Now, I need to explain to you the difference types of ingestion
that your patients are going to be using for cannabinoids.
There are those of you who are in different parts of the world
who will not be familiar with the terms, so I’ll try to define them.
The terms are fluid so what could be defined as a bong one day might not be a bong in another part of the country
or, you know, two years from now so keep in mind that as of now in the area of the world
where I come from, this is how we’re defining what these products are.
So obviously pills and capsules are used to distribute cannabis.
These are usually manufactured pharmaceutical companies with lots of clinical evidence in general,
I would argue, that pills and capsules are generally more reliable
with a more consistent level of medication in them.
Dabbing is, again, the definitions will vary but dabbing is when you take a hot poker of some sort.
It could be glass, it could be metal and you put it to either marijuana or to hash
and it burns or ignites and then you inhale the vapors from the ignited product.
Now the dabbing process refers to the burning of it and how it’s burned.
Bongs are a -- you can see a picture of it here.
Basically, most of us would define bongs as those things that have water in them
so they used to be called water bongs now we just call them bongs.
There are some people who would say that a bong does not have to have water in it,
but when you’re talking to patients and they say that they are using bongs
to smoke their drugs you’ll kind of get an idea of what I mean.
This is one type of bong.
In the NORML/MAPS study looking at people who are using bongs to get high,
they found that actually bongs filtered out a lot of the psychoactive substances.
The consequence of that is that patients or users are going to use more of the product
to get the desired effect of getting high.
Now we do see in terms of the different types of cannabinoids that there's more CBN and CBD
and less THC because the THC seems to be filtered out in the water.
We're not exactly sure how that’s occurring.
The THC levels seemed to be less than an unfiltered joint.
Now there is a suspicion based in this study that there is a lower incident of carcinoma
amongst bongs users compared to joint users.
I don’t know how reliable that information is but I present it to you for fullness.
Here’s another example of a bong.
This person actually took a red bell pepper made a little portable down stem
put the cannabis in the down stem lit it and cut a hole in the pepper and inhale through the pepper.
Now whether or not this pepper actually has water in it I can’t say I’m not really sure
but this is one form of a bong.
So here’s the general principle behind a bong that burning cannabis is put in that little stem.
There’s a down stem that goes into the water,
the person is inhaling through the top mouth piece and creating suctions
so the air goes through the burning cannabis through the stem into the water it comes up through bubbles
and its filtered through the water.
Now, you can get diffusers so those are little grills at the end of the down steam
that makes the bubbles really tiny so when you have smaller bubbles
there’s a higher surface to area ratio of the bubble so there’s more diffusion occurring in the water.
Bowls and bubblers are slightly different.
Essentially I likened them to pipes so in the far image the pipe behind
is actually a tobacco pipe and the image in front is a marijuana pipe.
To me they look virtually identical and I think that they are really the same kind of method of smoking.
One of the things that distinguishes a bowl from a bubbler is that the bowls generally don’t use water as a filter.
Now let’s talk about joints, this is the most common form of smoking.
This particular joint maker is very sophisticated cuz they are using commercial grade cigarette paper
and they are using a commercial grade filter and basically making a cigarette out of marijuana,
what we would call a joint.
The only difference between a joint and a blunt really is a blunt is kind of like a cigar
whereas a joint is kind of like a cigarette but again the definitions are fluid.
And they’ll be different in different parts of the country
so they’ll have a different definition in California than they will in say Eastern Canada
so it depends on where you are and where you live.
Tincture. So, this a more specific definition.
A tincture is any kind of drug that is delivered in an alcohol.
Tinctures are often useful to add to a recipe so the alcohol just boils off
as you are cooking so we often see patients when they wanna make cannabis cookies they’ll use a tincture.
Now I would ask you to discourage this kind of process in your patients.
So if you're patients are telling you that they are using tinctures to add to their cookies,
please tell them not to do that because you can get dangerously high levels of THC doing it this way.
Now, what are the advantages and disadvantages of tincture-based administration?
Now remember that what we’re doing here is we’re taking the oil from marijuana or cannabis,
we're dissolving it into alcohol, alcohol is kind of a universal solvent
and that it dissolves all aspects of the plant whether it’s a terpene,
whether it’s the cannabinoids that’s decarboxylated, it doesn’t matter what it is,
alcohol will dissolve them. So, the trichomes, the cannabinoids, the oils, the terpenes,
they’re all in it. The dropper delivers a sublingual dose.
There is little or no odor to this product so you can’t tell by odor if your patient
is using cannabinoids. It’s important the patients not swallow this product.
So in terms of my patients, this is probably 90% of my patients
who are using cannabinoids are using tinctures under the tongue.
The disadvantage is that they are sometimes made in homemade stills
so the tincture may actually contain methanol from inappropriate or improper alcohol distillation processes.
There’s a very strong alcohol taste which is off putting to some people
and here’s what’s interesting, despite the fact that this is a tincture and despite the fact
that I have told you multiple times that sublingual administration
gives you a faster on set of action than oral administration, in the case of cannabinoids tinctures are actually -
they actually have a slower onset of action than inhaled products,
so if a person smokes a joint they’ll get high pretty quick.
If a person takes cannabinoids in a dropper, they may not get high for two or three hours.
You can see where this problem is because then if they are not getting high from their tincture-based THC cannabinoids,
they’re going to take several drops.
This isn’t so much of a problem with the CBD oils because the CBD oils
are generally being taken by in at least in my patient population a 60 to 70 year old patient who has pain,
whether it’s from arthritis or from cancer or from chronic pain syndromes or fibromyalgia,
and these people have tried all kinds of drugs including opioids so they said,
okay, I want to try CBD oil and they do tend to follow the instructions because they are scared of it
so I don’t see overdoses or problems with my patients using CBD oil,
but in terms of patients who are purchasing THC oils or tinctures to get high,
there’s a lot of problems with the tincture, the THC tinctures.
I keep saying THC is should say TCH, my apologies.
The next category are edibles.
This is an incredibly common way of ingesting cannabinoid at least in Canada
and Canadians love their brownies and Canadian sure love their cannabis brownies.
Edibles refer to any food with cannabis and we are not talking about candies with cannabis,
we’re just talking about foods so here’s some example of some cannabis brownies here.
Generally speaking, edibles will have a 2-4-hour onset of getting high.
It’s a more intense high per gram consumed than any other form
and the reason why is because there's more decarboxylation that occurs internally.
Now in terms of patients who are taking cannabinoid edible for pain control and nausea control,
say for example our cancer patients, there is a 2-10-hour onset of action.
There are several patients who have decided to go with pain control and nausea control
with cannabinoid which actually increased hunger and increased the appetite
as opposed to chemotherapy which tends to increase nausea and decrease appetite.
So the cannabinoid sometimes as edibles, especially high calorie edibles like brownies, chocolate brownies,
are actually not an unreasonable way of controlling symptoms in patients with quite severe cancer syndromes.
In general, the edibles tend to have less of the THC and more of the CBD, mostly for medicinal purposes.
It’s relied upon for pain control and pain relief in most cancer patients that are using it.
Remember that, again, you need to decarboxylated the cannabinoid in order for them
to be affective so they have to be cooked within the brownie.
Decarbs refer to the cannabinoid plant extracts or little rolls of dried up plant and it’s put through a decarboxylator.
The decarboxylator can be heated and using heat to decarboxylate or they can be chemically decarboxylated.
The chemically decarboxylated products, when they are done in the home are often done incorrectly
and that causes side effects that chemically decarboxylated plants
that are purchased through large corporations tend to be done fairly and tend to have very few side effects.
So I’ll explain what hash is in a minute and I'll talk about the product but hash oils
generally are the pressed oil that comes from the plant. Hash is made from the resin of the cannabis plant.
If you take a cannabis plant and break it in half you’ll actually be able to feel the resin between your fingers.
The resin is compressed and these trichomes which are sort of the leafy parts,
the stemmy parts of the plant are compressed really hard and they turn into this kind of brownish substance called hash.
There are higher concentrations of THC in hash so in 2011,
we were seeing between 4% and 15% levels of THC; by 2019 you’ll see we are seeing a 18%, 19%, 20% levels
so the levels are slowly going up over time.
Remember that the pressed hash is a solid.
There are many ways to get hash. So one form is called bubble hash.
Bubble hash does not refer to the shape of the hash particle
which admittedly in this case are in little round balls that look like bubbles.
No, bubble hash refers to the bubbling that occurs during the processing of the hash
where you’re pulling certain substances out of it either through vacuum or through butane.
I won’t get into the chemical extraction process here but bottom line is that bubble hash
refers to the process of making it not to the shape of it itself.
Hash oil can be many, many different consistencies.
Here you can see that its very thick kind of resin.
Now hash oil takes that resin and you can refine it in many different ways.
Now alkali washing refers to washing it with a highly alkalize substance.
The problem is that if it’s improperly done, patients will have heart burn,
they’ll have gallbladder irritation and they can develop pancreatitis so patients
who are users of hash be aware that they may have illnesses secondary to the alkali washing of the hash.
Now, you can actually chemically convert CBD which is one of the cannabinoid components to TCH.
This is done through a process called saponification.
You dissolve it in a nonpolar solvent, there’s a chemical change that occurs called saponification
and it results in a less acidic and an almost pure THC product.
In the 1970s the THC content was only 10% and in 1997 the THC content reached 17.5%.
Another form of hash oil is something called shatter.
Now in 2018, we saw THC contents as high as 90% with this particular product.
This is a super purified ultra-refined kind of hash oil,
sometimes it is so refined that it actually becomes a solid and can break like hard candy.
There are products that decolorize this otherwise yellow product using activated charcoal.
This product can then look clear or perhaps a milky white color.
In Canada 90% THC hash oil has been approved for a commercial sale in 2019
so it is commercially available in some countries.
In the United States it’s kind of a gray area because they’re selling it as hemp oil.
Now selling hemp oil is legal.
This may not be because the purposes are to refine it so that THC levels are high
so even though hemp itself may not have high levels of THC the problems
is that when you alter or refine it the THC levels go up.
Finally there is something called butane honey oil.
This is a difficult one to describe without actually showing you pictures of a production process
but essentially the process of purification is occurring using butane
which is highly flammable and combustible substance
so when you here about THC refining areas that have blown up it’s because somehow the butane was ignited.
Butane is the same fuel that you see in lighters.
The chemical compounds - the chemical reaction that you get with butane as it mixes
with the hash oil is to further refine the THC and get rid of some of the other contaminants.
Pens. Pens are a little bit different than vapes so we’ll just talk quickly about pens,
pens are not pens that you write with, these are pens that have little tiny heating element
that vaporize a liquid that’s put into them.
Again, this isn’t quite the same thing as vaporizer or a vape.
These liquids can contain propylene glycol, glycerine, water and certain types of flavorings,
so as you start to recognize these different products from my previous lectures
you realize that there are some significant concerns about patients getting
what we call popcorn lung from these types of product
because we’re not so much from the original drug but the additives that are keeping it in a liquid phase.
Here’s an example of bronchiolitis obliterans or popcorn lung.
This CT scan was taken of patient that was only smoking a little bit on his pen on a daily basis
for about year and he developed quite a severe reaction
where there’s occlusion of the small bronchi.
Vapes or vaporizers are another form of ingestion.
This is a little bit different than a pen; the difference is subtle.
It’s a process that can use heat but often does not.
It vaporizes the product into a vapor, that vapor is kept in a loop
so the loop may stay inside the vaporizer for some time or it may be immediately inhaled.
Now, 30% of the THC can be destroyed by the pyrolysis within the vaporizer.
When we’ve done studies looking at vaporizers and these are good studies, these are reliable studies,
there was virtually no exposure to the harmful combustion products of marijuana using the vaporizer device,
so unlike a joint which has probably 50 carcinogenic compounds in it,
very similar to cigarettes by the way, and in fact may be more harmful than cigarettes,
a vaporizer on the other hand, a dry herb vaporizer,
may now have those harmful combustion products.
In a 2008 article, it’s a bit old but it’s still good, their conclusion was that
it was a suitable method for the administration of THC
if you so wanted to administer that particular product so vaporizers may not be the harmful things
that we think they are but remember we have to distinguish them from pens
which are using things like using other types of chemicals to keep it in a liquid phase
and keep it suitable for turning into a smoke that people can inhale.
So pens, vaporizers are a little bit different.
The definitions on the street are fluid and sometimes they get a mixed up and so people will sell a vaporizer
when it’s actually a pen or people will sell a pen and call it a vaporizer
and a lot of times people don’t know the difference so it’s important
that you know the difference in reality and then in practicality
you have to know what your patients are using.
Now, I want to talk a little bit more about the vapes.
The longer the vapor is stored in the loop the greater the loss of the THC.
In general, if you have the vapor in the loop for only three minutes
before ingestion the loss of THC is virtually negligible.
If you have that vape in the loop for say an hour or an hour and a half up to 50% of the THC is lost.
Now a Leiden University study showed that 30 to 40% of the THC was just simply exhaled after inhalation
so even though the THC was in the smoke as they exhaled it,
it was out of the body so it was never actually ingested in a classical sense.
Sprays. We don’t know much about the sprays to be perfectly honest.
They are relatively new phenomenon.
Essentially it’s a spray in a non-alcohol based solution that is sprayed usually under the tongue
but sometimes it can be sprayed in the back of the throat and swallowed.
We don’t know the effectiveness, we don’t know the THC levels,
we don’t know the dangers or the risks, so I’ll just kind of stop there.
Drinks are recent thing that has happened.
These are mostly CBD based drinks but they are THC based drinks that are outside there as well.
Creams, this is kind of an interesting phenomenon.
So a course creams are lipid-based generally speaking and so you can dissolve the cannabinoid into the cream.
There are many different kinds of creams.
It is popular in countries where the cannabinoid have been legalized
so this has becoming huge in the United States and in Canada.
It is thought to help with eczema and psoriasis.
My wife, being a dermatologist will tell you that she hasn’t seen any evidence that it is helpful
and there haven’t been any documented studies of a good quality
that show anti-inflammatory properties if it’s applied topically.
This is a current state of research, it’s a huge area of research and we may be seeing selected cannabinoid
that do have anti-inflammatory properties that will work on the skin in the future
at this point in time we don’t really have that.
So this is a statement from the National Academy of Sciences in 2017.
Admittedly it’s a bit of an old statement but I think it’s still relevant today
and here’s what they say.
They say that despite an increased cannabis use and a changing state level policy landscape,
conclusive evidence regarding the short- and long-term health effects,
both harms and benefits of cannabis, really remain elusive.
And I completely agree with that, we don’t have good science even today.
This was written back in 2017, but I think that comment stays the same
and I don’t think we’re going to see major changes for another 5 to 10 years.
I think also a lot of the harm is going to become more documented as well.
So getting back to the creams, we’re starting to see lip balms, not really a cream I agree,
it’s more like a gel but still people will use lip balms with THC
and they just put it on their lips and they just steadily get high by continuously licking their lips.
This is a non-odorous way of getting high in public that is becoming very popular.
So there is a belief out there that if you apply cannabinoid cream to the vagina it relaxes the vagina,
it increases lubrication and increases the sexual pleasure and I have had multiple patients tell me
that they wanted to use this product for that very purpose and they’ve all come back very disappointed,
so for my clinical experience it hasn’t worked particularly well.
There may be more research and more definitive answers for you in the future,
right now there’s no randomized control trials telling us
that this is a viable means of improving sexual activity in women.
Patches are a very interesting developed that’s happened just in the last little while.
This is actually a picture of a CBD patch that I took on one of my patients
who has quite a severe and terminal cancer and she’s in tremendous pain all the time
so she’s been using this 15% patch now for about a month.
Transdermal patches are interesting because it gives a relatively steady dose of the product.
It uses dimethyl sulfoxide which is a penetration enhancer mixed in with the high concentration of CBD oil.
It’s often used in chronic pain patients, patients who have chronic pain syndromes
whether it be fibromyalgia or neuropathic pain or it may be due to bone pain
because of cancer and metastases.
We generally focus these patches on administering CBD oil as opposed to say THC and getting high.
The onset of action is anywhere between 3 and 6 hours.
With my clinical experience, I would say it’s more than 6 hours.
The duration of action can be anywhere from 6-20 hours.
Some patches are actually one-week patches. There is a small tachyphylaxis effect.
If you’ve forgotten what tachyphylaxis means it means
that there’s a reduction in the effectiveness of a particular drug after a few hours of exposure.
There is a post application effective up to four weeks
so after you’ve removed the patch from the patients skin and you’ve washed the skin clean of any residual product,
you may still have some effect of the drug four weeks after you’ve stopped the patch.
Sols and butters are another means of administration.
Essentially the marijuana plant, the extract - sorry, not the extract but the plant itself is heated and decarboxylated
using the sous-vide method and then you take the decarboxylated plant,
you put it in water and you boil it until all of the oil start mixing with the water.
As you boil off the water, you're essentially making a butter.
Now butter, chemically speaking, is a sol which is a state of matter
so when we say sol or butters, we're essentially talking about the same thing.
Gums. So this is an interesting development.
CBD infused gums are used for pain relief quite extensively now.
Now, we see - mostly our patients with fibromyalgia are using it, we also see it in chronic pain syndromes,
we see it in cancer patients and interestingly enough, we see it in IBS patients too.
The onset of action is anywhere between 5 minutes and 60 minutes.
Presumably the 5 minutes portion of it is because much of it is being absorbed
in the oral cavity and the upper digestive system.
The duration of action is anywhere between to 60 and 120 minutes
but it is a cumulative action so if a person uses one jelly drop on one day
and then uses another on the other day, the second jelly drop is actually an enhance activity, and why is that?
It’s because the volume of distribution of the cannabinoids,
it’s a very high volume of distribution but as you saturate the extra vascular space with your cannabinoid,
you end up getting more and more of a hit each time you use the gum.
There may also be a residual effect of up to four weeks after you’ve eaten just one,
so these are long term drugs that have long term effects.
THCA crystals. This is an odd one. Users will report that they get a cleaner high off of a THCA crystals
but from my perspective, from a pharmacological perspective, it shouldn’t work
so it’s a bit of a mystery and a bit of a head scratcher.
I suspect that there’s a large placebo effect but who knows, it might actually be working.
Now, you may get a lot of side effects from using this THCA crystals.
It can be associated with an upset stomach to start off with and we suspect that the upset stomach
is coming from an improper alkaloid cannabinoid extraction process
and that results incomplete saponification of the product during the wash cycle.
Now, this shows yellow crystals, it can actually be a clear crystal or a white crystal
so it can take on many different looks to it.
I wanna be clear though this is not the same thing as shatter,
so people mistake THCA crystals with shutter, they're not the same thing.
THCA crystals have the carboxylated terpene as its main product,
whereas the shutter has actual decarboxylated cannabinoid in it so the shutter
or the oils will have active product.
This theoretically is an inactive product so this is why I say that it really shouldn’t work but it seems to.
Canna oils. Canna oils are difficult to define, they're different from the CBD oils that we sometimes see.
It’s often used in cooking an infusion and they are not processed or purified,
they’re just simply a pressed plant.
Sometimes it is mixed with coconut oil or with olive oil for consumption.
These products are heated under low heat for 15 to 20 minutes
to ensure that there's adequate mixing of the two different types of oils.
Now, remember that the low heat mixing, because you’re using something like olive oil
which heats at a much slower smoking point does not necessarily cause the decarboxylation.
So essentially, a canna oil, as a opposed to CBD oil,
has terpenes in it whereas the CBD oil has the active cannabinoid that’s decarboxylated.
There’re maybe toxic contaminants within the product, we don’t know
because the production of these canna oils is not particularly regulated
and there’s not really a governing body that oversees the proper manufacture.
It is more potent than CBD oil and now why would I say that when I just finished
saying that they probably contain decarboxylated cannabinoid.
It’s because we’re not entirely sure what’s in them, they may be decarboxylated,
they may not be. In any case, caution your patients
because we’re very concerned about the canna oils because of the inconsistency of the product.
THC soda, this has made a recent comeback. It’s kind of mixed in with our next category
which are the syrups and essentially the THC sodas are essentially very new, they’re sold on stores.
They have very small amount of THC per bottle,
the effects are similar to other ingested products.
I can’t really tell you any more than that, they’re relatively new.
Similarly, the syrups, I would say the same thing, they are relatively new.
They have 10-200 mg/bottle. The effects are similar to other ingested products,
and again, they're too new to tell you anything.
They're not really clinically evaluated and I would also mention that the syrups
are often used to make the carbonated beverages so they’re kind of one and the same.
Finally, we come to the last type of ingestion which is the bath soaks.
So these are incredibly common, very popular recently.
There’s no real psychoactive effects but people believe that it causes a very relaxing bath,
there’s no reason to suspect that there’s a medicinal benefit here.
Having said that, one must remember that sous -
vid means that you’re essentially boiling it in water without having it touch the water
so it may be that longer exposure in hot water may decarboxylate some of it, I don’t know.
That’s just me, armchair speculating, so that’s something you need to be aware of as well.