An Open-Label Pilot Study Testing the Feasibility of Assessing Total Symptom Burden in Trials of Cannabinoid Medications in Palliative Care

Background: There is considerable interest in the use of cannabinoids for symptom control in palliative care, but there is little high-quality evidence to guide clinical practice.

Objectives: Assess the feasibility of using global symptom burden measures to assess response to medicinal cannabis, to determine median tolerated doses of cannabidiol (CBD) and tetrahydrocannabinol (THC), and to document adverse events (AEs).

Design: Prospective two-arm open-label pilot trial of escalating doses of CBD and THC oil.

Setting/Subjects: Participants had advanced cancer and cancer-related symptoms in a palliative and supportive care service in an Australian cancer center.

Measurements: The main outcome measures were the number of participants screened and randomized over the time frame, the number of participants completing days 14 and 28 and providing total symptom distress scores (TSDSs) (measured using the Edmonton Symptom Assessment Scale), and the change from baseline of the TSDS at day 14.

Results: Of the 21 participants enrolled (CBD, n = 16; THC, n = 5), 18 (86%) completed the primary outcome measure at day 14 and 8 completed at day 28. The median maximum tolerated doses were CBD, 300 mg/day (range 100–600 mg); THC, 10 mg/day (range 5–30 mg). Nine of 21 patients (43%) met the definition of response (≥6 point reduction in TSDS). Drowsiness was the most common AE.

Conclusions: Trials of medicinal cannabis in advanced cancer patients undergoing palliative care are feasible. The doses of THC and CBD used in this study were generally well tolerated and the outcome measure of total symptom distress is promising as a measure of overall symptom benefit. Trial registration: ACTRN12618001205224.

Distribution of Chemical Phenotypes (Chemotypes) in European Agricultural Hemp (Cannabis sativa L.) Cultivars

In Europe, more than 50 approved cultivars of fiber hemp (Cannabis sativa L.) are in agricultural production. Their content of psychoactive tetrahydrocannabinol (THC) is legally restricted to <0.2% (%w/w in the dry, mature inflorescences). Cannabis strains with much higher THC contents are also grown, illegally or under license for drug production. Differentiation between these two groups relies on biochemical quantification of cannabinoid contents in mature floral material. For nonflowering material or tissue devoid of cannabinoids, the genetic prediction of the chemical phenotype (chemotype) provides a suitable method of distinction. Three discrete chemotypes, depending on the ratio of THC and the noneuphoric cannabidiol (CBD), can be distinguished: a "THC-predominant" type, a "CBD-predominant" type, and an intermediate chemotype. We present a systematic genetic prediction of chemotypes of 62 agricultural hemp cultivars grown in Europe. The survey reveals the presence of up to 35% B_T allele-carrying individuals (representing either a THC-predominant or an intermediate chemotype) in some cultivars-which is unexpected considering the legal THC limit of 0.2% THC. The fact that 100% of the seized drug-type seeds in this study revealed at least one B_T allele, reflects that plant breeding efforts have resulted in a fixation of the B_T allele in recreational Cannabis. To guarantee a sincere forensic application based on a genetic chemotype prediction, we recommend not to classify material of unknown origin if the samples size is below nine genetically independent individuals.

Inhibiting Analyte Theft in Surface-Enhanced Raman Spectroscopy Substrates: Subnanomolar Quantitative Drug Detection

Quantitative applications of surface-enhanced Raman spectroscopy (SERS) often rely on surface partition layers grafted to SERS substrates to collect and trap-solvated analytes that would not otherwise adsorb onto metals. Such binding layers drastically broaden the scope of analytes that can be probed. However, excess binding sites introduced by this partition layer also trap analytes outside the plasmonic “hotspots”. We show that by eliminating these binding sites, limits of detection (LODs) can effectively be lowered by more than an order of magnitude. We highlight the effectiveness of this approach by demonstrating quantitative detection of controlled drugs down to subnanomolar concentrations in aqueous media. Such LODs are low enough to screen, for example, urine at clinically relevant levels. These findings provide unique insights into the binding behavior of analytes, which are essential when designing high-performance SERS substrates.

A Case Report of Secondary Spontaneous Pneumothorax Induced by Vape

Electronic cigarettes (referred here as E-cigarettes or vapes) are devices that contain heated nicotine/cannabinol vaporized aerosol solution for consumption. While long-term toxicities of E-cigarettes are unknown, the acute adverse events of vaping that have occurred are concerning. There have been variations of pneumonitis presentations so far, however, very few case reports have been shown to have a complication of a pneumothorax. We hereby present a case of a 35-year-old male who presented with spontaneous pneumothorax and pneumonitis due to vaping.

Tetrahydrocannabinol Sensing in Complex Biofluid with Portable Raman Spectrometer Using Diatomaceous SERS Substrates

Using thin-layer chromatography in tandem with surface-enhanced Raman spectroscopy (TLC-SERS) and tetrahydrocannabinol (THC) sensing in complex biological fluids is successfully conducted with a portable Raman spectrometer. Both THC and THC metabolites are detected from the biofluid of marijuana-users as biomarkers for identifying cannabis exposure. In this article, ultra-sensitive SERS substrates based on diatomaceous earth integrated with gold nanoparticles (Au NPs) were employed to detect trace levels of cannabis biomarkers in saliva. Strong characteristic THC and THC metabolite SERS peaks at 1601 and 1681 cm-1 were obtained despite the moderate interference of biological molecules native to saliva. Urine samples were also analyzed, but they required TLC separation of THC from the urine sample to eliminate the strong influence of urea and other organic molecules. TLC separation of THC from the urine was performed by porous microfluidic channel devices using diatomaceous earth as the stationary phase. The experimental results showed clear separation between urea and THC, and strong THC SERS characteristic peaks. Principal component analysis (PCA) was used to analyze the SERS spectra collected from various THC samples. The spectra in the principal component space were well clustered for each sample type and share very similar scores in the main principal component (PC1), which can serve as the benchmark for THC sensing from complex SERS spectra. Therefore, we proved that portable Raman spectrometers can enable an on-site sensing capability using diatomaceous SERS substrates to detect THC in real biological solutions. This portable THC sensing technology will play pivotal roles in forensic analysis, medical diagnosis, and public health.

An assessment of urine THC immunoassay in healthy volunteers receiving an oral proton-pump inhibitor

Introduction: Limitations of urine drug-screening (UDS) by immunoassay include false-positive results. Pantoprazole, a proton-pump inhibitor (PPI), is reported to cause false-positive results for THC on UDS. The objective of this study was to determine if oral PPIs cause false-positive THC results using the THC One Step Marijuana Test Strip^®.Methods: Eligible healthy volunteers completed a 5-day course of a PPI followed by urine testing using the THC One Step Marijuana Test Strip^®. Phase one included 3 subjects taking pantoprazole 40 mg once daily for 5 days. On day 5, urine specimens underwent THC screening. Phase two included 9 subjects randomized to 5-day supply of once-daily oral esomeprazole 20 mg, lansoprazole 15 mg, or omeprazole 20 mg. All study methods and testing mirrored those in phase one.Results: All 12 subjects completed the study protocol. All urine samples collected on day 5 were negative for THC in all subjects.Discussion: Our results demonstrate that oral PPIs did not cause a false-positive THC using the THC One Step Marijuana Test Strip^®. Limitations include small sample size, use of a single commercial immunoassay, and inability to confirm medication compliance. Further, large-scale research using other commercial urine immunoassays is warranted.

Can Metal-Organic Frameworks Be Used for Cannabis Breathalyzers?

Δ⁹-Tetrahydrocannabinol (THC) is the principal psychoactive component of cannabis, and there is an urgent need to build low-cost and portable devices that can detect its presence from breath. Similarly to alcohol detectors, these tools can be used by law enforcement to determine driver intoxication and enforce safer and more regulated use of cannabis. In this work, we propose to use a class of microporous crystals, metal-organic frameworks (MOFs), to selectively adsorb THC that can be later detected using optical, electrochemical, or fluorescence-based sensing methods. We computationally screened more than 5000 MOFs, highlighting the materials that have the largest affinity with THC, as well as the highest selectivity against water, showing that it is thermodynamically feasible for MOFs to adsorb THC from humid breath. We propose and compare different models for THC and different computational protocols to rank the promising materials, also presenting a novel approach to assess the permeability of a porous framework to nonspherical molecules. We identified three adsorption motifs in MOFs with high affinity to THC, which we refer to as "narrow channels", "thick walls", and "parking spots". Therefore, we expect our protocols and our findings to be generalizable for different classes of microporous materials and also for investigating the adsorption properties of other large molecules that, like THC, have a nonspherical shape.

High-Frequency Medical Cannabis Use Is Associated With Worse Pain Among Individuals With Chronic Pain

Cannabis is widely used for chronic pain. However, there is some evidence of an inverse dose-response relationship between cannabis effects and pain relief that may negatively affect analgesic outcomes. In this cross-sectional survey, we examined whether daily cannabis use frequency was associated with pain severity and interference, quality of life measures relevant to pain (eg, anxiety and depressive symptoms), and cannabis use preferences (administration routes and cannabinoid ratio). Our analysis included 989 adults who used cannabis every day for chronic pain. Participant use was designated as light, moderate, and heavy (1-2, 3-4, and 5 or more cannabis uses per day, respectively). The sample was also subgrouped by self-reported medical-only use (designated MED, n = 531, 54%) versus medical use concomitant with a past-year history of recreational use (designated MEDREC, n = 458, 46%). In the whole sample, increased frequency of use was significantly associated with worse pain intensity and interference, and worse negative affect, although high-frequency users also reported improved positive affect. Subgroup analyses showed that these effects were driven by MED participants. Heavy MED participant consumption patterns showed greater preference for smoking, vaporizing, and high tetrahydrocannabinol products. In contrast, light MED participants had greater preference for tinctures and high cannabidiol products. Selection bias, our focus on chronic pain, and our cross-sectional design likely limit the generalizability of our results. Our findings suggest that lower daily cannabis use frequency is associated with better clinical profile as well as lower risk cannabis use behaviors among MED participants. Future longitudinal studies are needed to examine how high frequency of cannabis use interacts with potential therapeutic benefits. PERSPECTIVE: Our findings suggest that lower daily cannabis use frequency is associated with better clinical profile as well as safer use behaviors (eg, preference for cannabidiol and noninhalation administration routes). These trends highlight the need for developing cannabis use guidelines for clinicians to better protect patients using cannabis.

The Endocannabinoid System of Animals

Simple Summary

Our understanding of the Endocannabinoid System of animals, and its ubiquitous presence in nearly all members of Animalia, has opened the door to novel approaches targeting pain management, cancer therapeutics, modulation of neurologic disorders, stress reduction, anxiety management, and inflammatory diseases. Both endogenous and exogenous endocannabinoid-related molecules are able to function as direct ligands or, otherwise, influence the EndoCannabinoid System (ECS). This review article introduces the reader to the ECS in animals, and documents its potential as a source for emerging therapeutics.

Abstract

The endocannabinoid system has been found to be pervasive in mammalian species. It has also been described in invertebrate species as primitive as the Hydra. Insects, apparently, are devoid of this, otherwise, ubiquitous system that provides homeostatic balance to the nervous and immune systems, as well as many other organ systems. The endocannabinoid system (ECS) has been defined to consist of three parts, which include (1) endogenous ligands, (2) G-protein coupled receptors (GPCRs), and (3) enzymes to degrade and recycle the ligands. Two endogenous molecules have been identified as ligands in the ECS to date. The endocannabinoids are anandamide (arachidonoyl ethanolamide) and 2-AG (2-arachidonoyl glycerol). Two G-coupled protein receptors (GPCR) have been described as part of this system, with other putative GPC being considered. Coincidentally, the phytochemicals produced in large quantities by the Cannabis sativa L plant, and in lesser amounts by other plants, can interact with this system as ligands. These plant-based cannabinoids are termed phytocannabinoids. The precise determination of the distribution of cannabinoid receptors in animal species is an ongoing project, with the canine cannabinoid receptor distribution currently receiving the most interest in non-human animals.

"HASH"ing out pancreatitis: the new increasingly common culprit

Acute pancreatitis is a serious, potentially life threatning inflammatory disorder of the pancreas usually caused by alcohol use or gallstones. Other causes include certain drugs (such as antibiotics, antihypertensive medications, and immunosuppressants) and extremley high triglyceride levels.Cannabis use has been identified as an uncommon cause of acute pancreatitis. However, due to its rarity in the general population, it has been low on practitioners' differential diagnosis. As a result, the incidence is likely underrepresented as these patients' recurrent episodes of pancreatitis are likely labeled as idiopathic when in fact they are not. This case report highlights the importance of keeping a wide differential when considering possible causes of pancreatitis.

Δ9-Tetrahydrocannabinol Derivative-Loaded Nanoformulation Lowers Intraocular Pressure in Normotensive Rabbits

PURPOSE

Δ9-Tetrahydrocannabinol-valine-hemisuccinate, a hydrophilic prodrug of Δ9-tetrahydrocannabinol, synthesized with the aim of improving the ocular bioavailability of the parent molecule, was investigated in a lipid-based nanoparticle dosage form for ocular delivery.

METHODS

Solid lipid nanoparticles (SLNs) of Δ9-tetrahydrocannabinol-valine-hemisuccinate and Δ9-tetrahydrocannabinol, along with a nanoemulsion of Δ9-tetrahydrocannabinol-valine-hemisuccinate, were tested for glaucoma management in a normotensive rabbit model by using a multiple-dosing protocol. Marketed formulations of timolol maleate and pilocarpine HCl were also tested for their pharmacodynamic profile, post-single dose administration.

RESULTS

A peak intraocular pressure (IOP) drop of 30% from baseline was observed in rabbits treated with SLNs loaded with Δ9-tetrahydrocannabinol-valine-hemisuccinate at 90 minutes. Treated eyes of rabbits receiving Δ9-tetrahydrocannabinol-valine-hemisuccinate SLNs had significantly lower IOP than untreated eyes until 360 minutes, whereas the group receiving the emulsion formulation showed a drop in IOP until 90 minutes only. In comparison to marketed pilocarpine and timolol maleate ophthalmic solutions, Δ9-tetrahydrocannabinol-valine-hemisuccinate SLNs produced a greater effect on IOP in terms of both intensity and duration. In terms of tissue concentrations, significantly higher concentrations of Δ9-tetrahydrocannabinol-valine-hemisuccinate were observed in iris-ciliary bodies and retina-choroid with SLNs.

CONCLUSION

Δ9-Tetrahydrocannabinol-valine-hemisuccinate formulated in a lipid-based nanoparticulate carrier shows promise in glaucoma pharmacotherapy.

TRANSLATIONAL RELEVANCE

Glaucoma therapies usually focus on decreased aqueous humor production and increased outflow. However, such therapy is not curative, and there lies a need in preclinical research to focus efforts on agents that not only affect the aqueous humor dynamics but also provide neuroprotection. Historically, there have been bench-scale studies looking at retinal ganglion cell death post-axonal injury. However, for a smooth translation of this in vitro activity to the clinic, animal models examining IOP reduction, i.e., connecting the neuroprotective activity to a measurable outcome in glaucoma management (IOP), need to be investigated. This study investigated the IOP reduction efficacy of cannabinoids for glaucoma pharmacotherapy in a normotensive rabbit model, bringing forth a new class of agents with the potential of IOP reduction and improved permeation to the back of the eye, possibly providing neuroprotective benefits in glaucoma management.

Cannabis use as a risk factor for causing motor vehicle crashes: a prospective study

AIM

We conducted a responsibility analysis to determine whether drivers injured in motor vehicle collisions who test positive for Δ-9-tetrahydrocannabinol (THC) or other drugs are more likely to have contributed to the crash than those who test negative.

DESIGN

Prospective case-control study.

SETTING

Trauma centres in British Columbia, Canada.

PARTICIPANTS

Injured drivers who required blood tests for clinical purposes following a motor vehicle collision.

MEASUREMENTS

Excess whole blood remaining after clinical use was obtained and broad-spectrum toxicology testing performed. The analysis quantified alcohol and THC and gave semiquantitative levels of other impairing drugs and medications. Police crash reports were analysed to determine which drivers contributed to the crash (responsible) and which were 'innocently involved' (non-responsible). We used unconditional logistic regression to determine the likelihood (odds ratio: OR) of crash responsibility in drivers with 0 < THC < 2 ng/ml, 2 ng/ml ≤ THC < 5 ng/ml and THC ≥ 5 ng/ml (all versus THC = 0 ng/ml). Risk estimates were adjusted for age, sex and presence of other impairing substances.

FINDINGS

We obtained toxicology results on 3005 injured drivers and police reports on 2318. Alcohol was detected in 14.4% of drivers, THC in 8.3%, other drugs in 8.9% and sedating medications in 19.8%. There was no increased risk of crash responsibility in drivers with THC < 2 ng/ml or 2 ≤ THC < 5 ng/ml. In drivers with THC ≥ 5 ng/ml, the adjusted OR was 1.74 [95% confidence interval (CI) = 0.59-6.36; P = 0.35]. There was significantly increased risk of crash responsibility in drivers with blood alcohol concentration (BAC) ≥ 0.08% (OR = 6.00;95% CI = 3.87-9.75; P < 0.01), other recreational drugs detected (OR = 1.82;95% CI = 1.21-2.80; P < 0.01) or sedating medications detected (OR = 1.45; 95%CI = 1.11-1.91; P < 0.01).

CONCLUSIONS

In this sample of non-fatally injured motor vehicle drivers in British Columbia, Canada, there was no evidence of increased crash risk in drivers with Δ-9-tetrahydrocannabinol < 5 ng/ml and a statistically non-significant increased risk of crash responsibility (odds ratio = 1.74) in drivers with Δ-9-tetrahydrocannabinol ≥ 5 ng/ml.

Cannabis and the liver: Things you wanted to know but were afraid to ask

Many Canadians use cannabis for medicinal and recreational purposes. We describe the current understandings of how cannabis is metabolized in the liver and its potential interactions with other common drugs. We also summarize how cannabis may exert various effects in chronic liver diseases (CLDs), especially in chronic hepatitis C virus (HCV) and fatty liver disease.

Tetrahydrocannabinol Detection Using Semiconductor-Enriched Single-Walled Carbon Nanotube Chemiresistors

Semiconductor-enriched single-walled carbon nanotubes (s-SWCNTs) have potential for application as a chemiresistor for the detection of breath compounds, including tetrahydrocannabinol (THC), the main psychoactive compound found in the marijuana plant. Herein we show that chemiresistor devices fabricated from s-SWCNT ink using dielectrophoresis can be incorporated into a hand-held breathalyzer with sensitivity toward THC generated from a bubbler containing analytical standard in ethanol and a heated sample evaporator that releases compounds from steel wool. The steel wool was used to capture THC from exhaled marijuana smoke. The generation of the THC from the bubbler and heated breath sample chamber was confirmed using ultraviolet-visible absorption spectroscopy and mass spectrometry, respectively. Enhanced selectivity toward THC over more volatile breath components such as CO₂, water, ethanol, methanol, and acetone was achieved by delaying the sensor reading to allow for the desorption of these compounds from the chemiresistor surface. Additionally, machine learning algorithms were utilized to improve the selective detection of THC with better accuracy at increasing quantities of THC delivered to the chemiresistor.

Cannabis effects on brain structure, function, and cognition: considerations for medical uses of cannabis and its derivatives

Background: Cannabis is the most widely used illicit substance worldwide, and legalization for recreational and medical purposes has substantially increased its availability and use in the United States.Objectives: Decades of research have suggested that recreational cannabis use confers risk for cognitive impairment across various domains, and structural and functional differences in the brain have been linked to early and heavy cannabis use.Methods: With substantial evidence for the role of the endocannabinoid system in neural development and understanding that brain development continues into early adulthood, the rising use of cannabis in adolescents and young adults raises major concerns. Yet some formulations of cannabinoid compounds are FDA-approved for medical uses, including applications in children.Results: Potential effects on the trajectory of brain morphology and cognition, therefore, should be considered. The goal of this review is to update and consolidate relevant findings in order to inform attitudes and public policy regarding the recreational and medical use of cannabis and cannabinoid compounds.Conclusions: The findings point to considerations for age limits and guidelines for use.

Use of gas chromatography-mass spectrometry for definitive diagnosis of synthetic cannabinoid toxicity in a dog

OBJECTIVE

To report the use of gas chromatography-mass spectrometry to confirm a diagnosis of synthetic cannabis toxicosis in a dog and to describe the clinical course of the intoxication.

CASE SUMMARY

An 11-year-old neutered female Boxer dog was referred due to acute onset of vomiting, ataxia, dull mentation, and delirium that progressed to generalized seizures, unresponsive to diazepam. Prior to presentation, the dog was found lying down, minimally responsive with vomitus around it. A chewed bag containing dried plant material was found next to the dog. The dog was anesthetized and ventilated with positive pressure for 16 hours, and eventually made a full recovery. Gas chromatography-mass spectrometry analysis of the plant material and a plasma sample from the dog revealed presence of the synthetic cannabinoid N-[(1S)-1-(aminocarbonyl)-2-methylpropyl]-1-(cyclohexylmethyl)-1H-indazole-3-carboxamide, also known as AB-CHMINACA, a relatively new illegal synthetic cannabinoid, known by the local forensic police department as a drug of recreational abuse.

NEW OR UNIQUE INFORMATION PROVIDED

Reports of synthetic cannabinoid toxicosis in dogs are scarce and are based on urine test kits for tetrahydrocannabinol that have not been validated in the veterinary literature. This is the first report to describe utilization of gas chromatography-mass spectrometry on canine plasma to reach a definitive diagnosis.

Suspected Acute Respiratory Distress Syndrome Associated With the Use of Intravenous Lipid Emulsion Therapy in a Dog: A Case Report

A 12-year-old male neutered Bichon Frise presented to the Emergency Department for stupor and bradycardia after ingestion of chocolate covered 450 mg (90 mg/kg) tetrahydrocannabinol. The patient was hospitalized for supportive care, IV fluid therapy and monitoring in the intensive care unit. During hospitalization the patient became comatose and bradypneic. Treatment with intravenous lipid emulsion (ILE) therapy was instituted to accelerate toxin elimination, reduce the risk of complications related to progressive obtundation and shorten hospitalization time. Five hours after infusion, the patient developed severe respiratory distress and was ultimately euthanized. Post-mortem histologic evaluation of lung revealed severe pulmonary edema consistent with acute respiratory distress syndrome. There are infrequent reports of adverse effects associated with ILE therapy for toxicosis in veterinary medicine despite reports of complications such as acute respiratory distress syndrome in human literature. The purpose of this report is to describe the potential for a severe adverse event after treatment of a toxicosis with ILE therapy.

Cannabis-induced altered states of consciousness are associated with specific dynamic brain connectivity states

BACKGROUND

Cannabis, and specifically one of its active compounds delta-9-tetrahydrocannabinol in recreational doses, has a variety of effects on cognitive processes. Most studies employ resting state functional magnetic resonance imaging techniques to assess the stationary effects of cannabis and to-date one report addressed the impact of delta-9-tetrahydrocannabinol on the dynamics of whole-brain functional connectivity.

METHODS

Using a repeated-measures, within-subjects design, 19 healthy occasional cannabis users (smoking cannabis ⩽2 per week) underwent resting state functional magnetic resonance imaging scans. Each subject underwent two scans: in the intoxicated condition, shortly after smoking a cannabis cigarette, and in the non-intoxicated condition, with the subject being free from cannabinoids for at least one week before. All sessions were randomized and performed in a four-week interval. Data were analysed employing a standard independent component analysis approach with subsequent tracking of the functional connectivity dynamics, which allowed six connectivity clusters (states) to be individuated.

RESULTS

Using standard independent component analysis in resting state functional connectivity, a group effect was found in the precuneus connectivity. With a dynamic independent component analysis approach, we identified one transient connectivity state, characterized by high connectivity within and between auditory and somato-motor cortices and anti-correlation with subcortical structures and the cerebellum that was only found during the intoxicated condition. Behavioural measures of the subjective experiences of changed perceptions and tetrahydrocannabinol plasma levels during intoxication were associated with this state.

CONCLUSIONS

With the help of the dynamic connectivity approach we could elucidate neural correlates of the transitory perceptual changes induced by delta-9-tetrahydrocannabinol in cannabis users, and possibly identify a biomarker of cannabis intoxication.

CNR1 and FAAH variation and affective states induced by marijuana smoking

Background: Polymorphisms in cannabinoid receptor type 1 (encoded by CNR1) and fatty acid amide hydrolase (encoded by FAAH) have been associated with cannabis dependence, but it remains unknown whether variation within these genes influences cannabis' acute effects on affect. Objective: Conduct a secondary data analysis study to determine whether previously observed acute effects of tetrahydrocannabinol (THC) on mood was dependent upon variation in CNR1 and FAAH. Methods: A balanced placebo design was used crossing marijuana administration (i.e., 0% THC vs. 2.8% THC) with stimulus expectancy. Participants (N = 118; 64% male) provided DNA and completed the Profile of Mood States questionnaire prior to and after smoking. Haplotypes were constructed from genotyped single nucleotide polymorphisms for CNR1 (rs1049353 and rs806368) and FAAH (rs4141964, rs324420, and rs11576941); rs2023239 (CNR1) and rs6703669 (FAAH) were not part of a phased haplotype block. Analyses tested both main and interaction effects for genotype across CNR1 and FAAH, and drug, and expectancy effects. Results: THC increased levels of POMS Tension-Anxiety and Confusion-Bewilderment over and above the effects of variation in CNR1 and FAAH. Significant drug X genotype/haplotype and expectancy X genotype/haplotype interaction effects were observed for some but not all mood states [e.g., 'C' allele carriers of rs2023239 who received THC had higher levels of Anger-Hostility (β= 0.29 (0.12), p= .02) compared to those who received placebo]. Conclusion: These preliminary findings suggest individual differences in mood states after using marijuana depend on genetic variation. Such information might be useful in understanding either motivation for use of marijuana and/or risk for associated behaviors.

Dark Classics in Chemical Neuroscience: Δ9-Tetrahydrocannabinol

Cannabis ( Cannabis sativa) is the most widely used illicit drug in the world, with an estimated 192 million users globally. The main psychoactive component of cannabis is (-)- trans-Δ⁹-tetrahydrocannabinol (Δ⁹-THC), a compound with a diverse range of pharmacological actions. The unique and distinctive intoxication caused by Δ⁹-THC primarily reflects partial agonist action at central cannabinoid type 1 (CB₁) receptors. Δ⁹-THC is an approved therapeutic treatment for a range of conditions, including chronic pain, chemotherapy-induced nausea and vomiting, and multiple sclerosis, and is being investigated in indications such as anorexia nervosa, agitation in dementia, and Tourette's syndrome. It is available as a regulated pharmaceutical in products such as Marinol, Sativex, and Namisol as well as in an ever-increasing range of unregistered medicinal and recreational cannabis products. While cannabis is an ancient medicament, contemporary use is embroiled in legal, scientific, and social controversy, much of which relates to the potential hazards and benefits of Δ⁹-THC itself. Robust contemporary debate surrounds the therapeutic value of Δ⁹-THC in different diseases, its capacity to produce psychosis and cognitive impairment, and the addictive and "gateway" potential of the drug. This review will provide a profile of the chemistry, pharmacology, and therapeutic uses of Δ⁹-THC as well as the historical and societal import of this unique, distinctive, and ubiquitous psychoactive substance.

Trace Detection of Tetrahydrocannabinol in Body Fluid via Surface-Enhanced Raman Scattering and Principal Component Analysis

Tetrahydrocannabinol (THC) is the main active component in marijuana and the rapid detection of THC in human body fluid plays a critical role in forensic analysis and public health. Surface-enhanced Raman scattering (SERS) sensing has been increasingly used to detect illicit drugs; however, only limited SERS sensing results of THC in methanol solution have been reported, while its presence in body fluids, such as saliva or plasma, has yet to be investigated. In this article, we demonstrate the trace detection of THC in human plasma and saliva solution using a SERS-active substrate formed by in situ growth of silver nanoparticles (Ag NPs) on diatom frustules. THC at extremely low concentration of 1 pM in plasma and purified saliva solutions were adequately distinguished with good reproducibility. The SERS peak at 1603 cm^-1 with standard deviation of 3.4 cm^-1 was used for the evaluation of THC concentration in a methanol solution. Our SERS measurement also shows that this signature peak experiences a noticeable wavenumber shift and a slightly wider variation in the plasma and saliva solution. Additionally, we observed that THC in plasma or saliva samples produces a strong SERS peak at 1621 cm^-1 due to the stretching mode of O-C═O, which is related to the metabolic change of THC structures in body fluid. To conduct a quantitative analysis, principal component analysis (PCA) was applied to analyze the SERS spectra of 1 pM THC in methanol solution, plasma, and purified saliva samples. The maximum variability of the first three principal components was achieved at 71%, which clearly denotes the impact of different biological background signals. Similarly, the SERS spectra of THC in raw saliva solution under various metabolic times were studied using PCA and 98% of the variability is accounted for in the first three principal components. The clear separation of samples measured at different THC resident times can provide time-dependent information on the THC metabolic process in body fluids. A linear regression model was used to estimate the metabolic rate of THC in raw saliva and the predicted metabolic time in the testing data set matched well with the training data set. In summary, the hybrid plasmonic-biosilica SERS substrate can achieve ultrasensitive, near-quantitative detection of trace levels of THC in complex body fluids, which can potentially transform forensic sensing techniques to detect marijuana abuse.

Survey of Australian psychiatrists' and psychiatry trainees' knowledge about and attitudes towards medicinal cannabinoids

OBJECTIVE:

To assess Australian psychiatrists' and psychiatry trainees' knowledge about and attitudes towards medicinal cannabinoids, given the recent relaxation of cannabinoid-prescribing laws in Australia.

METHOD:

All Australian members of the Royal Australian and New Zealand College of Psychiatrists were invited to participate in an anonymous, 64-item online questionnaire, through Royal Australian and New Zealand College of Psychiatrists' newsletters. The questionnaire ran for a 10-week period from March to May 2017. Participants were asked about their knowledge of the evidence for and against prescribing pharmaceutical-grade cannabidiol and tetrahydrocannabinol, and their concerns about prescribing medicinal cannabinoids.

RESULTS:

In total, 88 doctors responded to the survey, with 55 completing all items (23 psychiatrists, 32 trainees). Overall, 54% of respondents would prescribe medicinal cannabinoids if it was legal to do so. Participants believed there was evidence for the use of cannabidiol and tetrahydrocannabinol in treating childhood epilepsy, chronic pain, and nausea and vomiting. They were most concerned about medicinal cannabinoids leading to psychotic symptoms, addiction and dependence, apathy and recreational use.

CONCLUSIONS:

Our sample of Australian psychiatrists and trainees were aware of the main clinical indications for medicinal cannabinoids, but were poor at differentiating between the indications for cannabidiol versus tetrahydrocannabinol. Further education about medicinal cannabinoids appears necessary.

Adherence to Consolidated Standards of Reporting Trials (CONSORT) Guidelines for Reporting Safety Outcomes in Trials of Cannabinoids for Chronic Pain: Protocol for a Systematic Review

Background

Chronic pain affects a significant proportion of the population and presents a major challenge to clinicians and pain specialists. Despite the availability of pharmacologic treatment options such as opioids, many patients continue to experience persistent pain. Cannabinoids present an alternative option with some data on efficacy; however, to date, a systematic review of adverse events (AEs) assessment and reporting in randomized clinical trials (RCTs) involving cannabinoids has not been performed. As a result, it is unclear whether a clear profile of cannabinoid-associated AEs has been accurately detailed in the literature. As cannabinoids are likely to become readily available for patients in the near future, it is important to study how well AEs have been reported in trials so that the safety profile of cannabinoids can be better understood.

Objective

With a potentially enormous shift toward cannabinoid use for managing chronic pain and spasticity, this study aims to reveal the adequacy of AE reporting and cannabinoid-specific AEs in this setting. Spasticity is a major contributor to chronic pain in patients with multiple sclerosis (MS), with a comorbidity of 75%. Many cannabinoid studies have been performed in MS-related painful spasticity with relevant pain outcomes, and these studies will be included in this review for comprehensiveness. The primary outcome will be the quality of AE assessment and reporting by adherence to the Consolidated Standards of Reporting Trials (CONSORT) guidelines. Secondary outcomes will include the type of AE, method of AE reporting, severity of AE, frequency of AEs, patient withdrawals, and reasons for withdrawals.

Methods

We will perform a systematic review by searching for primary reports of double-blind, randomized controlled trials of cannabinoids compared with placebo and any active comparator treatments for chronic pain, with a primary outcome directly related to pain (eg, pain intensity, pain relief, and pain-related interference). We will search the following databases: MEDLINE, Embase, Cochrane Library, and PsycINFO. RevMan software will be used for meta-analysis.

Results

The protocol has been registered on the International Prospective Register of Systematic Reviews (CRD42018100401). The project was funded in 2018 and screening has been completed. Data extraction is under way and the first results are expected to be submitted for publication in January or February 2019.

Conclusions

This review will better elucidate the safety of cannabinoids for the treatment of chronic pain and spasticity through identifying gaps in the literature for AE reporting. Like in any new therapy, it is essential that accurate information surrounding the safety and efficacy of cannabinoids be clearly outlined and identified to balance the benefit and harm described for patients.

Trial Registration

PROSPERO CRD42018100401; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=100401

International Registered Report Identifier (IRRID)

DERR1-10.2196/11637

Potential Use of Cannabinoids for the Treatment of Pancreatic Cancer

Background: Cannabinoid extracts may have anticancer properties, which can improve cancer treatment outcomes. The aim of this review is to determine the potentially utility of cannabinoids in the treatment of pancreatic cancer.

Methods: A literature review focused on the biological effects of cannabinoids in cancer treatment, with a focus on pancreatic cancer, was conducted. In vitro and in vivo studies that investigated the effects of cannabinoids in pancreatic cancer were identified and potential mechanisms of action were assessed.

Results: Cannabinol receptors have been identified in pancreatic cancer with several studies showing in vitro antiproliferative and proapoptotic effects. The main active substances found in cannabis plants are cannabidiol (CBD) and tetrahydrocannabinol (THC). There effects are predominately mediated through, but not limited to cannabinoid receptor-1, cannabinoid receptor-2, and G-protein-coupled receptor 55 pathways. In vitro studies consistently demonstrated tumor growth-inhibiting effects with CBD, THC, and synthetic derivatives. Synergistic treatment effects have been shown in two studies with the combination of CBD/synthetic cannabinoid receptor ligands and chemotherapy in xenograft and genetically modified spontaneous pancreatic cancer models. There are, however, no clinical studies to date showing treatment benefits in patients with pancreatic cancer.

Conclusions: Cannabinoids may be an effective adjunct for the treatment of pancreatic cancer. Data on the anticancer effectiveness of various cannabinoid formulations, treatment dosing, precise mode of action, and clinical studies are lacking.