Cardiovascular Complications of Marijuana and Related Substances: A Review

Significant Psychedelic Experiences Evaluated for Mystical Characteristics Associated with Cannabis Use Reduction and Psychological Flexibility Improvement: A Naturalistic Cross-Sectional Retrospective Survey

Treating cannabis use disorder remains a significant challenge in the field of addiction medicine. Some recent studies point to psychedelic-assisted psychotherapy as a potential treatment option for substance use disorders. The objective of this study was therefore to explore the impact of naturalistic psychedelic experiences on cannabis use and psychological flexibility. An online retrospective survey was carried out on 152 cannabis users who also reported a significant experience induced by psychedelics in the past. Following a psychedelic experience, there was a significant and sustained reduction of average CUDIT score (p < .001), frequency of cannabis use (p < .001), and acute duration of daily intoxication (p < .001). Cannabis use reduction during the first month post-experience was significantly associated with the intensity of the mystical experience (p = .01). Participants reported a concomitant increased lasting improvement of psychological flexibility following the experience (p < .001), which was correlated to the intensity of the mystical experience during the first month post-experience (p = .04). This study demonstrates that naturalistic psychedelic experiences may be followed by a decrease in cannabis use. Positive health outcomes appear potentially connected to the intensity of the mystical experience, as well as an improvement in psychological flexibility.

Potential perioperative cardiovascular outcomes in cannabis/cannabinoid users. A call for caution

Background

Cannabis is one of the most widely used psychoactive substances. Its components act through several pathways, producing a myriad of side effects, of which cardiovascular events are the most life-threatening. However, only a limited number of studies address cannabis's perioperative impact on patients during noncardiac surgery.

Methods

Studies were identified by searching the PubMed, Medline, EMBASE, and Google Scholar databases using relevant keyword combinations pertinent to the topic.

Results

Current evidence shows that cannabis use may cause several cardiovascular events, including abnormalities in cardiac rhythm, myocardial infarction, heart failure, and cerebrovascular events. Additionally, cannabis interacts with anticoagulants and antiplatelet agents, decreasing their efficacy. Finally, the interplay of cannabis with inhalational and intravenous anesthetic agents may lead to adverse perioperative cardiovascular outcomes.

Conclusions

The use of cannabis can trigger cardiovascular events that may depend on factors such as the duration of consumption, the route of administration of the drug, and the dose consumed, which places these patients at risk of drug-drug interactions with anesthetic agents. However, large prospective randomized clinical trials are needed to further elucidate gaps in the body of knowledge regarding which patient population has a greater risk of perioperative complications after cannabis consumption.

Cannabis, Cannabinoids, and Stroke: Increased Risk or Potential for Protection-A Narrative Review

Worldwide, approximately 15 million people per year suffer from stroke. With about 5 million deaths, stroke is the second most common cause of death and a major cause of long-term disability. It is estimated that about 25% of people older than 85 years will develop stroke. Cannabis sativa and derived cannabinoids have been used for recreational and medical purposes for many centuries. However, due to the legal status in the past, research faced restrictions, and cannabis use was stigmatized for potential negative impacts on health. With the changes in legal status in many countries of the world, cannabis and cannabis-derived substances such as cannabinoids and terpenes have gained more interest in medical research. Several medical effects of cannabis have been scientifically proven, and potential risks identified. In the context of stroke, the role of cannabis is controversial. The negative impact of cannabis use on stroke has been reported through case reports and population-based studies. However, potential beneficial effects of specific cannabinoids are described in animal studies under certain conditions. In this narrative review, the existing body of evidence regarding the negative and positive impacts of cannabis use prior to stroke will be critically appraised.

Cumulative Deleterious Effects of Tetrahydrocannabinoid (THC) and Ethanol on Mitochondrial Respiration and Reactive Oxygen Species Production Are Enhanced in Old Isolated Cardiac Mitochondria

Delta 9 tetrahydrocannabinol (THC), the main component of cannabis, has adverse effects on the cardiovascular system, but whether concomitant ethanol (EtOH) and aging modulate its toxicity is unknown. We investigated dose responses of THC and its vehicle, EtOH, on mitochondrial respiration and reactive oxygen production in both young and old rat cardiac mitochondria (12 and 90 weeks). THC dose-dependently impaired mitochondrial respiration in both groups, and such impairment was enhanced in aged rats (-97.5 ± 1.4% vs. -75.6 ± 4.0% at 2 × 10-5 M, and IC50: 0.7 ± 0.05 vs. 1.3 ± 0.1 × 10-5 M, p < 0.01, for old and young rats, respectively). The EtOH-induced decrease in mitochondrial respiration was greater in old rats (-50.1 ± 2.4% vs. -19.8 ± 4.4% at 0.9 × 10-5 M, p < 0.0001). Further, mitochondrial hydrogen peroxide (H2O2) production was enhanced in old rats after THC injection (+46.6 ± 5.3 vs. + 17.9 ± 7.8%, p < 0.01, at 2 × 10-5 M). In conclusion, the deleterious cardiac effects of THC were enhanced with concomitant EtOH, particularly in old cardiac mitochondria, showing greater mitochondrial respiration impairment and ROS production. These data improve our knowledge of the mechanisms potentially involved in cannabis toxicity, and likely support additional caution when THC is used by elderly people who consume alcohol.

The synthetic cannabinoids menace: a review of health risks and toxicity

Synthetic cannabinoids (SCs) are chemically classified as psychoactive substances that target the endocannabinoid system in many body organs. SCs can initiate pathophysiological changes in many tissues which can be severe enough to damage the normal functionality of our body systems. The majority of SCs-related side effects are mediated by activating Cannabinoid Receptor 1 (CB1R) and Cannabinoid Receptor 2 (CB2R). The activation of these receptors can enkindle many downstream signalling pathways, including oxidative stress, inflammation, and apoptosis that ultimately can produce deleterious changes in many organs. Besides activating the cannabinoid receptors, SCs can act on non-cannabinoid targets, such as the orphan G protein receptors GPR55 and GPR18, the Peroxisome Proliferator-activated Receptors (PPARs), and the Transient receptor potential vanilloid 1 (TRPV1), which are broadly expressed in the brain and the heart and their activation mediates many pharmacological effects of SCs. In this review, we shed light on the multisystem complications found in SCs abusers, particularly discussing their neurologic, cardiovascular, renal, and hepatic effects, as well as highlighting the mechanisms that intermediate SCs-related pharmacological and toxicological consequences to provide comprehensive understanding of their short and long-term systemic effects.

Cannabis and Cannabinoids in the Perioperative Period

Cannabis use is increasingly common, and with a growing number of jurisdictions implementing legalization frameworks, it is likely that providers will encounter more patients who use cannabis. Therefore, it is important for providers to understand the implications of cannabis use and practical considerations for the perioperative period. Cannabis affects multiple organ systems and may influence intraoperative anesthesia, as well as postoperative pain management. The effects of cannabis and key anesthetic considerations are reviewed here.

Proximity to Cannabis Retailers and Recent Cannabis Use among a Diverse Sample of California Adolescents

Background: As of May 2023, 23 states and Washington, DC have legalized the sale of cannabis for adults aged 21+, and 38 states, three territories, and D.C. have legalized medical cannabis. Exposure to cannabis retailers could increase adolescent cannabis use. Few studies have examined the impact of residential proximity to cannabis retailers on adolescent cannabis use, and previous findings are inconsistent. Methods: This study examined associations between proximity to cannabis retailers and past 30-day cannabis use. Data were from Project Cal Teens, a statewide survey of California adolescents regarding cannabis-related opinions/behaviors (N = 1406, mean age = 15.5 years, 48% female, 38% Hispanic/Latinx, 33% White, 15% Asian/Pacific Islander, 10% Black/African American, 5% Other/Multiracial). Participants were recruited via schools/social media in 2018-2020. Results: For every additional 5 driving miles to the nearest cannabis retailer, the risk of past 30-day cannabis use was reduced by 3.6% [IRR: 0.964; 95% CI: 0.935-0.994]. For every additional 5 miles from a licensed retailer, the risk of past 30-day cannabis use was reduced by 4.3% [IRR: 0.957; 95% CI: 0.926-0.989]. Interaction analyses revealed that among Hispanic/Latinx students, every 5 miles from a licensed retailer was associated with an 11.9% reduction in the risk of past 30-day cannabis use [IRR: 0.881; 95% CI: 0.820-0.945]. Conclusions: As the number of cannabis retailers in the U.S. increases with the continued legalization of adult cannabis use, research examining the effects of these policies on underage use is crucial. Interventions could include enforcement of zoning laws in/near residential areas to reduce accessibility of adolescents to cannabis retailers.

Cerebrovascular Events and Hospital Discharge Outcomes Associated With Drug Use: A Retrospective Case-Matched Study

Introduction Individuals using cocaine, methamphetamines, cannabis, and other mood-altering drugs (MADs) have been reported to have greater stroke risk when compared to individuals who do not use these drugs. Yet, the impact that MAD use has on stroke outcomes has not been adequately explored, with existing research not agreeing on the extent to which the use of these drugs influences stroke outcomes. This study aimed to determine the impact that the use of common MADs has on stroke outcome factors such as length of stay (LOS), discharge modified Rankin Scale (mRS), and discharge disposition. Methods A retrospective case-matched study was conducted with two adult cohorts treated for cerebrovascular accidents: those who use MADs and those who do not use MADs prior to their stroke. Subjects identified for the users of MADs cohort were matched at a 1:1 ratio to those who do not use MADs (control cohort) by age, sex, and stroke type (e.g., hemorrhagic or ischemic). Logistic regression was used to calculate odds ratios for functional outcomes for stroke patients with and without prior MAD use. Results Active users of MADs had an increased overall risk of poor stroke outcome, i.e., increased length of stay, discharge disposition other than to home or to rehabilitation, discharge modified Rankin scale (mRS) 3-6 after controlling for stroke severity from initial National Institutes of Health Stroke Scale (NIHSS) (X2{9}=21.68, p<0.01, Cox adjusted R2=0.31). This finding was driven predominately by increased hospital LOS (p=0.006) among the MAD cohort, whereas discharge mRS 3-6 (p=0.24) and discharge disposition to care facility (p=0.27) and expired (p=0.26) did not vary significantly between groups. Conclusion Our study suggests that patients who had actively used MADs prior to their stroke may be at risk of poorer stroke outcomes, namely an increased LOS. Future research should be conducted to further elucidate which factors, such as individual drugs, amount of drug, acute or recreational use versus chronic or long-term use, and route of administration, for instance, specifically contribute to a longer LOS so that they may be targeted for mitigation.

Cannabis Abuse Is Associated With Greater Medical Complications, Emergency Department Visits, and Readmissions Following Open Reduction and Internal Fixation for Distal Radius Fractures

BACKGROUND

Despite increased legalization, little is known about the influence of cannabis use disorder (CUD) following open reduction and internal fixation (ORIF) for distal radius fractures (DRFs). The aims were to determine whether CUD patients undergoing ORIF for DRF have increased: (1) medical complications; and (2) health care utilization (emergency department [ED] visits and readmission rates).

METHODS

Patients were identified from an insurance database from 2010 to 2020 using Current Procedural Terminology codes: 25607, 25608, and 25609. Patients with a history of CUD were 1:5 ratio matched to controls by age, sex, tobacco use, alcohol abuse, opioid dependence, and comorbidities. This yielded 13,405 patients with (n = 2,297) and without (n = 11,108) CUD. Outcomes were to compare 90-day medical complications, ED visits, and readmissions. Multivariable logistic regression models computed the odds ratios of CUD on dependent variables. P values less than .005 were significant.

RESULTS

The incidence of CUD among patients aged 20 to 69 years undergoing ORIF increased from 4.0% to 8.0% from 2010 to 2020 (P < .001). Cannabis use disorder patients incurred significantly higher rates and odds of developing 90-day medical complications (15.24% vs 5.76%), including pneumoniae (3.66% vs 1.67%), cerebrovascular accidents (1.04% vs 0.32%), pulmonary emboli (0.57% vs 0.16%), respiratory failures (1.00% vs 0.48%), and surgical site infections (1.70% vs 1.04%; all P < .004). Emergency department visits (2.53% vs 1.14%) and readmission rates (5.79% vs 4.29%) within 90 days were higher among cannabis abusers.

CONCLUSIONS

With a greater number of states legalizing cannabis, hand surgeons should be cognizant of the association with increased 90-day complications and health care utilization parameters.

Disparities in cannabis-related emergency department visits across depressed and non-depressed individuals and the impact of recreational cannabis policy in Ontario, Canada

BACKGROUND

Recreational cannabis policies are being considered in many jurisdictions internationally. Given that cannabis use is more prevalent among people with depression, legalisation may lead to more adverse events in this population. Cannabis legalisation in Canada included the legalisation of flower and herbs (phase 1) in October 2018, and the deregulation of cannabis edibles one year later (phase 2). This study investigated disparities in cannabis-related emergency department (ED) visits in depressed and non-depressed individuals in each phase.

METHODS

Using administrative data, we identified all adults diagnosed with depression 60 months prior to legalisation (n = 929 844). A non-depressed comparison group was identified using propensity score matching. We compared the pre-post policy differences in cannabis-related ED-visits in depressed individuals v. matched (and unmatched) non-depressed individuals.

RESULTS

In the matched sample (i.e. comparison with non-depressed people similar to the depressed group), people with depression had approximately four times higher risk of cannabis-related ED-visits relative to the non-depressed over the entire period. Phases 1 and 2 were not associated with any changes in the matched depressed and non-depressed groups. In the unmatched sample (i.e. comparison with the non-depressed general population), the disparity between individuals with and without depression is greater. While phase 1 was associated with an immediate increase in ED-visits among the general population, phase 2 was not associated with any changes in the unmatched depressed and non-depressed groups.

CONCLUSIONS

Depression is a risk factor for cannabis-related ED-visits. Cannabis legalisation did not further elevate the risk among individuals diagnosed with depression.

Prevalence of illicit drug use in young patients with sudden cardiac death

BACKGROUND

Illicit drug use may accelerate coronary disease and cardiac hypertrophy or stimulate arrhythmias. Rates of illicit drug use in young patients with sudden cardiac death (SCD) are uncertain.

OBJECTIVE

The purpose of this study was to identify rates of illicit drug use in young patients with SCD.

METHODS

A prospective statewide registry identified out-of-hospital patients with cardiac arrest aged 18-50 years from April 2019 to April 2021. Clinical characteristics were compared between patients with and without illicit drug use (defined by toxicological results or reported regular use). Illicit drugs included amphetamine-type substances, cocaine, heroin, cannabis, and other drugs.

RESULTS

A total of 554 (40.2%) of 1378 patients had confirmed cardiac cause of out-of-hospital cardiac arrest, with 523 undergoing toxicological assessment. There were 170 patients (32.5%) having either positive toxicology for illicit drugs (n = 138) or negative toxicology but reported regular drug use (n = 32). Patients with SCD and illicit drug use were more commonly male (81.2% vs 72.3%; P = .028), smokers (38.8% vs 19.8%; P ≤ .0001), and excess alcohol drinkers (30.6% vs 20.6%; P = .012) and had a psychiatric diagnosis (38.8% vs 25.7%; P = .002), lower body mass index (29.4 kg/m2 vs 31.7 kg/m2; P = .0063), and lower rates of hypertension (10.6% vs 18.6%; P = .019). Death commonly occurred while sedentary (47.5%) or during sleep (45.8%). Accounting for these baseline differences, there were no differences in rates of coronary disease or cardiomyopathy. Cannabis (n = 106) was the most common illicit drug identified and polysubstance abuse occurred frequently (n = 25).

CONCLUSION

Approximately one-third of young patients with SCD have positive toxicology at the time of death or reported frequent use of illicit drugs, with high rates of polysubstance abuse.

Arrhythmic Effects of Cannabis in Ischemic Heart Disease

Rationale: Cannabis use is increasing worldwide, especially among older individuals at risk for chronic ischemic heart disease (IHD). However, little is known about the arrhythmic effects of cannabis use in IHD. Accordingly, we prospectively assessed the relationship between cannabis use, heart rate (HR), and arrhythmias in healthy age-matched controls and subjects with IHD. Methods: Healthy controls (n=37, 57% men) and subjects with IHD (myocardial infarction ≥3 months ago; n=24, 58% men) who used cannabis wore a Zio® (iRhythm Technologies) monitor for 14 days. Noncannabis using ischemic subjects (n=35, 51% males) wore Zio monitors for standard clinical indications. Baseline HR was compared with average HR measured for 4 h following consumption and changes in HR and frequency of arrhythmias were correlated with cannabis use. Results: In controls, HR increased 20 min (4.99±6.7 bpm, p=0.08) after use, then declined 4 h following use (-7.4±7.7, p<0.001). Conversely, subjects with IHD showed minimal HR increase (1.6±3.9 bpm) and blunted HR decline (-3.4±5.6 bpm, p<0.001). Supraventricular tachycardia (SVT) (29.7% vs. 58.3%; p=0.04) and nonsustained ventricular tachycardia (NSVT) (5.6% vs. 47.8%, p=0.01) were the most frequently occurring arrhythmias in controls and IHD subjects, respectively. Incidence of SVT decreased as cannabis use increased in both groups. Conversely, NSVT tended to increase with increased use in controls, and was significantly more prevalent in IHD. However, overall arrhythmia burden did not differ between cannabis users and nonusers with IHD. Conclusion: Our findings demonstrate that chronic cannabis use is associated with only mild HR changes, which are blunted in IHD. In addition, our data suggest that among cannabis users, arrhythmias are more frequent in IHD subjects that in healthy subjects.

Changes in Arkansans' attitudes toward pharmacist involvement and regulation of medical cannabis following its availability in Arkansas

BACKGROUND

Pharmacists are likely to encounter questions from patients regarding medical cannabis (MC). This serves as an opportunity for pharmacists to provide reliable medical information about MC dosing, drug interactions, and impact on preexisting health conditions.

OBJECTIVES

This study examined changes in perceptions of the Arkansan community toward MC regulation and pharmacist involvement in MC dispensing after MC products became available in Arkansas.

METHODS

A longitudinal, self-administered online survey was conducted in February 2018 (baseline) and September 2019 (follow-up). Baseline participants were recruited through Facebook posts, emails, and printed flyers. Participants from the baseline survey (N = 1526) were invited to participate in the follow-up survey. Paired t tests were used to determine changes in responses, and multivariable regression analysis was used to identify factors associated with follow-up perceptions.

RESULTS

Participants (n = 607, response rate 39.8%) started the follow-up survey, resulting in 555 usable surveys. The largest group of participants was 40-64 year old (40.9%). The majority were female (67.9%), white (90.6%), and reported past 30-day cannabis use (83.1%). Compared to baseline, participants preferred less regulatory control of MC. They were also less likely to agree that pharmacists helped improve MC-related patient safety. Participants favoring less MC regulation were more likely to report 30-day cannabis use and perceived cannabis to have low health risk. Past 30-day cannabis use was also significantly associated with disagreement that pharmacists improve patient safety and are well-trained to provide MC counseling.

CONCLUSION

After MC product availability, Arkansans' attitudes changed toward less MC regulation and less agreement with the pharmacist's role in improving MC safety. These findings call for pharmacists to better promote their role in public health safety and demonstrate their knowledge concerning MC. Pharmacists should advocate for an expanded, active consultant role in dispensaries to improve safety of MC use.

Systematic review and rationale of using psychedelics in the treatment of cannabis use disorder

Introduction

Cannabis use disorder (CUD) is prevalent in ~2-5% of adults in the United States and is anticipated to increase as restrictions to cannabis decrease and tetrahydrocannabinol (THC) content in cannabis products increase. No FDA-approved medications for CUD are currently available, despite trials of dozens of re-purposed and novel drugs. Psychedelics have garnered interest as a therapeutic class in other substance use disorders, and self-report surveys suggest they may result in positive outcomes for CUD. Herein, we review the existing literature pertaining to psychedelic use in persons with or at risk for CUD and consider the potential rationale underpinning psychedelics as a treatment for CUD.

Methods

A systematic search was performed in several databases. Inclusion criteria were primary research reporting use of psychedelics or related substances and CUD for treatment in human subjects. Exclusion criteria were results including psychedelics or related substances without changes in cannabis use or risks associated with CUD.

Results

Three hundred and five unique results were returned. One article was identified using the non-classical psychedelic ketamine in CUD; three articles were identified as topically relevant based on their secondary data or consideration of mechanism. Additional articles were reviewed for purposes of background, review of safety considerations, and formulating rationale.

Conclusion

Limited data and reporting are available on the use of psychedelics in persons with CUD, and more research is needed given the anticipated increase in CUD incidence and increasing interest in psychedelic use. While psychedelics, broadly, have a high therapeutic index with infrequent serious adverse effects, particular adverse effects at risk in the CUD population, such as psychosis and cardiovascular events, should be considered. Possible mechanisms by which psychedelics have therapeutic potential in CUD are explored.

Exploring the Therapeutic Potential of Cannabinoid Receptor Antagonists in Inflammation, Diabetes Mellitus, and Obesity

Recently, research has greatly expanded the knowledge of the endocannabinoid system (ECS) and its involvement in several therapeutic applications. Cannabinoid receptors (CBRs) are present in nearly every mammalian tissue, performing a vital role in different physiological processes (neuronal development, immune modulation, energy homeostasis). The ECS has an essential role in metabolic control and lipid signaling, making it a potential target for managing conditions such as obesity and diabetes. Its malfunction is closely linked to these pathological conditions. Additionally, the immunomodulatory function of the ECS presents a promising avenue for developing new treatments for various types of acute and chronic inflammatory conditions. Preclinical investigations using peripherally restricted CBR antagonists that do not cross the BBB have shown promise for the treatment of obesity and metabolic diseases, highlighting the importance of continuing efforts to discover novel molecules with superior safety profiles. The purpose of this review is to examine the roles of CB1R and CB2Rs, as well as their antagonists, in relation to the above-mentioned disorders.

Cardiac Arrest Associated With Psilocybin Use and Hereditary Hemochromatosis

Recreational drug use is a significant public health concern in various countries. It is well understood that usage of psychedelics/hallucinogens, such as lysergic acid diethylamide (LSD), ecstasy, phencyclidine (PCP), and psilocybin-containing mushrooms, has increased significantly over the last few decades, particularly in adolescents and young adults, yet the effects of these recreational drugs are poorly understood. Psilocybin has recently been studied as an alternative to traditional antidepressant therapies with potentially benign side effects. Here, we present the case of a 48-year-old male with a past medical history of attention-deficit/hyperactivity disorder on lisdexamfetamine who presented after a syncopal episode witnessed by his wife at home. He was found to be in ventricular fibrillation and subsequently had an extensive workup with cardiac magnetic resonance imaging (MRI), ischemic evaluation, and electrophysiology, which were unrevealing. He then received an automatic implantable cardiac defibrillator and was incidentally found to have hereditary hemochromatosis on outpatient follow-up. His polypharmacy may have potentially led to catecholamine release, leading to ventricular arrhythmia.

E-cigarette, cannabis and combustible tobacco use: associations with xerostomia among California adolescents

OBJECTIVE

Xerostomia (subjective experience of dry mouth), while less common in younger populations, can contribute to caries and oral discomfort. Use of e-cigarettes and cannabis among adolescents is increasing and may be a xerostomia risk factor. This study evaluates xerostomia prevalence in an adolescent population, overall and by e-cigarette, cannabis and combustible tobacco use.

METHODS

Cross-sectional analyses of 12-month follow-up data (N=976; collected 2020-2021) from a cohort of adolescents recruited from public high schools in Northern California (USA) compared self-reported past 30-day e-cigarette, cannabis and other tobacco use and dry mouth (overall dry mouth experience; shortened xerostomia inventory, SXI). Dry mouth experience (never, occasionally, frequently/always) was modelled using ordered logistic regression with school-level clustering and adjustment for gender, race/ethnicity, alcohol use, asthma, physical activity and mutually for e-cigarette, cannabis and tobacco use.

RESULTS

Past 30-day use prevalence was 12% for e-cigarettes, 16% for cannabis and 3% for combustible tobacco. Occasional dry mouth experience (54%) was more common than frequent/always experience (5%). Frequent/always dry mouth was more prevalent among frequent (>5 days/month) e-cigarette (14%) and cannabis (19%) users and combustible tobacco users (19%) than non-users of those respective products (all comparisons p < 0.001). In covariable-adjusted models, frequent e-cigarette use was no longer significantly associated with dry mouth experience (OR: 1.40; 95% CI: 0.69, 2.84), while frequent cannabis use (OR: 3.17; 95% CI: 1.47, 6.82) and combustible tobacco use (OR: 1.92; 95% CI: 1.38, 2.68) were associated with greater odds of reporting more frequent dry mouth. Findings were qualitatively similar using the SXI.

CONCLUSIONS

In this study, xerostomia was not independently associated with e-cigarette use but was one potential health concern of adolescent cannabis and combustible tobacco use.

Oxidative Stress Underpins Clinical, Social, and Genetic Risk Factors for Atherosclerotic Cardiovascular Disease

Background

Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of death worldwide and is poorly predicted with current risk estimation tools. The biological mechanisms relating ASCVD risk factors to oxidative stress (OS) and how this accumulates ASCVD risk are misunderstood.

Purpose

To develop a comprehensive conceptual model explaining how expanded clinical, social, and genetic ASCVD risk factors accumulate ASCVD risk through OS.

Conclusions

OS (primarily from excess reactive oxygen species) and inflammation are present along the entire ASCVD pathophysiologic continuum. An expanded list of clinical and social ASCVD risk factors (including hypertension, obesity, diabetes, kidney disease, inflammatory diseases, substance use, poor nutrition, psychosocial stress, air pollution, race, and genetic ancestry) influence ASCVD largely through increased OS. Many risk factors exert a positive feedback mechanism to increase OS. One genetic risk factor, haptoglobin (Hp) genotype, is associated with higher ASCVD risk in diabetes and hypothesized to do the same in those with insulin resistance due to the Hp 2-2 genotype increasing OS.

Implications

Understanding the biological mechanisms of OS informs how these ASCVD risk factors relate to each other and compound ASCVD risk. Individualized ASCVD risk estimation should include a comprehensive, holistic perspective of risk factors to better address the clinical, social, and genetic influences of OS. Preventing and reducing OS is key to preventing ASCVD development or progression.

Reversible cerebral vasoconstriction syndrome associated with probable drug poisoning

Reversible cerebral vasoconstriction syndrome (RCVS) is a clinical condition characterized by arterial involvement of the intracranial vessels, manifesting with vasospasm. The most common clinical manifestation related to the syndrome is the thunderclap headache, which consists of a severe headache that reaches the peak of pain within minutes. The imaging study assumes a leading role in the complementary investigation. Laboratory tests and cerebrospinal fluid analysis are often nonspecific and without significant diagnostic importance. Non-contrast studies of the brain parenchyma reveal variable results that can often be normal. Angiographic findings, which initially may not reveal any changes, allow the visualization of diffuse narrowing of the vessels, with the posterior cerebral circulation being preferentially affected. The present study reports the case of a 19-year-old woman with no relevant medical history, except that she was a regular user of marijuana and a drug based on chloroform and ether. The patient showed clinical and imaging signs compatible with RCVS, and the narcotics used by her were considered precipitating factors.

Pharmacognosy and Effects of Cannabinoids in the Vascular System

Understanding the pharmacodynamics of cannabinoids is an essential subject due to the recent increasing global acceptance of cannabis and its derivation for recreational and therapeutic purposes. Elucidating the interaction between cannabinoids and the vascular system is critical to exploring cannabinoids as a prospective therapeutic agent for treating vascular-associated clinical conditions. This review aims to examine the effect of cannabinoids on the vascular system and further discuss the fundamental pharmacological properties and mechanisms of action of cannabinoids in the vascular system. Data from literature revealed a substantial interaction between endocannabinoids, phytocannabinoids, and synthetic cannabinoids within the vasculature of both humans and animal models. However, the mechanisms and the ensuing functional response is blood vessels and species-dependent. The current understanding of classical cannabinoid receptor subtypes and the recently discovered atypical cannabinoid receptors and the development of new synthetic analogs have further enhanced the pharmacological characterization of the vascular cannabinoid receptors. Compelling evidence also suggest that cannabinoids represent a formidable therapeutic candidate for vascular-associated conditions. Nonetheless, explanations of the mechanisms underlining these processes are complex and paradoxical based on the heterogeneity of receptors and signaling pathways. Further insight from studies that uncover the mechanisms underlining the therapeutic effect of cannabinoids in the treatment of vascular-associated conditions is required to determine whether the known benefits of cannabinoids thus currently outweigh the known/unknown risks.

Nabiximols effect on blood pressure and heart rate in post-stroke patients of a randomized controlled study

BACKGROUND

Cannabinoids may be useful to treat pain, epilepsy and spasticity, although they may bear an increased risk of cardiovascular events. This study aims to evaluate the cardiovascular safety of nabiximols, a cannabis-based drug, in patients with spasticity following stroke, thus presenting an increased cardiovascular risk.

METHODS

This is an ancillary study stemming from the SativexStroke trial: a randomized double-blind, placebo-controlled, crossover study aimed at assessing the effect of nabiximols on post-stroke spasticity. Patients were treated with nabiximols oromucosal spray or placebo and assessed before and after two phases of 1-month duration each. Only the phase with the active treatment was considered for each patient who completed the study. The average values of blood pressure (diastolic, systolic, differential) and heart rate from the first 5 days of the phase (lowest nabiximols dosage) were compared to the average values recorded during the last 5 days at the end of the phase (highest nabiximols dosage). Baseline comparisons between gender, stroke type and affected side and correlation between age and blood pressure and heart rate were performed. The study was registered with the EudraCT number 2016-001034-10.

RESULTS

Thirty-four patients completed the study and were included in the analysis. Thirty-one were taking antihypertensive drugs and, among these, 12 were taking beta-blockers. During the study, no arrhythmic events were recorded, blood pressure and heart rate did not show pathological fluctuations, and no cardiovascular or cerebrovascular events occurred. At baseline blood pressure and heart rate were comparable concerning gender, stroke type and affected side. A significant direct correlation emerged between differential blood pressure and age and an inverse correlation between diastolic blood pressure and age. No correlation emerged between systolic blood pressure or heart rate and age. Blood pressure and heart rate did not change during nabiximols treatment compared to the baseline condition.

CONCLUSION

This ancillary study adds evidence that, in patients who already underwent a cerebrovascular accident, nabiximols does not determine significant blood pressure and heart rate variation or cardiovascular complications. These data support the cardiovascular safety of nabiximols, encouraging more extensive studies involving cannabinoids characterized by slow absorption rates.

Analysis of STEMI and NSTEMI in a Community Cohort of Marijuana Users

Background

Marijuana is the most commonly used illicit drug in the United States. Current research has yet to come to a consensus on its association with acute coronary syndrome (ACS). Herein, we aimed to analyze how marijuana use relates to acute ST elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI).

Methods

Using a retrospective study design, we gathered data from August 2014 to September 2020 on all percutaneous coronary interventions (PCIs) done at Brookdale University Hospital Medical Center (BUHMC) in patients with NSTEMI and STEMI. To compare marijuana users (MUs) with non-users, t-tests and Chi-square tests were used. A total of 195 patients were included, with mean age at presentation of 47 years old; 59 were females (30.3%) and 136 were males (69.7%). We identified 37 patients who were MUs. MUs were younger than non-users (P < 0.01), had higher rates of alcohol (P = 0.025), opiate (P = 0.004) and cigarette (P ≤ 0.001) use. On admission, MUs had lower creatinine (P = 0.031), blood urea nitrogen (BUN) (P = 0.031), pro-B-type natriuretic peptide (PBNP) (P = 0.052), BMI (P = 0.014) and lower right coronary artery (RCA) disease (P = 0.026).

Results

After logistic regression analyses, results showed that the severity of coronary artery disease (CAD) and admission diagnosis of STEMI or NSTEMI were not found to be significantly related to marijuana use. Age, alcohol, cigarette, creatinine, BUN, PBNP, BMI and RCA disease were significantly related to marijuana use. There was a negative correlation between marijuana use and RCA disease (MUs = 29.7% vs. non-users = 50%, P = 0.026). There was no significant association with STEMI, NSTEMI or the severity of CAD.

Conclusion

As daily cannabis use is on the rise, more researches are needed to further determine the effects of marijuana use on CAD.

Adverse Effects of Cannabinoids and Tobacco Consumption on the Cardiovascular System: A Systematic Review

With the recent legalization of marijuana in several countries for recreational use, a controversial belief is spreading about it being "safe". In this systematic review, we decided to investigate this belief and present the adverse effects of marijuana and tobacco smoking on the cardiovascular system.

We carried out an electronic search on databases including PubMed, PubMed Central, and Medline. Medical Subject Headings (MeSH) terms and different keywords were used for data collection. We included studies published in the last 10 years that were in English. All types of study subjects were accepted. Grey literature, books, case reports and case series, overlapping and duplicate studies, and studies older than 10 years were excluded.

In this review, we included 18 studies, which we then separated into the "tobacco and cardiovascular disease" arm and the "cannabinoids and cardiovascular disease" arm. We had 11 and seven studies for each of the arms, respectively. The types of articles included in this review were traditional and systematic reviews and meta-analyses.

After reviewing all the data included in this article, we found out that cannabinoid consumption has a more devastating effect on the cardiovascular system when compared to tobacco. The shocking fact was that in several cases, deadly adverse effects were observed in patients within a few hours after consumption or even during their first time using cannabinoids.

Marijuana use does not affect weight loss or complication rate after bariatric surgery

INTRODUCTION

Marijuana use has been legalized in several states. It is unclear if marijuana use affects weight loss outcomes or complication rates following bariatric surgery. The purpose of this study was to determine if patients who use marijuana had higher complication rates or lower weight loss compared with non-users.

METHODS

All patients at a single institution who underwent primary bariatric surgery between July 2015 and July 2020 at a single institution after the legalization of marijuana within the jurisdiction were included. Data regarding marijuana use, weight and complications were abstracted retrospectively. Differences between groups were evaluated with Wilcoxon Rank-Sum tests and Fisher Freeman Halton test. Trends for marijuana use over time was evaluated with simple linear regression on summary data.

RESULTS

1107 patients met inclusion criteria. 798 (73.3%) were never users, 225 (19.4%) were previous users, and 84 (7.2%) were active users. The proportion of active users and previous users increased over time, with significantly more prior marijuana use reported in more recent years (p = 0.014). Active users had significantly higher pre-procedural BMIs than never users: 48.7 vs. 46.3 (p = 0.03). Any marijuana use (active and previous users) was associated with higher preoperative weight compared to never: 136.4 kg vs. 130.6 kg (p = 0.001). Overall complication rate was low in all groups, and there was no difference in the rates of any complications. Active and previous users tended to lose less weight than never users, but this was not statistically significant (p = 0.17).

CONCLUSIONS

Active and prior marijuana users tend to have higher BMIs on presentation, but use was not associated with complications or percent weight loss. The incidence of patient reported marijuana use is increasing in the study population. More studies on the effects of marijuana use in this patient population are warranted.

Tetrahydrocannabinol and cannabidiol medicines for chronic pain and mental health conditions

Combination tetrahydrocannabinol (THC)/cannabidiol (CBD) medicines or CBD-only medicines are prospective treatments for chronic pain, stress, anxiety, depression, and insomnia. THC and CBD increase signaling from cannabinoid receptors, which reduces synaptic transmission in parts of the central and peripheral nervous systems and reduces the secretion of inflammatory factors from immune and glial cells. The overall effect of adding CBD to THC medicines is to enhance the analgesic effect but counteract some of the adverse effects. There is substantial evidence for the effectiveness of THC/CBD combination medicines for chronic pain, especially neuropathic and nociplastic pain or pain with an inflammatory component. For CBD-only medication, there is substantial evidence for stress, moderate evidence for anxiety and insomnia, and minimal evidence for depression and pain. THC/CBD combination medicines have a good tolerability and safety profile relative to opioid analgesics and have negligible dependence and abuse potential; however, should be avoided in patients predisposed to depression, psychosis and suicide as these conditions appear to be exacerbated. Non-serious adverse events are usually dose-proportional, subject to tachyphylaxis and are rarely dose limiting when patients are commenced on a low dose with gradual up-titration. THC and CBD inhibit several Phase I and II metabolism enzymes, which increases the exposure to a wide range of drugs and appropriate care needs to be taken. Low-dose CBD that appears effective for chronic pain and mental health has good tolerability and safety, with few adverse effects and is appropriate as an initial treatment.

A Scoping Review of Gender, Sex and Sexuality Differences in Polysubstance Use in Adolescents and Adults

BACKGROUND

Polysubstance use is a common, problematic behavior that increases risk of harm to self and others. Research suggests that rates may vary based on gender, sex and sexuality. Understanding the current state of this literature may inform prevention and treatment of polysubstance use, leading to reduced public health burden.

OBJECTIVES

This review aimed to synthesize research on gender, sex and sexuality differences in polysubstance use in adults and adolescents.

METHODS

A scoping review was conducted using all EBSCO databases, PubMed and Google Scholar to identify articles examining the effects of gender, sex and sexuality on polysubstance use. Polysubstance use was defined broadly as the use of any combination of substances over any time period and included licit (alcohol, tobacco) and illicit substances, concurrent and simultaneous use, from lifetime to daily use and use at any frequency. Studies were considered if they were published in peer-reviewed journals between January 1990 and October 2020 and were written in English. Publicly available data sources were also utilized to fully capture prevalence data that has not been published elsewhere.

RESULTS

Findings were mostly inconsistent and often conflicting. Only two findings were generally consistent: adult men were overall more likely to report polysubstance use than adult women, and sexual and gender minorities report more frequent polysubstance use than non-minorities.

CONCLUSIONS

Research has been unable to clearly elucidate differences in polysubstance use prevalence and patterns according to gender, sex and sexuality. Several recommendations are offered to advance future research and address limitations of current research.

Relation of Cannabis Use to Elevated Atherosclerotic Cardiovascular Disease Risk Score

We hypothesized that cannabis use is associated with cardiovascular disease (CVD) risk factors. This could explain the reported link between cannabis and cardiovascular events including stroke and myocardial infarction. This analysis included 7,159 participants (age 37.8 ± 12.4 years, 48.6% men, and 61.5% Caucasian) from the National Health and Nutrition Examination Survey years 2011 to 2018. Cannabis use was defined by self-report. Participants with a history of stroke or myocardial infarction were excluded. Composite CVD risk was assessed using the American College of Cardiology/American Heart Association 10-year atherosclerotic cardiovascular risk (ASCVD) score. Participants were classified based on their ASCVD risk levels as low (<5.0%), borderline (5.0% to 7.4%), intermediate (7.5% to 19.9%), and high (≥20.0%). Multinomial logistic regression was used to examine the association between cannabis use and ASCVD risk category using low-risk ASCVD category as the reference level. About 63.9% (n = 4,573) of participants had ever used cannabis. Ever cannabis use was associated with 60% increased odds of high-risk ASCVD score (odds ratio [OR] 95% confidence interval [CI] 1.60 [1.04 to 2.45], p = 0.03). We also observed a dose-response relation between increased use of cannabis and a higher risk of ASCVD. Those reporting ≥2 uses per month had 79% increased odds of high-risk ASCVD score (OR [95% CI] 1.79 [1.10 to 2.92], p = 0.02) and those reporting ≥1 use per day had 87% increased odds of high-risk ASCVD score (OR [95% CI] 1.87 [1.16 to 3.01], p <0.001]. In conclusion, cannabis use is associated with elevated CVD risk. Individuals using cannabis should be screened for CVD risk, and appropriate risk reduction strategies should be implemented.

Serum Metabolomic Analysis of Male Patients with Cannabis or Amphetamine Use Disorder

Studies have demonstrated that chronic consumption of abused drugs induces alterations in several proteins that regulate metabolism. For instance, methamphetamine exposure reduces glucose levels. Fatty and amino acid levels were altered in groups exposed to abused drugs. Therefore, in our study, we investigated the serum metabolomic profile of patients diagnosed with cannabis and/or amphetamine use disorders. Blood was obtained from subjects (control, amphetamine, and cannabis). Detection of serum metabolites was performed using gas chromatography. The ratio peak areas for metabolites were analyzed across the three groups. Both cannabis and amphetamine groups showed higher d-erythrotetrafuranose, octadecanoic acid, hexadecenoic acid, trans-9-octadecanoic acid, lactic acid and methyl thio hydantoin metabolites compared with the control group. Moreover, cannabis patients were found to possess higher glycine, 9,12 octadecanoic acid malonic acid, phosphoric acid and prostaglandin F1a than controls. Our analysis showed that the identified metabolic profile of cannabis or amphetamine use disorder patients was different than control group. Our data indicated that chronic exposure to cannabis or amphetamine dysregulated metabolites in the serum. Future studies are warranted to explore the effects of these abused drugs on the metabolic proteins.

The Relationship Between Plasma Tetrahydrocannabinol Levels and Intraocular Pressure in Healthy Adult Subjects

Background

Δ9-tetrahydrocannabinol (THC) has been shown to decreased intraocular pressure (IOP). This project aims to define the relationship between plasma THC levels and IOP in healthy adult subjects.

Methods

Eleven healthy subjects received a single dose of inhaled cannabis that was self-administered in negative pressure rooms. Measurements of IOP and plasma THC levels were taken at baseline and every 30 min for 1 h and afterwards every hour for 4 h. IOP reduction and percent change in IOP over time were calculated. Linear regression models were used to measure the relationship between IOP and plasma THC levels. Two line linear regression models with F-tests were used to detect change points in the regression. Then, Pearson correlations were computed based on the change point.

Results

Twenty-two eyes met inclusion criteria. The average peak percentage decrease in IOP was 16% at 60 min. Percent IOP reduction as well as total IOP reduction demonstrated a negative correlation with THC plasma levels showing r-values of −0.81 and −0.70, respectively. F-tests revealed a change point in the regression for plasma levels &gt;20 ng/ml. For levels &gt;20 ng/ml, the correlation coefficients changed significantly with r-values of 0.21 and 0.29 (p &lt; 0.01).

Conclusion

Plasma THC levels are significantly correlated with IOP reduction up to plasma levels of 20 ng/ml. Plasma levels &gt;20 ng/ml were not correlated with further decrease in IOP. More research is needed to determine the efficacy of THC in reducing IOP for eyes with ocular hypertension and glaucoma.

Effects of Marijuana Use on Smokers Switching to E-Cigarettes in a Randomized Clinical Trial

INTRODUCTION

Co-use of tobacco and marijuana is common, and research suggests that marijuana use may be a barrier to smoking cessation. Research to date has not evaluated how marijuana use affects e-cigarette switching behaviors and related outcomes in a harm reduction trial.

AIMS AND METHODS

This secondary analysis includes African American (48%) and Latinx (52%) adult smokers randomized to the e-cigarette group (N = 114) of a harm reduction clinical trial from 2018 to 2019. Participants were provided JUUL e-cigarettes and encouraged to make an exclusive switch for 6 weeks. Our primary outcome was cigarettes smoked per week. Secondary health outcomes were e-cigarette substitution (calculated by measuring e-cigarette pod use), expired carbon monoxide (CO), and respiratory symptoms. Marijuana products were recorded at three timepoints and coded for combustion.

RESULTS

Marijuana use during the study (n = 52, 46%) was not associated with week 6 cigarettes smoked or e-cigarette substitution, and combustible marijuana use was not associated with week 6 respiratory symptoms (ps > .05). After controlling for cigarettes smoked at week 6, combustible marijuana use was significantly associated with a 4.4 ppm increase in CO compared with no use of marijuana (p = .001).

CONCLUSIONS

Marijuana use was not a barrier to switching to e-cigarettes in this 6-week trial. Marijuana use contributed to elevated CO, reflecting greater exposure to toxic combustion products, beyond the effects of cigarette smoking. Marijuana co-use may increase risk of adverse health outcomes and may be a confounding factor when using CO as an endpoint to bioverify exclusive e-cigarette use.

IMPLICATIONS

This is the first known study to examine the effects of marijuana use on smokers switching to e-cigarettes. Marijuana use was not a barrier to cigarette reduction in a 6-week randomized clinical trial. Marijuana use uniquely contributed to higher carbon monoxide among cigarette smokers, indicating greater exposure to toxic combustion products, which could increase risk of adverse health outcomes. Furthermore, combustible marijuana use may be a confounding factor when CO is used as an endpoint to bioverify exclusive e-cigarette use.

Is Adversity in Childhood Linked to Marijuana Use in Adulthood?: Findings from the Behavioral Risk Factor Surveillance System

Background: Adverse childhood experiences (ACEs) are potentially traumatic events, which can have long-term, negative consequences. Few studies have examined ACEs' relationship to marijuana use. Objectives: We examined the association between ACEs and past-month marijuana use among adults and the pathways between childhood adversity and marijuana use. Methods: Adults from five states (n = 22,991) who responded to the 2019 Behavioral Risk Factors Surveillance System were included. We examined the prevalence of ACEs and marijuana use. We employed generalized structural equation modeling to assess the relationship between ACEs and marijuana use and the role of depression and poor mental and physical health as possible mediators. Results: Overall, 65.0% of the population reported 1+ ACE. Heavy marijuana use and past-month marijuana use prevalence rates were 10.3% and 5.0%, respectively. We found mediation effects for depression and poor mental health but not poor physical health. The number of ACEs was associated with a statistically significant increase in any past-month marijuana use-indirect effects ranged from 1.0 (95% CI, 1.0-1.0) to 1.4 (95% CI, 1.2-1.7), direct effects ranged from 1.1 (95% CI, 07-1.7) to 5.3 (95% CI 3.2-8.8), and total effects ranged from 1.1 (95% CI, 0.7-1.7) to 5.9 (95% CI, 3.6-9.8). Women, married persons, and middle aged and older adults had a lower odds of marijuana use. Reporting at least one HIV risk behavior was associated with an increased odds of marijuana use. Conclusion: ACE exposure was positively associated with marijuana use. Depression and poor mental health separately mediated this relationship.

Lower-Risk Cannabis Use Guidelines (LRCUG) for reducing health harms from non-medical cannabis use: A comprehensive evidence and recommendations update

BACKGROUND

Cannabis use is common, especially among young people, and is associated with risks for various health harms. Some jurisdictions have recently moved to legalization/regulation pursuing public health goals. Evidence-based 'Lower Risk Cannabis Use Guidelines' (LRCUG) and recommendations were previously developed to reduce modifiable risk factors of cannabis-related adverse health outcomes; related evidence has evolved substantially since. We aimed to review new scientific evidence and to develop comprehensively up-to-date LRCUG, including their recommendations, on this evidence basis.

METHODS

Targeted searches for literature (since 2016) on main risk factors for cannabis-related adverse health outcomes modifiable by the user-individual were conducted. Topical areas were informed by previous LRCUG content and expanded upon current evidence. Searches preferentially focused on systematic reviews, supplemented by key individual studies. The review results were evidence-graded, topically organized and narratively summarized; recommendations were developed through an iterative scientific expert consensus development process.

RESULTS

A substantial body of modifiable risk factors for cannabis use-related health harms were identified with varying evidence quality. Twelve substantive recommendation clusters and three precautionary statements were developed. In general, current evidence suggests that individuals can substantially reduce their risk for adverse health outcomes if they delay the onset of cannabis use until after adolescence, avoid the use of high-potency (THC) cannabis products and high-frequency/-intensity of use, and refrain from smoking-routes for administration. While young people are particularly vulnerable to cannabis-related harms, other sub-groups (e.g., pregnant women, drivers, older adults, those with co-morbidities) are advised to exercise particular caution with use-related risks. Legal/regulated cannabis products should be used where possible.

CONCLUSIONS

Cannabis use can result in adverse health outcomes, mostly among sub-groups with higher-risk use. Reducing the risk factors identified can help to reduce health harms from use. The LRCUG offer one targeted intervention component within a comprehensive public health approach for cannabis use. They require effective audience-tailoring and dissemination, regular updating as new evidence become available, and should be evaluated for their impact.

Applications of Cannabis Sativa L. in Food and Its Therapeutic Potential: From a Prohibited Drug to a Nutritional Supplement

Hemp (Cannabis sativa L.) is a herbaceous anemophilous plant that belongs to the Cannabinaceae family. The cannabis seed (hemp) has long been utilized as a food source and is commercially important as an edible oil source. In this review, the positive and negative health effects of cannabis, the relationship between cannabis and various diseases, and the use of cannabis in various food products have been discussed. In addition, the scientific literature on the potential use of cannabis and its derivatives as a dietary supplement for the prevention and treatment of inflammatory and chronic degenerative diseases in animals and humans has been reviewed. Cannabis is being developed as a key ingredient in a variety of food items, including bakery, confectionery, beverages, dairy, fruits, vegetables, and meat. Hemp seeds are high in readily digestible proteins, lipids, polyunsaturated fatty acids (PUFA), insoluble fiber, carbs, and favorable omega-6 PUFA acid to omega-3 PUFA ratio and have high nutritional value. The antioxidants of cannabis, such as polyphenols, help with anxiety, oxidative stress, and the risk of chronic illnesses, including cancer, neurological disorders, digestive problems, and skin diseases. Cannabis has been shown to have negative health impacts on the respiratory system, driving, and psychomotor functions, and the reproductive system. Overall, the purpose of this research is to stimulate more in-depth research on cannabis's adaptation in various foods and for the treatment of chronic illnesses.

Cannabis-Based Medicines and Medical Cannabis in the Treatment of Nociplastic Pain

Nociplastic pain is defined as pain due to sensitization of the nervous system, without a sufficient underlying anatomical abnormality to explain the severity of pain. Nociplastic pain may be manifest in various organ systems, is often perceived as being more widespread rather than localized and is commonly associated with central nervous system symptoms of fatigue, difficulties with cognition and sleep, and other somatic symptoms; all features that contribute to considerable suffering. Exemplified by fibromyalgia, nociplastic conditions also include chronic visceral pain, chronic headaches and facial pain, and chronic musculoskeletal pain. It has been theorized that dysfunction of the endocannabinoid system may contribute to persistent pain in these conditions. As traditional treatments for chronic pain in general and nociplastic pain in particular are imperfect, there is a need to identify other treatment options. Cannabis-based medicines and medical cannabis (MC) may hold promise and have been actively promoted by the media and advocacy. The medical community must be knowledgeable of the current evidence in this regard to be able to competently advise patients. This review will briefly explain the understanding of nociplastic pain, examine the evidence for the effect of cannabinoids in these conditions, and provide simplified guidance for healthcare providers who may consider prescribing cannabinoids for these conditions.

Marijuana Use and Stress Cardiomyopathy in the Young

Background

Increased accessibility, recreational use, and regional legalization of marijuana (cannabis) have been paralleled by widespread recognition of its serious cardiovascular complications (acute myocardial infarction, stroke, sudden death) particularly in the young. We aimed to examine trends in hospital admissions and outcomes of adults with stress cardiomyopathy (SC) in temporal relation to marijuana use.

Methods and results

A search of the 2003-2011 Nationwide Inpatient Sample (NIIS) database identified 33,343 admissions for SC of which 210 (0.06%) were temporally related to marijuana use. Demographics, clinical characteristics, and outcomes of marijuana users (MU) and non-marijuana users (NMU) with SC were compared. MU were younger (44±14 vs. 66±13 years), more often male (36% vs. 8%), and had lower prevalence of hypertension (38% vs. 62%), diabetes (2.4% vs. 17.6%), and hyperlipidemia (16% vs. 52%) while more often suffered from depression (33% vs. 15%), psychosis (12% vs. 4%), anxiety disorder (28% vs. 16%), alcohol use disorder (13% vs. 3%), tobacco use (73% vs. 29%), and polysubstance abuse (11% vs. 0.3%) [all p<0.001]. In addition, MU more often suffered a cardiac arrest and required placement of a defibrillator while congestive heart failure was more frequent in NMU. Logistic regression analysis on the entire database (n=71,753,900), adjusted for known risk factors for SC, identified marijuana use as an independent predictor of SC (OR=1.83; 95% CI=1.57-2.12, p<0.0001). Among MU, older age (>48 years) was a strong predictor of any major adverse cardiac event (OR=7.8; 95% CI=2.88-21.13; p<0.0001).

Conclusions

Marijuana use is linked to SC in younger individuals and is associated with significant morbidity despite being younger in age and having a more favorable cardiac risk factor profile in affected individuals.

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.

Marijuana Use and the Risk of Early Ischemic Stroke: The Stroke Prevention in Young Adults Study

BACKGROUND AND PURPOSE

Few studies have examined the dose-response and temporal relationships between marijuana use and ischemic stroke while controlling for important confounders, including the amount of tobacco smoking. The purpose of our study was to address these knowledge gaps.

METHODS

A population-based case-control study with 1090 cases and 1152 controls was used to investigate the relationship of marijuana use and early-onset ischemic stroke. Cases were first-ever ischemic stroke between the ages of 15 and 49 identified from 59 hospitals in the Baltimore-Washington region. Controls obtained by random digit dialing from the same geographic region were frequency-matched to cases by age, sex, region of residence and, except for the initial study phase, race. After excluding subjects with cocaine and other vasoactive substance use, the final study sample consisted of 751 cases and 813 controls. All participants underwent standardized interviews to characterize stroke risk factors and marijuana use. Unconditional logistic regression analysis was used to assess the relationships between marijuana use and risk of ischemic stroke, adjusting for age, sex, race, study phase, the amount of current tobacco smoking, current alcohol use, hypertension, and diabetes.

RESULTS

After adjusting for other risk factors, including the amount of current tobacco smoking, marijuana use was not associated with ischemic stroke, regardless of the timing of use in relationship to the stroke, including ever use, use within 30 days, and use within 24 hours. There was a nonsignificant trend towards increased stroke risk among those who smoked marijuana at least once a week (odds ratio, 1.9 [95% CI, 0.8-4.9]).

CONCLUSIONS

These analyses do not demonstrate an association between marijuana use and an increased risk of early-onset ischemic stroke, although statistical power was limited for assessing the association among very heavy users.

Pharmacological and Toxicological Effects of Phytocannabinoids and Recreational Synthetic Cannabinoids: Increasing Risk of Public Health

Synthetic Cannabinoids (CBs) are a novel class of psychoactive substances that have rapidly evolved around the world with the addition of diverse structural modifications to existing molecules which produce new structural analogues that can be associated with serious adverse health effects. Synthetic CBs represent the largest class of drugs detected by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) with a total of 207 substances identified from 2008 to October 2020, and 9 compounds being reported for the first time. Synthetic CBs are sprayed on natural harmless herbs with an aim to mimic the euphoric effect of Cannabis. They are sold under different brand names including Black mamba, spice, K2, Bombay Blue, etc. As these synthetic CBs act as full agonists at the CB receptors, they are much more potent than natural Cannabis and have been increasingly associated with acute to chronic intoxications and death. Due to their potential toxicity and abuse, the US government has listed some synthetic CBs under schedule 1 classification. The present review aims to provide a focused overview of the literature concerning the development of synthetic CBs, their abuse, and potential toxicological effects including renal toxicity, respiratory depression, hyperemesis syndrome, cardiovascular effects, and a range of effects on brain function.

The Endocannabinoid System and Cannabidiol: Past, Present, and Prospective for Cardiovascular Diseases

In the past, cannabis was commonly associated with mysticism and illegality. Fortunately, in recent years perspectives and discourses have changed. More prominence has been given to the rigorous scientific effort that led to the discovery of cannabis' many physiological actions and endogenous signalling mechanisms. The endocannabinoid system is a complex and heterogeneous pro-homeostatic network comprising different receptors with several endogenous ligands, numerous metabolic enzymes and regulatory proteins. Therefore, it is not surprising that alterations and dysfunctions of the endocannabinoid system are observed in almost every category of disease. Such high degree of pathophysiological involvement suggests the endocannabinoid system is a promising therapeutic target and prompted the translation of resurgent scientific findings into clinical therapies. Shifting attitudes toward cannabis also raised other matters such as increased patient awareness, prescription requests, self-medication, recreational use, recognition of new knowledge gaps, renewed scientific activity, and seemingly exponential growth of the cannabis industry. This review, following a general overview of cannabis and the endocannabinoid system, assiduously describes its role within the context of cardiovascular diseases, paying particular attention to the Janus influence that endocannabinoid system modulators can have on the cardiovascular system.

Cannabis use disorder among atrial fibrillation admissions, 2008-2018

BACKGROUND

Despite changes inthe legality of cannabis use and the increasing prevalence of cannabis use disorder (CUD), there is little data investigating the association between CUD and inpatient atrial fibrillation (AF) hospitalizations.

METHODS

Using the National Inpatient Sample, we identified Atrial Fibrillation (AF) hospitalizations with and without a codiagnosis of CUD using International Classification of Diseases diagnosis codes and compared demographics, socioeconomics, comorbidities, outcomes, and trends between cohorts.

RESULTS

Between 2008 and 2018, we identified 5,155,789 admissions for AF of which 31,768 (0.6%) had a codiagnosis of CUD. The proportion of admissions with a history of CUD increased from 0.3% in 2008 to 1.0% in 2018 (p < .001). Hospital discharges of patients with CUD were significantly younger (53 vs. 72 years, p < .001), had a higher proportion of black race (CUD: 26.6% vs. 8.0%, p < .001), and had a higher proportion of income in the lowest income quartile than without a codiagnosis of CUD (CUD: 40.5% vs. 26.2%, p < .001).

CONCLUSIONS

CUD is increasingly prevalent among AF hospitalizations, particularly among young patients. Codiagnosis of CUD in AF hospitalizations is also more common in underserved patients. As a result, it is important for future research to examine and understand the impact of CUD on this population, particularly in the light of changing legislation surrounding the legality of cannabis.

Reverse Takotsubo Cardiomyopathy Precipitated by Chronic Cocaine and Cannabis Use

This case report describes a 31-year-old man with 10 years of cocaine and cannabis dependence who developed reverse Takotsubo cardiomyopathy (rTC), a rare variant of Takotsubo cardiomyopathy. He presented to the Emergency Department (ED) with severe left temporal headache and vomiting which began whilst smoking cannabis and several hours after smoking methamphetamine and using cocaine via insufflation. Computed tomography and angiography of the brain was normal, and the headache resolved with analgesia. Urine drug screen was positive for benzodiazepines, cannabinoids, cocaine, opiates (attributed to morphine administered in ED) and amphetamines. Three hours later he had a seizure and within 10 min developed cardiogenic shock with antero-inferior ST segment depression on electrocardiogram and troponin-T rise to 126 ng/L. Coronary angiography demonstrated normal coronary arteries. Transthoracic echocardiogram demonstrated severely impaired left ventricular (LV) systolic function with ejection fraction 15-20% and hypokinesis sparing the apex. Thyrotoxicosis, nutritional, vasculitic, autoimmune and viral screens were negative. Cardiac magnetic resonance imaging demonstrated severe LV functional impairment with dilated and hypocontractile basal segments, and T2 hyperintensity consistent with myocardial oedema and rTC. He received supportive management. Proposed mechanisms of rTC include catecholamine cardiotoxicity and coronary artery vasospasm. In this case, multiple insults including severe headache, cannabis hyperemesis and cocaine and methamphetamine-induced serotonin toxicity culminated in a drug-induced seizure which led to catecholamine cardiotoxicity resulting in rTC. Clinicians should be cognizant of stress cardiomyopathy as a differential diagnosis in patients with substance use disorders.

Cannabis Use and Oral Health in a National Cohort of Adults

BACKGROUND

Cannabis use is common and increasing among adults. Evidence connects cannabis use to poor periodontal health, but few prospective studies exist of adults in the United States.

METHODS

This investigation examined associations between cannabis use and self-reported adverse oral health conditions among participants (N = 18,872) in the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative cohort. Survey-weighted regression modeling estimated associations between cannabis use and seven self-reported measures of oral health status, adjusted for tobacco use and other disease risk factors.

RESULTS

Reporting past-30-days cannabis use in any of PATH Waves 1-3 was positively and statistically significantly associated at Wave 4 with multiple periodontal disease sequalae and with self-rated fair or poor overall oral health (adjusted odds ratio versus never-users: 1.75; 95% confidence interval: 1.52, 2.01).

CONCLUSIONS

These findings provide further evidence that cannabis use is an independent risk factor for poor oral health, although study limitations (self-reported outcomes, limited information on cannabis use frequency and modality) must be considered.

PRACTICAL IMPLICATIONS

Dental professionals should engage patients in clear, nonjudgmental dialogue about cannabis use to address oral health risks and avoid potential patient safety issues in care delivery. General recommendations for addressing cannabis use in dental practice are presented.

Drugs of Abuse and Heart Failure

Substance use is common among those with heart failure (HF) and is associated with worse clinical outcomes. Alcohol, tobacco, cannabis, and cocaine are commonly abused substances that can contribute to the development and worsening of HF. Heavy alcohol consumption can lead to dilated cardiomyopathy, whereas moderate intake may decrease incident HF. Tobacco increases the risk of HF through coronary artery disease and coronary artery disease-independent mechanisms. Continued smoking worsens outcomes for those with HF and cessation is associated with an improved risk of major adverse cardiac events. Cannabis has complex interactions on the cardiovascular system depending on the method of consumption, amount consumed, and content of cannabinoids. Delta-9-tetrahydrocannabinol can increase sympathetic tone, cause vascular dysfunction, and may increase the risk of myocardial infarction. Cannabidiol is cardioprotective in preclinical studies and is a potential therapeutic target. Cocaine increases sympathetic tone and is a potent proarrhythmogenic agent. It increases the risk of myocardial infarction and can also lead to a dilated cardiomyopathy. The use of beta-blockers in those with HF and cocaine use is likely safe and effective. Future studies are needed to further elucidate the impact of these substances both on the development of HF and their effects on those who have HF.

Cannabinoids and myocardial ischemia: Novel insights, updated mechanisms, and implications for myocardial infarction

Cannabis is the most widely trafficked and abused illicit drug due to its calming psychoactive properties. It has been increasingly recognized as having potential health benefits and relatively less adverse health effects as compared to other illicit drugs; however, growing evidence clearly indicates that cannabis is associated with considerable adverse cardiovascular events. Recent studies have linked cannabis use to myocardial infarction (MI); yet, very little is known about the underlying mechanisms. A MI is a cardiovascular disease characterized by a mismatch in the oxygen supply and demand of the heart, resulting in ischemia and subsequent necrosis of the myocardium. Since cannabis is increasingly being considered a risk factor for MI, there is a growing need for better appreciating its potential health benefits and consequences. Here, we discuss the cellular mechanisms of cannabis that lead to an increased risk of MI. We provide a thorough and critical analysis of cannabinoids' actions, which include modulation of adipocyte biology, regional fat distribution, and atherosclerosis, as well as precipitation of hemodynamic stressors relevant in the setting of a MI. By critically dissecting the modulation of signaling pathways in multiple cell types, this paper highlights the mechanisms through which cannabis may trigger life-threatening cardiovascular events. This then provides a framework for future pharmacological studies which can identify targets or develop drugs that modulate cannabis' effects on the cardiovascular system as well as other organ systems. Cannabis' impact on the autonomic outflow, vascular smooth muscle cells, myocardium, cortisol levels and other hemodynamic changes are also mechanistically reviewed.

Cannabis Abuse and Perioperative Complications Following Inpatient Spine Surgery in the United States

MINI

Due to its complicated legal status, the effects of cannabis on elective spine surgery patients have not been well studied. In this nationwide analysis, we find that cannabis abuse is associated with higher perioperative thromboembolism and neurologic complications, respiratory complications, sepsis, length of stay, hospital charges, and rates of unfavorable discharge disposition.