Cannabis, cannabinoids, and health

Use of Cannabidiol in the Management of Insomnia: A Systematic Review

Background: Cannabidiol (CBD), one of the major cannabinoids derived from the cannabis plant, is available over the counter. CBD is often used by patients for the management of insomnia, yet research supporting CBDs effectiveness as a treatment for insomnia is inadequate. Objective: The objective of this review was to critically evaluate the literature regarding the therapeutic benefits of CBD in the management of insomnia. Methods: A comprehensive search of the following databases from inception to December 29, 2021, was conducted: Ovid MEDLINE^® and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. The search included randomized controlled trials, nonrandomized experimental studies, cross-sectional studies, cohort studies, case series, and case reports. Risk of bias was assessed with the Agency for Healthcare Research and Quality design-specific recommended criteria. Results: Thirty-four studies were eligible for inclusion. All studies reported improvement in the insomnia symptoms of at least a portion of their participants. Of the 34 studies, 19 studies used CBD predominant therapy and 21 studies used nearly equal ratios of CBD to Δ⁹-tetrahydrocannabinol (THC). Of the studies that performed hypothesis testing, 4 of 7 studies with a CBD predominant arm and 12 of 16 studies with a nearly equal ratio of CBD to THC arm reported significant improvement in insomnia outcomes. However, only 2 of the 34 studies focused on patients with insomnia, of which 1 study was a case report. Additionally, several studies used nonvalidated subjective measures, and most studies failed to include objective measures for symptom assessment. Conclusions: The results of our systematic review suggest that CBD alone or with equal quantities of THC may be beneficial in alleviating the symptoms of insomnia. Nevertheless, future research assessing CBDs effectiveness in population of patients specifically with insomnia utilizing validated subjective and objective measures is necessary before definitive inferences can be made.

Development of a Community-Based Network to Promote Anti-Drug Messaging and Identify Hidden Drug Abusers in Hong Kong

Developing a community-based network by training peers as anti-drug ambassadors (ADAs) is a feasible strategy to identify hidden drug abusers. The Ask, Warn, Advise, Refer and Do-it-again (AWARD) model of smoking cessation is useful for enhancing people's confidence in making referrals to anti-drug services. This study evaluated the effectiveness of such a network by examining the change in knowledge, attitudes and practices (KAP) of 198 ADAs aged 13-18 before and after six months of our training. A one-group pre-test and repeated post-test design was used. One-way repeated-measures analysis of variance was applied to assess the changes in KAP, with p-values adjusted by Bonferroni correction. The results showed that the ADAs statistically significantly improved their KAP regarding drug abuse at the six-month follow-up compared to baseline. All ADAs who knew drug abusers (n = 3) had referred them to services based on the AWARD model. A total of 154 anti-drug abuse activities were conducted, reaching 4561 people. Based on the results, we concluded that the community-based network was effective in improving the KAP of ADAs regarding drug abuse, as well as referring hidden drug abusers. Future studies should consider implementing the network on a larger scale, thus maximizing its anti-drug capacity.

Behavioral effects on the offspring of rodent mothers exposed to Tetrahydrocannabinol (THC): A meta-analysis

Pre and perinatal administration of Tetrahydrocannabinol (THC) in rodents and their offspring has many effects that have been studied using different methods that have not been integrated using quantitative methods. The effect of THC administration on behavior can be better understood by meta-analytic techniques. We examined whether there is an overall effect on the behavior of the offspring when THC is administered to mothers. Eligibility criteria included experiments using an experimental design with a control group without THC, in which THC is administered to mothers during pregnancy and lactation in rodents, and in which at least one type of behavioral (locomotor, emotional or cognitive) measurement in the offspring was implemented. Cohen’s d was obtained for each study, then each individual study was weighted, and moderator analysis was performed. Analysis was performed using fixed and random effect models, and the heterogeneity was assessed by calculating Qb, I² and the prediction interval. Furthermore, 3 sub-meta-analyses were carried out according to the type of behavior. The general analysis determined a low weighted effect size of THC on the behavior of the offspring, moderated by type of rat strain. The sub-meta-analyses showed a medium effect for cognitive effects of THC in the offspring, and a low effect on locomotor activity and emotional behavior. In addition, publication bias was not detected. More research is needed to contribute to the understanding of the effect of THC exposure on offspring.

Effect of Lipid Vehicles on Solubility, Stability, and Topical Permeation of Delta-9-Tetrahydrocannabinol

Delta-9-tetrahydrocannabinol (THC) is one of the most effective antinociceptive agents used in the treatment of peripheral neuropathy. THC is highly lipophilic and susceptible to thermal and oxidative degradation. Identifying appropriate solvents in which THC is stable as well as adequately solubilized is crucial in developing topical dosage forms. Lipid solvent systems are of utmost utility and relevance for formulating highly lipophilic drugs. Hence, the objective of this project was to screen the solubility of THC in lipidic excipients, monitor THC content in the selected vehicles during stability, and study the influence of these excipients on permeation of THC across skin. The solubility of THC in liquid lipid excipients was in the range of 421 to 500 mg/g. The solubility of THC in solid lipid excipients was in the range of 250 to 750 mg/g. THC in its neat form was poorly stable, but when dissolved in lipid-based excipients, its stability improved significantly. THC in lipid excipients was more stable at 4 ± 3°C compared to samples stored at 25 ± 2°C. The antioxidants (butylated hydroxytoluene and ascorbyl palmitate) used in the excipients further improved the stability of THC. The results demonstrated that the liquid and solid lipid excipients used in the study could solubilize THC freely and mitigate the degradation of THC significantly. The binary combination of lipid excipients enhanced THC skin permeation and retention, demonstrating the potential for topical formulation development of THC.

Correlation between oral fluid and blood THC concentration: A systematic review and discussion of policy implications

Cannabis is the second most commonly used impairing substance by drivers, after alcohol. As more countries legalize cannabis, there is concern that cannabis-impaired driving will increase. In many countries, police use roadside devices to test for oral fluid THC (the primary psychotropic component in cannabis) to identify drivers who used cannabis; including in countries with non-zero per se limits for THC in blood. This practice is questioned as previous research demonstrates a poor correlation between oral fluid and blood THC concentrations at the individual level. We conducted a meta-analysis to identify all research that compared oral fluid with blood THC levels. We obtained individual-level data from study authors and analyzed pooled individual-level data to calculate sensitivity and specificity of oral fluid THC (at various cut-off values) to detect blood THC above different concentration limits. Finally, we explored practical implications of using oral fluid THC in an enforcement context. Our review found THC concentrations measured in over 18,000 paired samples of oral fluid and blood. We found a good correlation between the presence of THC in oral fluid and presence of THC in blood (sensitivity = 71.2%, specificity = 97.7%). However oral fluid THC, at commonly used cut-off values, is less sensitive and less specific when used as a biomarker to detect people with blood THC concentrations above commonly used per se limits (such as 5 ng/mL). As such, there will be a large number of "false positive" tests if oral fluid THC testing were used as a biomarker for "illegal" THC concentrations in randomly selected drivers. We argue that the adverse implications of false positive oral fluid THC tests in this context outweigh the possible road safety benefits and we recommend against oral fluid THC screening in randomly selected drivers in countries with non-zero per se limits for blood THC. In contrast, oral fluid THC tests appear to be useful for investigating "high-risk" drivers who come to police attention because of evidence of impairment.

N-acetyl cysteine in the treatment of cannabis use disorder: A systematic review of clinical trials

BACKGROUND AND AIM

Cannabis is the most consumed illicit drug globally, with a high risk of developing cannabis use disorder (CUD). No approved pharmacological treatment exists for CUD, but N-Acetyl Cysteine (NAC) has shown promising results in different clinical studies. This study aims to conduct a systematic review of NAC clinical trials for the treatment of CUD.

METHODS

Systematic review of randomized controlled trials (RCTs) was conducted to determine the effect of NAC for the treatment of cannabis dependence/cannabis use disorder (CUD). Articles were electronically searched across different databases using PubMed, Google Scholar, EMBASE, Cochrane Library, Medline and PsycINFO from inception to June 2021. Several study characteristics, including study duration, sample size, study population and age group, intervention, adverse effects, and outcome measure were extracted. A PICO table was used for data extraction.

RESULTS

We included 08 RCTs in the qualitative analysis. The risk of bias (RoB) was assessed according to Cochrane RoB criteria, and a 5 point grading system according to the Oxford Centre for Evidence-Based Medicine was used to rate the methodological quality (level of evidence) of the included articles. Mild and well-tolerated adverse events were reported in the placebo and NAC group.

CONCLUSIONS

The studies collectively offer mixed results, although the strength of the evidence available on which to make a recommendation is strong. NAC has shown to be effective in promoting abstinence, medication adherence and reducing cannabis use and craving among cannabis dependent users. This review also suggests recommendations for future research.

Understanding the Placental Biology of Tobacco Smoke, Nicotine, and Marijuana (THC) Exposures During Pregnancy

Widespread public health campaigns have reduces the prevalence of tobacco and nicotine exposures during pregnancy in the United States. However, tobacco and nicotine exposures during pregnancy persist as a common modifiable perinatal risk exposure. Furthermore, declines in tobacco use have been accompanied by parallel rises in both the prevalence and incidence of marijuana use in pregnancy. This is worrisome, as the macromolecules which comprise tobacco and marijuana smoke affect placental function. In this chapter we summarize the decades of evidence contributing to our understanding of the placental molecular pathophysiology accompanying these chemical exposures, thereby rendering risk of adverse perinatal outcomes.

Cannabis for Medical Use: Analysis of Recent Clinical Trials in View of Current Legislation

Cannabis has long been regarded as a recreational substance in the Western world. The recent marketing authorization of some medicinal products of industrial origin and the introduction onto the market of inflorescences for medical use mean that medical doctors can now prescribe Cannabis-based medicines in those countries which allow it. Nevertheless, there is still considerable controversy on this topic in the scientific community. In particular, this controversy concerns: the plant species to be used; the pathologies that can be treated and consequently the efficacy and safety of use; the routes of administration; the methods of preparation; the type and dosage of cannabinoids to be used; and, the active molecules of interest. As such, although medical Cannabis has been historically used, the results of currently completed and internationally published studies are inconclusive and often discordant. In light of these considerations, the aim of this work is to analyse the current legislation in countries that allow the use of medical Cannabis, in relation to the impact that this legislation has had on clinical trials. First of all, a literature search has been performed (PubMed and SciFinder) on clinical trials which involved the administration of Cannabis for medical use over the last 3 years. Of the numerous studies extrapolated from the literature, only about 43 reported data on clinical trials on medical Cannabis, with these mainly being performed in Australia, Brazil, Canada, Denmark, Germany, Israel, Netherlands, Switzerland, the United Kingdom and the United States of America. Once the reference countries were identified, an evaluation of the legislation in relation to Cannabis for medical use in each was carried out via the consultation of the pertinent scientific literature, but also of official government documentation and that of local regulatory authorities. This analysis provided us with an overview of the different legislation in these countries and, consequently, allowed us to analyse, with greater awareness, the results of the clinical trials published in the last 3 years in order to obtain general interest indications in the prosecution of scientific research in this area.

Genome-Wide Identification and Expression Analysis of Homeodomain Leucine Zipper Subfamily IV (HD-ZIP IV) Gene Family in Cannabis sativa L

The plant-specific homeodomain zipper family (HD-ZIP) of transcription factors plays central roles in regulating plant development and environmental resistance. HD-ZIP transcription factors IV (HDZ IV) have been involved primarily in the regulation of epidermal structure development, such as stomata and trichomes. In our study, we identified nine HDZ IV-encoding genes in Cannabis sativa L. by conducting a computational analysis of cannabis genome resources. Our analysis suggests that these genes putatively encode proteins that have all the conserved domains of HDZ IV transcription factors. The phylogenetic analysis of HDZ IV gene family members of cannabis, rice (Oryza sativa), and Arabidopsis further implies that they might have followed distinct evolutionary paths after divergence from a common ancestor. All the identified cannabis HDZ IV gene promoter sequences have multiple regulation motifs, such as light- and hormone-responsive elements. Furthermore, experimental evidence shows that different HDZ IV genes have different expression patterns in root, stem, leaf, and flower tissues. Four genes were primarily expressed in flowers, and the expression of CsHDG5 (XP_030501222.1) was also correlated with flower maturity. Fifty-nine genes were predicted as targets of HDZ IV transcription factors. Some of these genes play central roles in pathogen response, flower development, and brassinosteroid signaling. A subcellular localization assay indicated that one gene of this family is localized in the Arabidopsis protoplast nucleus. Taken together, our work lays fundamental groundwork to illuminate the function of cannabis HDZ IV genes and their possible future uses in increasing cannabis trichome morphogenesis and secondary metabolite production.

Extraction of Bioactive Compounds From Cannabis sativa L. Flowers and/or Leaves Using Deep Eutectic Solvents

The increasing demand for medical cannabis urges the development of new and effective methods for the extraction of phytocannabinoids. Deep eutectic solvents (DESs) are an alternative to the use of hazardous organic solvents typically used in the industry. In this study, hydrophilic and hydrophobic DESs were developed based on terpenes, sugars, and natural organic acids as green extraction media for the extraction of cannabis bioactive compounds. The factors influencing the extraction of bioactive components, such as the type of DESs and extraction time, were investigated. Initial screening in hemp showed that the DES composed of Men: Lau (a 2:1-M ratio) had a greater extraction efficiency of cannabidiol (CBD) and cannabidiolic acid (CBDA) (11.07 ± 0.37 mg/g) of all the tested DESs and higher than ethanol. Besides having a higher or equivalent extraction yield as the organic solvents tested, DESs showed to be more selective, extracting fewer impurities, such as chlorophyll and waxes. These results, coupled with the non-toxic, biodegradable, low-cost, and environmentally friendly characteristics of DESs, provide strong evidence that DESs represent a better alternative to organic solvents.

Translational models of cannabinoid vapor exposure in laboratory animals

Cannabis is one of the most frequently used psychoactive substances in the world. The most common route of administration for cannabis and cannabinoid constituents such as Δ-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) is via smoking or vapor inhalation. Preclinical vapor models have been developed, although the vaporization devices and delivery methods vary widely across laboratories. This review examines the emerging field of preclinical vapor models with a focus on cannabinoid exposure in order to (1) summarize vapor exposure parameters and other methodological details across studies; (2) discuss the pharmacological and behavioral effects produced by exposure to vaporized cannabinoids; and (3) compare behavioral effects of cannabinoid vapor administration with those of other routes of administration. This review will serve as a guide for past and current vapor delivery methods in animals, synergize findings across studies, and propose future directions for this area of research.

Analyzing the Impact of Cannabinoids on the Treatment of Spinal Disorders

PURPOSE OF REVIEW

Cannabis is among the most used illicit substances globally, with medical applications, increased legalization, and shifting social attitudes leading to increased use in recent years. Cannabinoids are a group of psychoactive substances found within the cannabis plant, with the most common being Δ9-tetrahydrocannabinol and cannabidiol. Due to the high prevalence of use, it is increasingly important to evaluate the effects of cannabis and cannabinoids on spine patients, in both operative and nonoperative settings.

RECENT FINDINGS

Cannabis and cannabinoids may be effective in treating patients with chronic conditions such as back pain and spinal cord injuries. Longitudinal effects and implications on surgical outcomes and complications are poorly understood. High-quality, outcomes-focused research can inform approaches for clinicians to approach cannabis and cannabinoid use. Studies to elucidate the standardization of cannabis regimens can help develop guidelines for potential therapeutic applications. Cannabis and cannabinoids may be useful alternatives or additions for many spine patients, but future research is needed for recommendations to be determined. Our manuscript reviews the available literature regarding cannabis use and various spinal conditions, organizing our findings into the following narrative themes: (1) the management of chronic lower back pain, (2) perioperative outcomes, (3) cannabis use in general orthopaedic procedures, and (4) spinal cord injuries.

Diagnostic Difficulties and Treatment Challenges of a Young Patient With Severe Acute Psychosis and Complete Recovery

First break psychosis in young adults is sometimes presented as a dichotomous model of organic or substance-induced etiology or a primary psychiatric disorder on the schizophrenia spectrum and related disorders. In this case of a young adult with a typical age of onset for psychotic symptoms also presenting with cannabis use, excessive vaping, history of COVID-19 illness, pineal cyst, and extreme elevation of blood pressure, the diagnostic certainty decreases. Increased risk of progression to schizophrenia in individuals with cannabis use disorder and genetic loading has been extensively reported in the literature. Clinicians may face significant diagnostic and treatment challenges when managing a patient with severe psychotic symptoms. For the clinicians acutely managing such patients facing these exact questions of unknown certainty in progression to full-blown schizophrenia, we highlight a case of severe acute psychosis and complete recovery on a first-generation antipsychotic and mood stabilizer. 

Medical marijuana for inflammatory bowel disease: the highs and lows

Increased interest in cannabis as a potential treatment and/or adjuvant therapy for inflammatory bowel disease (IBD) has been driven by patients with refractory disease seeking relief as well those who desire alternatives to conventional therapies. Available data have shown a potential role of cannabis as a supportive medication, particularly in pain reduction; however, it remains unknown whether cannabis has any impact on the underlying inflammatory process of IBD. The purpose of this review article is to summarize the available literature concerning the use of cannabis for the treatment of IBD and highlight potential areas for future study.

Endocannabinoid system and cannabis hyperemesis syndrome: a narrative update

Cannabis use has been increasing in the United States and throughout the world. It is derived from one of the earliest plants cultivated by humans - Cannabis sativa. Cannabis (also called marijuana) is the most commonly used psychoactive substance worldwide. The cannabis plant has more than 400 chemicals, of which more than 100 cannabinoids (such as cannabigerol, cannabidiol, and cannabinol) have been identified. The endocannabinoid system (ECS) plays an essential role in the effects of cannabis on end organs. Although cannabis use has been reported for many decades, some of its unique adverse effects of nausea, vomiting, and abdominal pain, termed as cannabis hyperemesis syndrome (CHS), were noted recently. The legal status of cannabis in the United States has been rapidly changing from state to state. The incidence of CHS is expected to rise with rising access to cannabis in the United States. Furthermore, CHS is frequently underdiagnosed due to a lack of uniform criteria, subjective nature of symptoms, and overlap with cyclical vomiting syndrome (CVS). Understanding the ECS and its role in biphasic response (proemetic and antiemetic) of CHS is critical to explain its pathophysiology. As the use of cannabis increases globally, awareness of CHS is warranted for early recognition and prompt treatment to avoid complications. We describe the putative mechanism of CHS with an overview of the clinical features in these patients. Furthermore, we highlight the differences between CHS and CVS with important differentials to consider. We provide a narrative update on the current evidence on CHS pathophysiology, diagnosis, treatment, and identifying research gaps.

Alterations in rat prefrontal cortex kynurenic acid levels are involved in the enduring cognitive dysfunctions induced by tetrahydrocannabinol exposure during the adolescence

INTRODUCTION

Cannabis abuse during adolescence is a risk factor for cognitive impairments in psychiatric disorders later in life. To date, the possible causal relationship between cannabinoids, kynurenic acid (KYNA; i.e., a neuroactive metabolite of tryptophan degradation) and cognition has not been investigated in adolescence. Early exposure to delta 9-tetrahydrocannabinol (THC; i.e., the main psychotropic component of cannabis) causes enduring cognitive deficits, which critically involve impaired glutamatergic function in the prefrontal cortex (PFC). In addition, prenatal cannabis exposure results in enduring increases in PFC KYNA levels. Based on these findings, the effects of chronic THC exposure in rats, during another critical period of neurodevelopment particularly sensitive to perturbation by exogenous stimuli, such as adolescence, have been investigated.

METHODS

Male Wistar rats were chronically treated with vehicle or ascending intraperitoneal (i.p.) doses of THC starting on postnatal day (PND) 35 until PND 45. In adulthood (PND 75), cognitive assessment (Y-maze) and extracellular KYNA/glutamate levels were measured in the PFC by in vivo microdialysis, before and after a challenge with KYN (5 mg/kg i.p., the biological precursor of KYNA). By using the selective, brain-penetrable KAT II inhibitor PF-04859989, we then examined whether blockade of KYNA neosynthesis prevents the cognitive impairment.

RESULTS

Compared to vehicle-treated controls, extracellular basal KYNA levels were higher in the PFC of adult rats chronically exposed to THC in adolescence (p < 0.01). No changes were observed in extracellular glutamate levels. Following a challenge with KYN, extracellular KYNA levels similarly increased in both groups (i.e., vehicle- and THC-treated; p < 0.001 and p < 0.01, respectively). Chronic adolescent THC exposure negatively affected short-term memory (reduced spontaneous alternation), in adult animals (p < 0.001), while PF-04859989 (30 mg/kg i.p.) restored the cognitive impairment (p < 0.05).

DISCUSSION

We propose that the observed alterations in PFC KYNA signaling might be involved in the cognitive dysfunction induced by the exposure to THC during the adolescence. In the translational realm, these experiments raise the prospect of prevention of KYNA neosynthesis as a possible novel approach to counteract some of the detrimental long-term effects of adolescence cannabis use.

The Influence of Cannabidiol on the Pharmacokinetics of Methylphenidate in Healthy Subjects

INTRODUCTION

Cannabidiol (CBD) is a widely utilized nonpsychoactive cannabinoid available as an over-the-counter supplement, a component of medical cannabis, and a prescriptive treatment of childhood epilepsies. In vitro studies suggest CBD may inhibit a number of drug-metabolizing enzymes, including carboxylesterase 1 (CES1). The aim of this study was to evaluate effect of CBD on the disposition of the CES1 substrate methylphenidate (MPH).

METHODS

In a randomized, placebo-controlled, crossover study, 12 subjects ingested 750 mg of CBD solution, or alternatively, a placebo solution twice daily for a 3-day run-in period followed by an additional CBD dose (or placebo) and a single 10 mg dose of MPH and completed serial blood sampling for pharmacokinetic analysis. MPH and CBD concentrations were measured by liquid chromatography with tandem mass spectrometry.

RESULTS

The Cmax (mean ± CV) for the CBD group and placebo group was 13.5 ± 43.7% ng/mL and 12.2 ± 36.4% ng/mL, respectively. AUCinf (ng/mL*h) for the CBD group and placebo group was 70.7 ± 32.5% and 63.6 ± 25.4%, respectively. The CBD AUC0-8h (mean ± CV) was 1,542.2 ± 32% ng/mL*h, and Cmax was 389.2 ± 39% ng/mL. When compared to MPH only, the geometric mean ratio (CBD/control, 90% CI) for AUCinf and Cmax with CBD co-administration was 1.09 (0.89, 1.32) and 1.08 (0.85, 1.37), respectively.

DISCUSSION/CONCLUSION

Although the upper bound of bioequivalence was not met, the mean estimates of AUC and Cmax ratios were generally small and unlikely to be of clinical significance.

Vapor cannabis exposure generationally affects male reproductive functions in mice

This study was performed to examine whether vapor exposure to cannabis plant matter negatively impacts male reproductive functions and testis development in mice. Adult CD-1 male mice (F0) were exposed to air (control) or 200 mg of vaporized cannabis plant matter 3x/day over a 10 day period. Subsequently, F0 males were bred with drug naïve CD-1 females to generate F1 males, and F1 offspring were used to generate F2 males. Cannabis vapor exposure decreased sperm count and/or motility in F0 and F1 males and disrupted the progression of germ cell development, as morphometric analyses exhibited an abnormal distribution of the stages of spermatogenesis in F0 males. Although plasma levels of testosterone were not affected by cannabis exposure in any ages or generations of males, dysregulated steroidogenic enzymes, Cyp11a1 and Cyp19a1, were observed in F0 testis. In the neonatal testis from F1 males, while apoptosis was not altered, DNA damage and DNMT1, but not DNMT3A and DNMT3B, were increased in germ cells following cannabis exposure. In contrast, the alterations of DNA damage and DNMT1 expression were not observed in F2 neonatal males. These results suggest that cannabis vapor exposure generationally affects male reproductive functions, probably due to disruption of spermatogenesis in the developing testis.

Cannabis Use and Misuse in Older Adults

Cannabis is the most frequently used illegal psychoactive substance by older adults. With population aging, legalization and medicalization of cannabis, and changes in perceptions of older adults toward its use, recreational and medical cannabis use/misuse is on the rise in seniors. Although there are solid data related to the adverse events of cannabis in older adults, efficacy data are lacking. Older adults are at increased risk of developing cannabis use disorder alongside other medical and psychiatric comorbidities. We review the benefits and risks associated with cannabis use, and screening and management strategies for cannabis use disorder in older adults.

Medical Cannabis as Adjunctive Therapy for Head and Neck Cancer Patients

The goal of this systematic review was to define a consensus within the current literature regarding the impact/effect of cannabis or cannabinoids on the treatment of patients with head and neck cancer. We conducted a review of PubMed, Embase, and Web of Science databases, using a comprehensive search strategy, focusing on articles relating to head & neck cancer and cannabis/cannabinoids without a time limit for publication.

Two, independent reviewers screened articles based on title/abstract and included the ones selected by both. We then conducted a full-text review and excluded all articles which did not meet inclusion criteria. A single reviewer then assessed studies for methodological quality and extracted relevant data using a premade data collection tool. We identified five studies that met inclusion criteria. Studies were of varying quality and the majority investigated recreational cannabis use with only one study reporting dosing across participants. Lack of standardized cannabis exposure presents a wide array of potential confounding variables across the remaining studies. Meta-analysis was not attempted due to variability in reported outcomes.

It is impossible to draw any conclusions regarding the benefit or adverse effects of current medical cannabis products in this patient population. The literature regarding the effect of cannabis/cannabinoids on head & neck cancer patients is limited. However, the current lack of evidence does not definitively disprove the efficacy of cannabis. High-quality studies are necessary for physicians to provide advice to patients who are either using or interested in cannabis as an adjunctive treatment.

Cardiac Complications of Common Drugs of Abuse: Pharmacology, Toxicology and Management

Cardiovascular complications from drugs of abuse are becoming more apparent due to increased usage worldwide. Substance abuse can cause both acute and chronic cardiovascular complications and is increasing in prevalence especially in young adults. These substances contribute to the development of acute coronary syndrome, type II myocardial injury, arrhythmias, cardiomyopathies and have numerous other cardiovascular complications. Although no screening guidelines exist, clinical awareness of these potential complications and their prevention, clinical presentation, diagnosis, and treatment are critically important. Management of cardiovascular disease should be coupled with appropriate social and mental health interventions to provide sustained clinical benefit. The higher the number of substances used recreationally, the greater the risk of premature heart disease. Epidemiological studies showed that 1 in 5 young adults misuse several substances and often start using at younger ages with a greater risk for adverse health outcomes over the long-term. The aim of this review is to highlight the basic epidemiology, cardiac complications, and disease-specific treatment options of commonly abused substances including methamphetamine, cocaine, alcohol, anabolic-androgenic steroids, cannabis, and tobacco.

The Potential Use of Cannabis in Tissue Fibrosis

Fibrosis is a condition characterized by thickening or/and scarring of various tissues. Fibrosis may develop in almost all tissues and organs, and it may be one of the leading causes of morbidity and mortality. It provokes excessive scarring that excels the usual wound healing response to trauma in numerous organs. Currently, very little can be done to prevent tissue fibrosis, and it is almost impossible to reverse it. Anti-inflammatory and immunosuppressive drugs are among the few treatments that may be efficient in preventing fibrosis. Numerous publications suggest that cannabinoids and extracts of Cannabis sativa have potent anti-inflammatory and anti-fibrogenic properties. In this review, we describe the types and mechanisms of fibrosis in various tissues and discuss various strategies for prevention and dealing with tissue fibrosis. We further introduce cannabinoids and their potential for the prevention and treatment of fibrosis, and therefore for extending healthy lifespan.

Very Fast RP–UHPLC–PDA Method for Identification and Quantification of the Cannabinoids from Hemp Oil

In recent years, hemp oils have become ubiquitous in health products on the European market. As the trend continues to grow and more cannabinoids are researched for their therapeutic benefits, more academic and industrial interests are drawn to this direction. Cannabidiol, Δ9-tetrahydrocannabinol, and their acidic forms remain the most examined cannabinoids in hemp and cannabis oils, in the case of cannabidiol due to its proven health implications in numerous articles, and in the case of Δ9-tetrahydrocannabinol, due to the legislation in the European area. These oils sold on the internet contain a wide range of cannabinoids that could demonstrate their effects and benefits. As a result of these claims, we developed a robust and rapid method that can identify and quantify 10 of the most common cannabinoids found in hemp oils: cannabivarin, cannabidiolic acid, cannabigerolic acid, cannabigerol, cannabidiol, cannabinol, Δ9-tetrahydrocannabinol, Δ8-tetrahydrocannabinol, cannabichromene, and tetrahydrocannabinolic acid in less than 11 min, with reverse-phase–high-performance liquid chromatography–photodiode matrix system (RP–UHPLC–PDA) equipped with C18 column, eluting in a gradient using water and acetonitrile with formic acid as mobile phases. The quantification of 9 sample products presented in different matrixes was performed using a calibration curve obtained by analyzing standard solutions from a 10-cannabinoid-mix-certified reference standard. The developed method demonstrated the ability to identify and quantify the main cannabinoids in hemp oil and is a useful tool for pharmaceutical professionals.

The changing landscape of the use of medical marijuana after traumatic brain injury: a narrative review

OBJECTIVE

To summarize the potential therapeutic benefits of medical marijuana for patients with traumatic brain injury (TBI).

METHODS

A systematic search was conducted using PubMed and Cochran's library for information regard the safety and efficacy of medical marijuana as a therapeutic agent. We investigated, in depth, articles specifically evaluating medical marijuana's use in TBI, as well as articles that summarized the effects of marijuana in general. Articles from the year 2000-2020 were included.

RESULTS

A total of 37 articles met our inclusion criteria. An additional 3 articles were obtained from reference lists.

CONCLUSION

Studies have shown that medical marijuana can potentially aid the recovery from TBI by modulating the endocannabinoid system, reducing inflammation and secondary injury. Adverse cognitive and physiological effects have been observed in the acute setting as well as chronically, though more research is necessitated. There is also the concern of significant drug-drug interactions that have not been thoroughly studied. Thus, while there is evidence that medical marijuana can be beneficial in the treatment of TBI, more research is necessitated to fully explore the long-term efficacy and adverse effects.

The Effect of Cannabis-Based Medicine on Neuropathic Pain and Spasticity in Patients with Multiple Sclerosis and Spinal Cord Injury: Study Protocol of a National Multicenter Double-Blinded, Placebo-Controlled Trial

Disease or acquired damage to the central nervous system frequently causes disabling spasticity and central neuropathic pain (NP), both of which are frequent in multiple sclerosis (MS) and spinal cord injury (SCI). Patients with MS and SCI often request treatment with cannabis-based medicine (CBM). However, knowledge about effects, side effects, choice of active cannabinoids (Δ9-tetrahydrocannabinol (THC), cannabidiol (CBD) alone or in combination), and doses of CBM remains limited. Using a double-blind, parallel design in a national multicenter cohort, this study examines the effect of CBM on spasticity and NP. Patients are randomized to treatment with capsules containing either THC, CBD, THC and CBD, or placebo. Primary endpoints are patient-reported pain and spasticity on a numerical rating scale. Other endpoints include quality of life and sleep, depression and anxiety, and relief of pain and spasticity. Side-effects of CBM are described. In a sub-study, the pharmacodynamics (PD) and pharmacokinetics (PK) of oral capsule CBM are examined. We expect that the study will contribute to the literature by providing information on the effects and side-effects of CBD, THC, and the combination of the two for central neuropathic pain and spasticity. Furthermore, we will describe the PD/PK of THC and CBD in a patient population.

The synthetic CB1 cannabinoid receptor selective agonists: Putative medical uses and their legalization

More than 500 molecules have been identified as components of Cannabis sativa (C. sativa), of which the most studied is Δ⁹-tetrahydrocannabinol (Δ⁹-THC). Several studies have suggested that Δ⁹-THC exerts diverse biological effects, ranging from fragmentation of DNA to behavioral disruptions. Currently, it is accepted that most of the pharmacological properties of Δ⁹-THC engage the activation of the cannabinoid receptors, named CB₁ and CB₂. Interestingly, multiple pieces of evidence have suggested that the cannabinoid receptors play an active role in the modulation of several diseases leading to the design of synthetic cannabinoid-like compounds. Advances in the development of synthetic CB₁ cannabinoid receptor selective agonists as therapeutical approaches are, however, limited. This review focuses on available evidence searched in PubMed regarding the synthetic CB₁ cannabinoid receptor selective agonists such as AM-1235, arachidonyl-2' chloroethylamide (ACEA), CP 50,556-1 (Levonantradol), CP-55,940, HU-210, JWH-007, JWH-018, JWH-200 (WIN 55,225), methanandamide, nabilone, O-1812, UR-144, WIN 55,212-2, nabiximols, and dronabinol. Indeed, it would be ambitious to describe all available evidence related to the synthetic CB₁ cannabinoid receptor selective agonists. However, and despite the positive evidence on the positive results of using these compounds in experimental models of health disturbances and preclinical trials, we discuss evidence in regards some concerns due to side effects.

Exploring the Role of Nutraceuticals in Major Depressive Disorder (MDD): Rationale, State of the Art and Future Prospects

Major depressive disorder (MDD) is a complex and common disorder, with many factors involved in its onset and development. The clinical management of this condition is frequently based on the use of some pharmacological antidepressant agents, together with psychotherapy and other alternatives in most severe cases. However, an important percentage of depressed patients fail to respond to the use of conventional therapies. This has created the urgency of finding novel approaches to help in the clinical management of those individuals. Nutraceuticals are natural compounds contained in food with proven benefits either in health promotion or disease prevention and therapy. A growing interest and economical sources are being placed in the development and understanding of multiple nutraceutical products. Here, we summarize some of the most relevant nutraceutical agents evaluated in preclinical and clinical models of depression. In addition, we will also explore less frequent but interest nutraceutical products which are starting to be tested, also evaluating future roads to cover in order to maximize the benefits of nutraceuticals in MDD.

Adolescent exposure to delta-9-tetrahydrocannabinol and ethanol heightens sensitivity to fear stimuli

Cannabis use disorder (CUD) has doubled in prevalence over the past decade as a nation-wide trend toward legalization allows for increased drug accessibility. As a result, marijuana has become the most commonly used illicit drug in the United States particularly among the adolescent population. This is especially concerning since there is greater risk for the harmful side effects of drug use during this developmental period due to ongoing brain maturation. Increasing evidence indicates that CUD often occurs along with other debilitating conditions including both alcohol use disorder (AUD) and anxiety disorders such post-traumatic stress disorder (PTSD). Additionally, exposure to cannabis, alcohol, and stress can induce alterations in glutamate regulation and homeostasis in the prefrontal cortex (PFC) that may lead to impairments in neuronal functioning and cognition. Therefore, in order to study the relationship between drug exposure and the development of PTSD, these studies utilized rodent models to determine the impact of adolescent exposure to delta-9-tetrahydrocannabinol (THC) and ethanol on responses to fear stimuli during fear conditioning and used calcium imaging to measure glutamate activity in the prelimbic cortex during this behavioral paradigm. The results from these experiments indicate that adolescent exposure to THC and ethanol leads to enhanced sensitivity to fear stimuli both behaviorally and neuronally. Additionally, these effects were attenuated when animals were treated with the glutamatergic modulator N-acetylcysteine (NAC). In summary, these studies support the hypothesis that adolescent exposure to THC and ethanol leads to alterations in fear stimuli processing through glutamatergic reliant modifications in PFC signaling.

Efficacy of cannabinoids against glioblastoma multiforme: A systematic review

INTRODUCTION

The increased incidence of Glioblastoma Multiforme, the most aggressive and most common primary brain tumour, is evident worldwide. Survival rates are reaching only 15 months due to its high recurrence and resistance to current combination therapies including oncotomy, radiotherapy and chemotherapy. Light has been shed in the recent years on the anticancer properties of cannabinoids from Cannabis sativa.

OBJECTIVE

To determine whether cannabinoids alone or in combination with radiotherapy and/or chemotherapy inhibit tumour progression, induce cancer cell death, inhibit metastasis and invasiveness and the mechanisms that underlie these actions.

METHOD

PubMed and Web of Science were used for a systemic search to find studies on the anticancer effects of natural cannabinoids on glioma cancer cells in vitro and/or in vivo.

RESULTS

A total of 302 papers were identified, of which 14 studies were found to fit the inclusion criteria. 5 studies were conducted in vitro, 2 in vivo and 7 were both in vivo and in vitro. 3 studies examined the efficacy of CBD, THC and TMZ, 1 study examined CBD and radiation, 2 studies examined efficacy of THC only and 3 studies examined the efficacy of CBD only. 1 study examined the efficacy of CBD, THC and radiotherapy, 2 studies examined the combination of CBD and THC and 2 more studies examined the efficacy of CBD and TMZ.

CONCLUSION

The evidence in this systematic review leads to the conclusion that cannabinoids possess anticancer potencies against glioma cells, however this effect varies with the combinations and dosages used. Studies so far were conducted on cells in culture and on mice as well as a small number of studies that were conducted on humans. Hence in order to have more accurate results, higher quality studies mainly including human clinical trials with larger sample sizes are necessitated urgently for GBM treatment.

Global Trends in Cannabis and Cannabidiol Research from the Year 1940 to 2019

Legalization of Cannabis in countries, like Canada, and global demand for non-hallucinating chemical components, such as Cannabidiols (CBD), have stimulated the increased interest from academics, industry, and regulatory agencies. Subsequent research publications in scientific journals in this field are expected to grow rapidly. However, there have been few research reviews that have quantified patterns in research publications concerning cannabis, nor a literature-based perspective on the historical development, current status, and future direction of cannabis research. Here, a bibliometric analysis is performed to address this gap in the scientific literature. A total of 1167 relevant articles (Supplementary file 1) were screened and analyzed using three software tools: HistCite, CiteSpace, and Bibliometric Online Analysis Platform. The performances of relevant countries, institutions, authors, and journals were presented, and the evolutionary trends of different categories were revealed. The historical development of cannabis and CBD research can be clearly divided into three stages, which focus on the chemistry, pharmacology, and molecular biology aspects of Cannabis sativa in general and then a focus on CBD related publications. A timeline was drawn to highlight the major trends in the literature, including scientific discoveries. In the end, several suggestions for future research directions in this field are provided.

Gastroparesis with Cannabis Use: A Retrospective Study from the Nationwide Inpatient Sample

Background: With increasing utilization of cannabis in the United States (US), clinicians may encounter more cases of Gastroparesis (GP) in coming years.Objective: The primary outcome was inpatient mortality for GP with cannabis use. Secondary outcomes included system-based complications and the burden of the disease on the US healthcare system.Methods: From the Nationwide Inpatient Sample (NIS), we identified adult hospitalizations with a primary discharge diagnosis of GP for 2016 and 2017. Individuals ≤18 years of age were excluded. The study population was subdivided based on a secondary diagnosis of cannabis use. The outcomes included biodemographic characteristics, mortality, complications, and burden of disease on the US healthcare system.Results: For 2016 and 2017, we identified 99,695 hospitalizations with GP. Of these hospitalizations, 8,870 had a secondary diagnosis of cannabis use while 90,825 served as controls. The prevalence of GP with cannabis use was 8.9%. For GP with cannabis use, the patients were younger (38.5 vs 48.1 years, p < 0.001) with a Black predominance (Table 1) and lower proportion of females (52.3 vs 68.3%, p < 0.001) compared to the non-cannabis use cohort. Additionally, the cannabis use cohort had higher percentage of patients with co-morbidities like hypertension, diabetes mellitus and a history of smoking. The inpatient mortality for GP with cannabis use was noted to be 0.27%. Furthermore, we noted shorter mean length of stay (LOS) (3.4 vs 4.4 days, aMD: -0.7, 95%CI: -0.9 - [-0.5], p < 0.001), lower mean total hospital charge (THC) ($30,400 vs $38,100, aMD: -5100, 95%CI: -6900 - [-3200], p < 0.001), and lower rates of sepsis (0.11 vs 0.60%, aOR: 0.22, 95% CI: 0.05-0.91, p = 0.036) for GP hospitalizations with cannabis use compared to the non-cannabis use cohort.Conclusion: Inpatient mortality for GP hospitalizations with cannabis use was 0.27%. Additionally, these patients had shorter LOS, lower THC, and lower sepsis rates.

Extraction of naturally occurring cannabinoids: an update

INTRODUCTION

Organic molecules that interact with the cannabinoid receptors are called cannabinoids, which can be endogenous, natural or synthetic compounds. They possess similar pharmacological properties as produced by the plant, Cannabis sativa L. Before cannabinoids can be analysed, they need to be extracted from the matrices.

OBJECTIVE

To review literature on the methods and protocols for the extraction of naturally occurring cannabinoids.

METHODOLOGY

An extensive literature search was performed incorporating several databases, notably, Web of Knowledge, PubMed and Google Scholar, and other relevant published materials. The keywords used in the search, in various combinations, with cannabinoids and extraction being present in all combinations, were Cannabis, hemp, cannabinoids, Cannabis sativa, marijuana, and extraction.

RESULTS

In addition to classical maceration with organic solvents, e.g. ethanol, pressurised solvent extraction, solvent heat reflux, Soxhlet extraction, supercritical fluid extraction, ultrasound-assisted extraction and microwave-assisted extraction, are routinely used nowadays for the extraction of cannabinoids from plant materials and cannabis consumer products. For the extraction of cannabinoids from biological samples, e.g. human blood, and also from food and beverages, and wastewater, solid-phase extraction and its variants, as well as liquid-liquid extraction are commonly used. Parameters for extraction can be optimised by response surface methodology or other mathematical modelling tools. There are at least six US patents on extraction of cannabinoids available to date.

CONCLUSIONS

Irrespective of the extraction method, extraction temperature, extraction time and extraction pressure play a vital role in overall yield of extraction. Solvent polarity can also be an important factor in some extraction methods.

Postoperative Pain Management Is Influenced by Previous Cannabis Use in Neurosurgical Patients

ABSTRACT

BACKGROUND: Cannabis use for medical and recreational purposes is growing. Cannabis may have drug-drug interactions for managing pain, anxiety, and seizures. The research regarding cannabis use in patients with craniotomy surgeries is sparse and often conducted in states where cannabis use is legal. This study compared 24-hour postoperative craniotomy pain levels in patients who reported cannabis use in a state where cannabis is not yet legal. METHODS: This is an observational prospective, nonrandomized, pilot study of postoperative craniotomy patients. Patients were consented and given a one-time self-report questionnaire regarding postoperative pain, pain management method, type of pain medication used at home (including cannabis), route of administration, and frequency of use. Subjects scored pain on both the numeric rating scale and the visual analog scale. Demographic data were collected from the electronic medical record. RESULTS: Forty-five patients with a mean age of 57 years, 62% female, participated in this study. There were 33% who reported previous cannabis use. One-way analysis of variance showed a significant difference in the mean postoperative pain scores for the cannabis users (4.58) and nonusers (3.89; P = .0056). There was no significant difference between age (P = .1894) and adequacy of pain control (P = .6584) between users and nonusers. CONCLUSION: In this pilot study, a one-time survey in critical care on the sensitive topic of cannabis use is feasible and seems to generate honest responses. One-third of patients reported home use of cannabis in a state where cannabis is illegal.

Perioperative and anaesthetic considerations of marijuana use

The psychoactive substance cannabis is the most-commonly used drug around the world, and its use is becoming more prevalent globally. Additionally, it is becoming available in an increasing variety of forms. As such, it is imperative that perioperative practitioners have an understanding of the drug, its effects, and its implications in perioperative care. There is currently a lack of a standardised approach to a patient who uses cannabis, and prospective studies prove difficult given the current legal status of cannabis. This literature review seeks to provide information regarding cannabis and its use. Specifically, we explore the systemic effects of marijuana as well as perioperative and anaesthetic implications so that safer, more effective care may be administered.

A Rapid Nano-Liquid Chromatographic Method for the Analysis of Cannabinoids in Cannabis sativa L. Extracts

Cannabis sativa L. is an herbaceous plant belonging to the family of Cannabaceae. It is classified into three different chemotypes based on the different cannabinoids profile. In particular, fiber-type cannabis (hemp) is rich in cannabidiol (CBD) content. In the present work, a rapid nano liquid chromatographic method (nano-LC) was proposed for the determination of the main cannabinoids in Cannabis sativa L. (hemp) inflorescences belonging to different varieties. The nano-LC experiments were carried out in a 100 µm internal diameter capillary column packed with a C18 stationary phase for 15 cm with a mobile phase composed of ACN/H₂O/formic acid, 80/19/1% (v/v/v). The reverse-phase nano-LC method allowed the complete separation of four standard cannabinoids in less than 12 min under isocratic elution mode. The nano-LC method coupled to ultraviolet (UV) detection was validated and applied to the quantification of the target analytes in cannabis extracts. The nano-LC system was also coupled to an electrospray ionization–mass spectrometry (ESI-MS) detector to confirm the identity of the cannabinoids present in hemp samples. For the extraction of the cannabinoids, three different approaches, including dynamic maceration (DM), ultrasound-assisted extraction (UAE), and an extraction procedure adapted from the French Pharmacopeia’s protocol on medicinal plants, were carried out, and the results achieved were compared.

Metabolism of 4F-MDMB-BICA in zebrafish by liquid chromatography-high resolution mass spectrometry

In this study, in vivo metabolic studies of the synthetic cannabinoid 4F-MDMB-BICA were investigated using zebrafish models. The metabolites were identified and structurally illustrated by liquid chromatography-high resolution mass spectrometry. Fourteen phase-I metabolites and four phase-II metabolites were generated from zebrafish. The main metabolic pathways of the phase-I metabolism included N-dealkylation, N-dealkylation combined with hydroxylation, amide hydrolysis, oxidative defluorination, oxidative defluorination to butyric acid, acetic acid formation at the indole side chain, hydroxylation, ester hydrolysis followed by hydroxylation, dehydrogenation, dehydrogenation, and N-dealkylation, and oxidative defluorination subsequently combined with dehydrogenation. The main biotransformations of the phase-II metabolism were glucuronidation and sulfation. Two phase-I metabolites (A1 and A11) and four phase-II metabolites (A2, A3, A4, and A12) were reported for the first time. A14, which was confirmed in human biological samples, was detected only in zebrafish samples but not found in human liver microsome incubation study. The current study indicates that the zebrafish model is a promising tool for elucidating the metabolism of NPS in the future.

Cannabis-Based Oral Formulations for Medical Purposes: Preparation, Quality and Stability

Current legislation in Italy provides that medical Cannabis may be administered orally or by inhalation. One of the fundamental criteria for the administration of oral formulations is that they deliver a known consistent quantity of the active ingredients to ensure uniform therapies leading to the optimisation of the risks/benefits. In 2018, our group developed an improved Cannabis oil extraction technique. The objective of the present work was to carry out a stability study for the oil extracts obtained by this method. Furthermore, in order to facilitate the consumption of the prescribed medical Cannabis therapy by patients, a standard procedure was defined for the preparation of a single-dose preparation for oral use (hard capsules) containing the oil extract; thereafter, the quality and stability were evaluated. The hard capsules loaded with the oil extract were analysed and found to be uniform in content. The encapsulation process did not alter the quantity of the active molecule present in the oil. The stability tests yielded excellent results. Since the capsule dosage form is easily transported and administered, has pleasant organoleptic properties and is stable at room temperature for extended periods of time, this would facilitate the adherence to therapy by patients in treatment.

Recent developments in geriatric psychopharmacology

INTRODUCTION

There is a tremendous growing need to address the burden of geriatric psychiatric disorders. Recent developments relevant to geriatric psychiatry have focused on Alzheimer's disease (AD), severe/refractory depression, and cancer/end of life care.

AREAS COVERED

This is a non-systematic, narrative review (databases and websites for search: PubMed, Google Scholar, Medscape, ClinicalTrials.gov; focusing on the last 6 years), and covers developments in disease-modifying therapies for AD, diagnostic radiotracers for AD, medications for neuropsychiatric symptoms of dementia, ketamine/esketamine, psychedelics, and cannabinoids.

EXPERT OPINION

The focus of on-going trials of anti-amyloid agents has been on individuals with very early stage AD; several agents are under phase 3 investigation, and aducanumab is under FDA review. Amyloid and tau PET scans have been approved by the FDA to assist in the diagnoses of AD. Promising pharmaceuticals for neuropsychiatric symptoms of dementia include pimavanserin, brexpiprazole, escitalopram, dextromethorphan/quinidine, and lithium. Esketamine, although approved for treatment-resistant depression in general adults, failed to demonstrate efficacy in elderly patients in a phase 3 trial. There is preliminary evidence for benefit of psychedelic-assisted psychotherapy in end-of-life and cancer-related depression/anxiety. Evidence for the use of cannabinoids is currently lacking.

Community nurses' support for patients with fibromyalgia who use cannabis to manage pain

Supporting patients to manage chronic pain conditions, such as fibromyalgia (FM), remains a challenge for community nurses. Research suggests that despite the absence of a licensed cannabis-based product for medicinal use (CBPM) available for people with FM in the UK, there is an appetite for FM patients to use cannabis for pain management. Nurses have expressed anxieties when balancing tensions between helping patients and working within medical guidelines, as well as a need for further education about patient cannabis use. This article provides community nurses with insight into how cannabis use affects the pain experience for people living with FM. Despite potential harms, cannabis is perceived by users to have a positive impact on the lived experience of pain, and it may be preferred to prescribed opioid medication. This understanding can help to inform empathic practice and recommendations are made for reducing the risks of cannabis use to patient health.

Sex differences in cannabis forms and exposure reasons in cannabis-related poison control center cases aged 50

CONTEXT/OBJECTIVES

A significant proportion of individuals aged 50+ in the U.S. use cannabis for medical or recreational purposes, sometimes with adverse effects. Given differences in cannabis use among men and women, we examined sex differences in (1) cannabis forms used, (2) exposure reasons, and (3) medical outcomes in older-adult poison control center (PCC) cases.

METHODS

Data came from the American Association of Poison Control Centers' National Poison Data System, 2009-2019. We focused on the 3633 cases aged 50+ in which plant and other non-synthetic cannabinoid cannabis forms were the only or primary substance. Logistic regression was used to examine associations of sex with cannabis forms. Multinomial logistic regression models were fit to examine associations of sex with exposure reasons (therapeutic errors/adverse reactions, intentional misuse/abuse, other) and medical outcomes (no-to-minimal, moderate, or major effects).

RESULTS

Females constituted 57.4% of cases. In multivariable analyses, female cases had 1.20 (95% CI = 1.01-1.43) greater odds of involving cannabis forms other than plant forms and 1.93 greater odds (95% CI = 1.66-2.24) of therapeutic errors/adverse effects compared to intentional misuse/abuse. Older age and occurrence in recreational-cannabis-legal states were positively associated with other cannabis forms. Older age, recreational and/or medical cannabis-legal states, CBD, pharmaceuticals, concentrated extracts, and chronic exposure were associated with higher odds of therapeutic errors/adverse effects. Sex was not significantly associated with medical outcomes.

CONCLUSIONS

Female cases compose a large share of PCC cases aged 50+ and are associated with higher odds of involving cannabis forms other than plants and therapeutic errors/adverse reactions compared to intentional misuse/abuse.

DNA Methylation-Based Biomarkers of Environmental Exposures for Human Population Studies

PURPOSE OF REVIEW

This manuscript orients the reader to the underlying motivations of environmental biomarker development for human population studies and provides the foundation for applying these novel biomarkers in future research. In this review, we focus our attention on the DNA methylation-based biomarkers of (i) smoking, among adults and pregnant women, (ii) lifetime cannabis use, (iii) alcohol consumption, and (iv) cumulative exposure to lead.

RECENT FINDINGS

Prior environmental exposures and lifestyle modulate DNA methylation levels. Exposure-related DNA methylation changes can either be persistent or reversible once the exposure is no longer present, and this combination of both persistent and reversible changes has essential value for biomarker development. Here, we present available biomarkers representing past and cumulative exposures using individual DNA methylation profiles. In the present work, we describe how the field of environmental epigenetics can leverage machine learning algorithms to develop exposure biomarkers and reduce problems of misreporting exposures or limited access technology. We emphasize the crucial role of the individual DNA methylation profiles in those predictions, providing a summary of each biomarker, and highlighting their advantages, and limitations. Future research can cautiously leverage these DNA methylation-based biomarkers to understand the onset and progression of diseases.

Cannabinoid and Opioid Use Among Total Joint Arthroplasty Patients: A 6-Year, Single-Institution Study

Evidence is limited regarding cannabinoid use among total joint arthroplasty (TJA) patients, despite increased availability and popularity for treating chronic pain. The authors hypothesized that preoperative cannabinoid use increased and opioid use decreased during a 6-year interval in total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients, and also asked whether complications were associated with use of these substances. This retrospective, single-institution study reviewed electronic medical records and the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database for TJA cases from 2012 through 2017. Primary outcomes were the prevalence and trends of active cannabinoid and opioid use, as determined by routine preoperative urine toxicology screening. Multivariable regression analyses were conducted to investigate a secondary outcome, whether there was an association between cannabinoid or opioid use and postoperative complications. A total of 1778 operations (1161 TKAs and 617 THAs) performed on 1519 patients were reviewed. The overall prevalence of pre-operative cannabinoid and opioid use was 11% and 23%, respectively. Comparing 2012 with 2017, cannabinoid use increased from 9% to 15% (P=.049), and opioid use decreased from 24% to 17% (P=.040). Cannabinoid users were more likely to be taking opioids than nonusers (P=.002). Controlling for age, sex, surgery type, and American Society of Anesthesiologists score, cannabinoid use was not associated with 90-day readmission, infection, reoperation, or other VASQIP-captured complications. Laboratory testing indicated a much higher prevalence of cannabinoid use among TJA patients than previously reported. During a 6-year period, cannabinoid use increased more than 60%, and opioid use decreased approximately 30%. These findings indicate that cannabinoid use did not appear to be associated with perioperative complications. [Orthopedics. 2021;44(1):e101-e106.].

The positive and negative cardiovascular effects of cannabis

INTRODUCTION

The use of cannabis and its derivatives have increased steadily over the past few decades, prompting patients and clinicians to increasingly inquire about its health effects and safety profile. However, despite promising evidence suggesting therapeutic utilization, cannabis remains a controlled substance in most countries and is largely considered to have no medical or recreational benefit; thus, a lack of observational studies and randomized control trials exist to outline positive and negative health implications. Ultimately, this leaves patients, health-care professionals, and policymakers without necessary evidence required to make informed decisions on cannabis use.

AREAS COVERED

This review outlines cannabis in a clinical setting and delves into specific effects of cannabinoids on cardiovascular health and disease. It discusses positive and negative health implications associated with cannabis, mechanisms in cardiovascular disease, and reveals methods guiding cannabis use in the clinical setting.

EXPERT OPINION

Advances in research are necessary to guide decisions regarding cannabinoid use. Countries that have federally legalized cannabis have a unique opportunity to study cardiovascular implications in an unbiased and comprehensive manner. Ultimately, as cannabis use will inevitably increase, researchers, clinicians, and policymakers must work together to ensure cannabis is utilized in a way that is therapeutically beneficial.

Cannabis, a cause for anxiety? A critical appraisal of the anxiogenic and anxiolytic properties

BACKGROUND

Cannabis has been documented for use in alleviating anxiety. However, certain research has also shown that it can produce feelings of anxiety, panic, paranoia and psychosis. In humans, Δ9-tetrahydrocannabinol (THC) has been associated with an anxiogenic response, while anxiolytic activity has been attributed mainly to cannabidiol (CBD). In animal studies, the effects of THC are highly dose-dependent, and biphasic effects of cannabinoids on anxiety-related responses have been extensively documented. A more precise assessment is required of both the anxiolytic and anxiogenic potentials of phytocannabinoids, with an aim towards the development of the 'holy grail' in cannabis research, a medicinally-active formulation which may assist in the treatment of anxiety or mood disorders without eliciting any anxiogenic effects.

OBJECTIVES

To systematically review studies assessing cannabinoid interventions (e.g. THC or CBD or whole cannabis interventions) both in animals and humans, as well as recent epidemiological studies reporting on anxiolytic or anxiogenic effects from cannabis consumption.

METHOD

The articles selected for this review were identified up to January 2020 through searches in the electronic databases OVID MEDLINE, Cochrane Central Register of Controlled Trials, PubMed, and PsycINFO.

RESULTS

Acute doses of CBD were found to reduce anxiety both in animals and humans, without having an anxiogenic effect at higher doses. Epidemiological studies tend to support an anxiolytic effect from the consumption of either  CBD or THC, as well as whole plant cannabis. Conversely, the available human clinical studies demonstrate a common anxiogenic response to THC (especially at higher doses).

CONCLUSION

Based on current data, cannabinoid therapies (containing primarily CBD) may provide a more suitable treatment for people with pre-existing anxiety or as a potential adjunctive role in managing anxiety or stress-related disorders. However, further research is needed to explore other cannabinoids and phytochemical constituents present in cannabis (e.g. terpenes) as anxiolytic interventions. Future clinical trials involving patients with anxiety disorders are warranted due to the small number of available human studies.

Cannabinoids and Prostate Cancer: A Systematic Review of Animal Studies

Prostate cancer is a major cause of death among men worldwide. Recent preclinical evidence implicates cannabinoids as powerful regulators of cell growth and differentiation, as well as potential anti-cancer agents. The aim of this review was to evaluate the effect of cannabinoids on in vivo prostate cancer models. The databases searched included PubMed, Embase, Scopus, and Web of Science from inception to August 2020. Articles reporting on the effect of cannabinoids on prostate cancer were deemed eligible. We identified six studies that were all found to be based on in vivo/xenograft animal models. Results: In PC3 and DU145 xenografts, WIN55,212-2 reduced cell proliferation in a dose-dependent manner. Furthermore, in LNCaP xenografts, WIN55,212-2 reduced cell proliferation by 66-69%. PM49, which is a synthetic cannabinoid quinone, was also found to result in a significant inhibition of tumor growth of up to 90% in xenograft models of LNCaP and 40% in xenograft models of PC3 cells, respectively. All studies have reported that the treatment of prostate cancers in in vivo/xenograft models with various cannabinoids decreased the size of the tumor, the outcomes of which depended on the dose and length of treatment. Within the limitation of these identified studies, cannabinoids were shown to reduce the size of prostate cancer tumors in animal models. However, further well-designed and controlled animal studies are warranted to confirm these findings.

Roles of Cannabinoids in Melanoma: Evidence from In Vivo Studies

Melanoma is the fourth most common type of cancer diagnosed in Australians after breast, prostate, and colorectal cancers. While there has been substantial progress in the treatment of cancer in general, malignant melanoma, in particular, is resistant to existing medical therapies requiring an urgent need to develop effective treatments with lesser side effects. Several studies have shown that "cannabinoids", the major compounds of the Cannabis sativaL. plant, can reduce cell proliferation and induce apoptosis in melanoma cells. Despite prohibited use of Cannabis in most parts of the world, in recent years there have been renewed interests in exploiting the beneficial health effects of the Cannabis plant-derived compounds. Therefore, the aim of this study was in the first instance to review the evidence from in vivo studies on the effects of cannabinoids on melanoma. Systematic searches were carried out in PubMed, Embase, Scopus, and ProQuest Central databases for relevant articles published from inception. From a total of 622 potential studies, six in vivo studies assessing the use of cannabinoids for treatment of melanoma were deemed eligible for the final analysis. The findings revealed cannabinoids, individually or combined, reduced tumor growth and promoted apoptosis and autophagy in melanoma cells. Further preclinical and animal studies are required to determine the underlying mechanisms of cannabinoids-mediated inhibition of cancer-signaling pathways. Well-structured, randomized clinical studies on cannabinoid use in melanoma patients would also be required prior to cannabinoids becoming a viable and recognized therapeutic option for melanoma treatment in patients.

Cannabidiol as a Novel Therapeutic for Immune Modulation

The immune-suppressive effects of cannabidiol (CBD) are attributed to the modulation of essential immunological signaling pathways and receptors. Mechanistic understanding of the pharmacological effects of CBD emphasizes the therapeutic potential of CBD as a novel immune modulator. Studies have observed that the antagonists of CB₁ and CB₂ receptors and transient receptor potential vanilloid 1 reverse the immunomodulatory effects of CBD. CBD also inhibits critical activators of the Janus kinase/signal transducer and activator of transcription signaling pathway, as well as the nucleotide-binding oligomerization domain-like receptor signaling pathway, in turn decreasing pro-inflammatory cytokine production. Furthermore, CBD protects against cellular damage incurred during immune responses by modulating adenosine signaling. Ultimately, the data overwhelmingly support the immunosuppressive effects of CBD and this timely review draws attention to the prospective development of CBD as an effective immune modulatory therapeutic.