00:01
Now, I need to explain to you the
difference types of ingestion that
your patients are going to
be using for cannabinoids.
00:09
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.
00:16
The terms are fluid.
00:18
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.
00:26
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.
00:36
So obviously pills and capsules
are used to distribute cannabis.
00:41
These are usually manufactured pharmaceutical
companies with lots of clinical evidence.
00:47
In general, I would argue, that pills
and capsules are generally more reliable
with a more consistent
level of medication in them.
00:56
Dabbing is, again, the definitions will vary but
dabbing is when you take a hot poker of some sort.
01:04
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.
01:17
Now the dabbing process refers to the
burning of it and how it’s burned.
01:24
Bongs are a -- you can see a picture of it here.
01:28
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.
01:36
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.
01:46
This is one type of bong.
01:48
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.
01:58
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.
02:06
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.
02:17
We're not exactly sure how that’s occurring.
02:21
The THC levels seemed to be
less than an unfiltered joint.
02:26
Now there is a suspicion in this study
that there is a lower incident of carcinoma
amongst bong users compared to joint users.
02:34
I don’t know how reliable that information
is but I present it to you for fullness.
02:39
Here’s another example of a bong.
02:42
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 inhaled through the pepper.
02:56
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.
03:05
So here’s the general principle behind a bong
that burning cannabis is put in that little stem.
03:11
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.
03:22
It comes up through bubbles and
it's filtered through the water.
03:26
Now, you can get diffusers so those are
little grills at the end of the down stem
that make the bubbles really tiny.
03:32
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.
03:40
Bowls and bubblers are slightly different,
essentially I likened them to pipes.
03:45
So in the far image, the pipe
behind is actually a tobacco pipe
and the image in front is a marijuana pipe.
03:53
To me they look virtually identical and
I think that they are really the same
kind of method of smoking.
04:01
One of the things that distinguishes
a bowl from a bubbler is that
the bowls generally don’t use water as a filter.
04:08
Now let’s talk about joints, this
is the most common form of smoking.
04:11
This particular joint maker is very
sophisticated because 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.
04:26
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.
04:38
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.
04:48
Tincture, so this a more specific definition.
04:51
A tincture is any kind of drug
that is delivered in an alcohol.
04:58
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.
05:12
Now I would ask you to discourage
this kind of process in your patients.
05:17
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.
05:27
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.
05:43
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.
05:57
So, the trichomes, the cannabinoids, the
oils, the terpenes, they’re all in it.
06:01
The dropper delivers a sublingual dose.
06:05
There is little or no odor to this
product so you can’t tell by odor
if your patient is using cannabinoids.
06:12
It’s important the patients
not swallow this product.
06:16
So in terms of my patients, this is probably
90% of my patients who are using cannabinoids
who are using tinctures under the tongue.
06:24
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.
06:37
There’s a very strong alcohol taste
which is off putting to some people.
06:41
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 onset of
action than oral administration,
in the case of cannabinoids tinctures are actually
- they actually have a slower onset of action
than inhaled products.
07:01
So if a person smokes a joint
they’ll get high pretty quick.
07:05
If a person takes cannabinoids in a dropper,
they may not get high for 2 or 3 hours.
07:10
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.
07:19
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'.
07:43
and they do tend to follow the
instructions because they are scared of it.
07:46
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.
08:05
The next category are edibles.
08:07
This is an incredibly common way of
ingesting cannabinoid at least in Canada
and Canadians love their brownies and
Canadians sure love their cannabis brownies.
08:19
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.
08:30
Generally speaking, edibles will have
a 2-4-hour onset of getting high.
08:36
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.
08:46
Now in terms of patients who are taking
cannabinoid edibles for pain control
and nausea control, say for example our cancer
patients, there is a 2-10-hour onset of action.
08:59
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.
09:14
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.
09:29
In general, the edibles tend to have
less of the THC and more of the CBD,
mostly for medicinal purposes.
09:36
It’s relied upon for pain control and pain
relief in most cancer patients that are using it.
09:43
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.
09:52
Decarbs.
09:54
Decarbs refer to the cannabinoid plant
extracts or little rolls of dried up plant
and it’s put through a decarboxylator.
10:04
The decarboxylator can be heated
and using heat to decarboxylate
or they can be chemically decarboxylated.
10:12
The chemically decarboxylated products,
when they are done in the home
are often done incorrectly
and that causes side effects.
10:20
The chemically decarboxylated plants that
are purchased through large corporations
tend to be done fairly well and
tend to have very few side effects.
10:31
Hash oils.
10:32
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.
10:42
Hash is made from the resin of the cannabis plant.
10:46
If you take a cannabis plant and break it in
half, you’ll actually be able to feel the resin
between your fingers.
10:51
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.
11:05
There are higher concentrations of THC in hash.
11:09
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.
11:25
Remember that the pressed hash is a solid.
11:29
There are many ways to get hash,
so one form is called bubble hash.
11:34
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.
11:42
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.
11:54
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.
12:05
Hash oil can be many, many
different consistencies.
12:09
Here you can see that its
very thick kind of resin.
12:13
Now hash oil takes that resin and you
can refine it in many different ways.
12:19
Now alkali washing refers to washing
it with a highly alkalize substance.
12:26
The problem is that if it’s improperly
done, patients will have heartburn,
they’ll have gallbladder irritation
and they can develop pancreatitis.
12:35
So patients who are users of hash be
aware that they may have illnesses
secondary to the alkali washing of the hash.
12:43
Now, you can actually chemically convert CBD
which is one of the cannabinoid components to THC.
12:52
This is done through a
process called saponification.
12:56
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.
13:09
In the 1970s the THC content was only 10%
and in 1997 the THC content reached 17.5%.
13:20
Another form of hash oil is
something called 'shatter'.
13:24
Now in 2018, we saw THC contents as high
as 90% with this particular product.
13:32
This is a super purified
ultra-refined kind of hash oil.
13:36
Sometimes it is so refined that it actually
becomes a solid and can break like hard candy.
13:42
There are products that decolorize this otherwise
yellow product using activated charcoal.
13:49
This product can then look clear
or perhaps a milky white color.
13:54
In Canada 90% THC hash oil has been
approved for a commercial sale in 2019
so it is commercially available in some countries.
14:04
In the United States it’s kind of a gray
area because they’re selling it as hemp oil.
14:09
Now selling hemp oil is legal.
14:12
This may not be because the purposes are
to refine it so that THC levels are high.
14:17
So even though hemp itself may not
have high levels of THC, the problem is
is that when you ultrarefine
it, the THC levels go up.
14:25
Finally there is something
called butane honey oil.
14:29
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.
14:43
So when you hear about THC-refining
areas that have blown up,
it’s because somehow the butane was ignited.
14:51
Butane is the same fuel that you see in lighters.
14:55
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.
15:10
Pens.
15:11
Pens are a little bit different than vapes
so we’ll just talk quickly about pens.
15:18
Pens are not pens that you write with.
15:21
These are pens that have
little tiny heating elements
that vaporize a liquid that’s put into them.
15:26
Again, this isn’t quite the same
thing as vaporizer or a vape.
15:31
These liquids can contain propylene glycol,
glycerine, water and certain types of flavorings.
15:40
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.
16:00
Here’s an example of bronchiolitis
obliterans or popcorn lung.
16:04
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.
16:20
Vapes or vaporizers are another form of ingestion.
16:23
This is a little bit different than
a pen; the difference is subtle.
16:28
It’s a process that can use
heat but often does not.
16:32
It vaporizes the product into a vapor.
16:36
That vapor is kept in a loop so the loop
may stay inside the vaporizer for some time
or it may be immediately inhaled.
16:46
Now, 30% of the THC can be destroyed
by the pyrolysis within the vaporizer.
16:54
When we’ve done studies looking at
vaporizers and these are good studies.
16:58
These are reliable studies.
16:59
There was virtually no exposure to the
harmful combustion products of marijuana
using the vaporizer device.
17:08
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 not have those harmful combustion products.
17:27
In a 2008 article, it’s a
bit old but it’s still good.
17:31
Their conclusion was that it was a suitable
method for the administration of THC
if you so wanted to administer
that particular product.
17:39
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
lik 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.
18:00
So pens, vaporizers are a little bit different.
18:03
The definitions on the street are
fluid and sometimes they get 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.
18:17
so it’s important that you know the
difference in reality and then in practicalit
you have to know what your patients are using.
18:26
Now, I want to talk a little
bit more about the vapes.
18:29
The longer the vapor is stored in the
loop, the greater the loss of the THC.
18:37
In general, if you have the vapor in the
loop for only three minutes before ingestion,
the loss of THC is virtually negligible.
18:49
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.
18:58
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.
19:18
Sprays.
19:20
We don’t know much about the
sprays to be perfectly honest.
19:22
They are relatively new phenomenon.
19:24
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.
19:34
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.
19:43
Drinks are recent thing that has happened.
19:45
These are mostly CBD-based drinks but they are
THC-based drinks that are outside there as well.
19:51
Creams, this is kind of an interesting phenomenon.
19:54
So of course creams are
lipid-based, generally speaking
and so you can dissolve the
cannabinoid into the cream.
20:00
There are many different kinds of creams.
20:04
It is popular in countries where
the cannabinoid have been legalized
so this is becoming huge in the
United States and in Canada.
20:12
It is thought to help with eczema and psoriasis.
20:16
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.
20:30
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.
20:41
At this point in time we don’t really have that.
20:45
So this is a statement from the
National Academy of Sciences in 2017.
20:50
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.
21:11
And I completely agree with that, we
don’t have good science even today.
21:15
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.
21:25
I think also a lot of the harm is going
to become more documented as well.
21:33
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.
21:49
This is a non-odorous way of getting high
in public that is becoming very popular.
21:55
Vaginal creams.
21:56
So there is a belief out there that if you
apply cannabinoid creams to the vagina,
it relaxes the vagina, it increases
lubrication and increases the sexual pleasure.
22:07
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.
22:14
So for my clinical experience, it
hasn’t worked particularly well.
22:18
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.
22:32
Patches are a very interesting development
that’s happened just in the last little while.
22:38
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.
22:46
So she’s been using this 15%
patch now for about a month.
22:51
Transdermal patches are interesting because it
gives a relatively steady dose of the product.
22:58
It uses dimethyl sulfoxide which
is a penetration enhancer mixed in
with the high concentration of CBD oil.
23:07
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.
23:20
We generally focus these patches on administering
CBD oil as opposed to say, THC and getting high.
23:28
The onset of action is
anywhere between 3 and 6 hours.
23:31
With my clinical experience, I
would say it’s more than 6 hours.
23:34
The duration of action can
be anywhere from 6-20 hours.
23:38
Some patches are actually one-week patches.
23:41
There is a small tachyphylaxis effect.
23:44
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.
23:54
There is a post-application
effective up to four weeks,
so after you’ve removed the patch from the
patient's 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.
24:12
Sols and butters are another
means of administration.
24:14
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.
24:33
As you boil off the water, you're
essentially making a butter.
24:36
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.
24:47
Gums.
24:48
So this is an interesting development.
24:51
CBD-infused gums are used for
pain relief quite extensively now.
24:57
Now, we see - mostly our patients
with fibromyalgia are using it.
25:01
We also see it in chronic pain syndromes, we see
it in cancer patients and interestingly enough,
we see it in IBS patients too.
25:08
The onset of action is anywhere
between 5 minutes and 60 minutes.
25:12
Presumably, the 5 minutes portion of it
is because much of it is being absorbed
in the oral cavity and the upper digestive system.
25:21
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 enhanced activity.
25:38
And why is that?
It’s because the volume of
distribution of the cannabinoids.
25:43
It’s a very high volume of
distribution but as you saturate
the extravascular space with your cannabinoid,
you end up getting more and more of a hit
each time you use the gum.
25:56
There may also be a residual effect of up
to four weeks after you’ve eaten just one.
26:01
So these are long-term drugs
that have long-term effects.
26:07
THCA crystals.
26:10
This is an odd one.
26:12
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.
26:27
I suspect that there’s a large placebo effect
but who knows, it might actually be working.
26:32
Now, you may get a lot of side
effects from using this THCA crystals.
26:36
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 extraction process
and that results in incomplete saponification
of the product during the wash cycle.
26:52
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.
27:02
I wanna be clear though this is
not the same thing as shatter.
27:06
So people mistake THCA crystals with
shatter, they're not the same thing.
27:11
THCA crystals have the carboxylated
terpene as its main product,
whereas the shatter has actual
decarboxylated cannabinoids in it
so the shatter or the oils will have active product.
27:29
This theoretically is an inactive
product so this is why I say that it
really shouldn’t work but it seems to.
27:38
Canna oils.
27:39
Canna oils are difficult to define, they're
different from the CBD oils that we sometimes see.
27:45
It’s often used in cooking and infusion
and they are not processed or purified,
they’re just simply a pressed plant.
27:53
Sometimes it is mixed with coconut
oil or with olive oil for consumption.
27:59
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.
28:08
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.
28:19
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.
28:28
There’re may be toxic
contaminants within the product.
28:31
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.
28:41
It is more potent than CBD oil and now why
would I say that when I just finished saying
that they probably contain
decarboxylated cannabinoids.
28:52
It’s because we’re not
entirely sure what’s in them.
28:55
They may be decarboxylated, they may not be.
28:58
In any case, caution your patients
because we’re very concerned
about the Canna oils because of
the inconsistency of the product.
29:08
THC soda, this has made a recent comeback.
29:11
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.
29:21
They have very small amount of THC per bottle.
29:24
The effects are similar to other ingested products.
29:28
I can’t really tell you any more
than that, they’re relatively new.
29:31
Similarly, the syrups, I would say the
same thing, they are relatively new.
29:35
They have 10-200 mg per bottle.
29:38
The effects are similar to other ingested products,
and again, they're too new to tell you anything.
29:43
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.
29:54
Finally, we come to the last type of
ingestion which is the bath soaks.
29:58
So these are incredibly
common, very popular recently.
30:04
There’s no real psychoactive effects but people
believe that it causes a very relaxing bath.
30:09
There’s no reason to suspect that
there’s a medicinal benefit here.
30:13
Having said that, one must remember that sous vide
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.