wellness.
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Cannabis Use Throughout History
According to Time magazine, Emperor Shen Neng of China in the 2700s BCE was prescribing cannabis tea for treatment of gout, rheumatism, malaria, and poor memory. The medicine spread throughout Asia, the Middle East, and Africa. In India, it continues to be used in Ayurvedic medicine and for religious purposes.
Ancient physicians prescribed cannabis for pain relief, toothaches, and anxiety, to improve appetite and sleep, and for childbirth. Cannabis was part of the United States Pharmacopeia (USP) from 1850 to 1942; it was prescribed for the treatment of opioid addiction, alcoholism, seizures, menstrual cramps, asthma, and an array of conditions. Cannabis was sold in various forms, including topicals, tinctures, asthma cigarettes, and as an ingredient in many medicines.
In recent years, there has been a better understanding of the plant’s therapeutic potential and diverse applications in biofuel, textiles, building materials, food, nutritional supplements, animal feed, and much more. The plant is a bioaccumulator and can be used for remediation of radiation or heavy metals. Standards are essential to ensure that people don’t consume cannabis that has been grown in contaminated soil.
3M: “Growing Worker Safety Concerns in the Medical Marijuana Industry” (April 2018).
CDC: Morbidity and Mortality Weekly Report, “Fatal Occupational Asthma in Cannabis Production — Massachusetts, 2022” (November 2023).
Commonwealth of Massachusetts: “Massachusetts Department of Public Health Calls for Tougher Action by Cannabis Industry to Improve Health and Safety after Work-Related Asthma Death” (November 2023).
High Times: “The Marihuana Tax Act of 1937” (July 2018).
Journal of Occupational and Environmental Medicine: “Medical Students’ Abilities to Take an Occupational History: Use of the WHACS Mnemonic” (November 2000).
Massachusetts Department of Public Health: “Cannabis Flower Technician Experiences Fatal Asthma Exacerbation – Massachusetts” (PDF, November 2023).
NIOSH: “Epidemiology and Pathophysiology of Work-Related Asthma.”
OSHA: “OSHA Infosheet: Respirator Medical Evaluation Questionnaire” (PDF).
The Synergist: “Emerging Issues in Cannabis and Workers’ Compensation: Setting Priorities for Future Research” (September 2023).
The Synergist: “Growing Pains: Personal Protective Equipment for Workers in the Emerging Cannabis Industry” (May 2017).
The Synergist: “The Marijuana Dilemma: Drugs in a Drug-Free Workplace” (June/July 2020).
The Synergist: “Respiratory Sensitizers: Strategies to Address Occupational Asthma Caused by Respirable Allergens” (June/July 2020).
Time: “A Brief History of Medical Marijuana” (October 2009).