A Clinical Framework for Evaluating Cannabis Product Quality and Safety

Use of artisanal and non-regulated cannabis-based products for the treatment of epilepsy in a low-income population

INTRODUCTION

Several artisanal and non-regulated cannabis-based products used for the treatment of epilepsy are available and can be easily obtained. Many of these preparations lack proper quality validation and exhibit cannabinoid contents significantly different from those stated on their labels, along with the presence of potentially harmful compounds. This study aims to evaluate the frequency of use and prescription patterns of these products among patients with epilepsy from a low-income population.

METHODS

Observational and cross-sectional study. A survey was conducted on patients with epilepsy at a public hospital in Bogotá, Colombia.

RESULTS

A total of 380 patients were evaluated, with 10.3 % (n = 39) reporting the use of artisanal and non-regulated cannabis-based products for the treatment of epilepsy. Among these patients, 84.6 % (n = 33) used the product on their own initiative, without a medical recommendation. Only 7.7 % (n = 3) of the patients had a record of the consumption of these products in their medical history. Age (p = 0.002), type of therapeutic response (p = 0.01), number of previous antiseizure medications used (p < 0.01), and non-pharmacological treatment such as vagal nerve stimulation (p < 0.01) showed a statistically significant association with the utilization of these products.

CONCLUSION

One in ten patients with epilepsy has used artisanal and non-regulated cannabis-based products for the treatment of their condition. The majority of patients used these products on their own initiative, without a medical recommendation. The prevalence of consuming these products was higher among younger individuals with uncontrolled epilepsy, who had previously used multiple antiseizure medications and other non-pharmacological alternatives such as vagal nerve stimulation.

Comparative restriction enzyme analysis of methylation (CREAM) reveals methylome variability within a clonal in vitro cannabis population

The primary focus of medicinal cannabis research is to ensure the stability of cannabis lines for consistent administration of chemically uniform products to patients. In recent years, tissue culture has emerged as a valuable technique for genetic preservation and rapid multiplication of cannabis clones. However, there is concern that the physical and chemical conditions of the growing media can induce somaclonal variation, potentially impacting the viability and uniformity of clones. To address this concern, we developed Comparative Restriction Enzyme Analysis of Methylation (CREAM), a novel method to assess DNA methylation patterns and used it to study a population of 78 cannabis clones maintained in tissue culture. Through bioinformatics analysis of the methylome, we successfully detected 2,272 polymorphic methylated regions among the clones. Remarkably, our results demonstrated that DNA methylation patterns were preserved across subcultures within the clonal population, allowing us to distinguish between two subsets of clonal lines used in this study. These findings significantly contribute to our understanding of the epigenetic variability within clonal lines in medicinal cannabis produced through tissue culture techniques. This knowledge is crucial for understanding the effects of tissue culture on DNA methylation and ensuring the consistency and reliability of medicinal cannabis products with therapeutic properties. Additionally, the CREAM method is a fast and affordable technology to get a first glimpse at methylation in a biological system. It offers a valuable tool for studying epigenetic variation in other plant species, thereby facilitating broader applications in plant biotechnology and crop improvement.

Cannabis vaporisation: Understanding products, devices and risks

ISSUES

Vaporisation is a common method of cannabis administration. Inconsistent terminology and jargon regarding vaporisation has led to confusion. The increasing public interest and access to cannabis, combined with possible safety concerns associated with certain cannabis vaping products, warrants improved consumer and public and health care professional knowledge.

APPROACH

To improve this knowledge, we conducted a review of the common terminology, regulatory status, products and device types related to cannabis vaporisation.

KEY FINDINGS

Cannabis vaporisation devices can be separated into nine types. While vaporisation reduces respiratory risks associated with cannabis combustion, not all vaping products and device types carry the same level of safety. Metered dose inhalers and dried product vaporisers present the lowest safety risk due to a lower risk of toxin exposure and the use of lower tetrahydrocannabinol potency products.

IMPLICATIONS

As both vaping and cannabis use increase in popularity, focusing on accurate health education will help facilitate health promotion to encourage lower risk use. The current lack of understanding on risk differences between types of cannabis vaporisation is a missed opportunity for harm reduction. Increased opportunities for public health and health care professional education on different cannabis vaporisation devices and associated risks are warranted. Improvements to health warning labelling may also be beneficial.

CONCLUSION

Not all cannabis vaporisation devices and products carry the same level of risk. A better understanding of risk differentiation is needed among consumers and health professionals. Continued research, policy development and health education can lead to safer cannabis vaporisation.

Clinical Application of Cannabis Vaporization: Examining Safety and Best Practices

Introduction: Cannabis vaporization is useful for individuals requiring fast-acting method of cannabis administration and for individuals using smoked cannabis as a harm reduction tool. There is a need for guidance on how to assess if a patient is a vaporization candidate and how to safely initiate and monitor cannabis vaporization. Methods: An overview of safe cannabis vaporization, including practical guidance and tactics to promote the lowest-risk use, is provided. This review was developed through a combination of expert clinical opinion and reviewing the available literature. Results: Dried cannabis vaporizers and metered-dose inhalers are recommended to be used over other vaporization devices. Assessing the benefit versus risks of vaporized cannabis and providing guidance for choosing a vaporization device, choosing a cannabis chemovar, and employing a mindful vaping technique are important steps in the safe utilization of vaporized cannabis. Dosing optimization and monitoring to limit adverse events and improve symptom control are essential. Discussion: The utilization of cannabis vaporization presents an important opportunity for clinicians and other health professionals to help facilitate safer cannabis administration and reduce the prevalence of smoked cannabis.

The Dark Side of Cannabidiol: The Unanticipated Social and Clinical Implications of Synthetic Δ8-THC

Introduction: The explosive growth of the cannabis industry in the United States over the past decade has spurred a multitude of products derived from phytocannabinoids produced by Cannabis sativa L. Decades of cannabis prohibition coupled with the more recent 2018 Farm Bill have lead to several unanticipated consequences and the widespread availability of synthetic cannabinoids derived from hemp CBD, including Δ8-THC, Δ10-THC and HHC. Methods: Herein, we review the available literature of the complexity of the chemistry of its current manufacture, namely, the acid-catalyzed ring closure of cannabidiol (ACRCC), the myriad of issues involving the unsolved technical problems with quality control of ACRCC-Δ8-THC and the multitude of isomerized byproducts, and the lack of consistent regulation regarding consumer safety and labeling. Results: We provide what we believe is the first comprehensive listing of all the documented ACRCC-Δ8-THC byproducts. Perhaps, most importantly, we highlight the growing concern that, other than Δ8-THC itself, the compounds in ACRCC-Δ8-THC product mixtures have not been subjected to any human toxicological evaluation. This is especially troubling as ACRCC-Δ8-THC products relate to vaping, and their contribution to a growing and lethal epidemic of electronic cigarette, or vaping, product use-associated lung injury (EVALI). Conclusions: Quality control is totally inadequate in the newly emerging Δ8-THC industry. American consumers are ingesting products that are mislabeled with many compounds that have never received any toxicological testing. EVALI cases continue to be reported with a fatality rate approaching 2% (in California).

A Clinical Framework for Assessing Cannabis-Related Impairment Risk

Clinicians play an important role in promoting safe and responsible medical cannabis use. One essential component to safe use is considering a patient's risk of neurocognitive impairment. However, there remains a lack of practical guidance on how clinicians can evaluate this risk for medical cannabis patients. Here, a practical framework is presented for clinicians to assess and stratify cannabis-associated impairment risk. The proposed framework is intended to practically guide healthcare providers in gaining a more comprehensive review of a patient's impairment-related factors. This framework can be used to assess impairment risk for patients currently using or considering medical cannabis and is recommended for all patients who perform safety-sensitive duties. Healthcare providers (HCP) managing patient's medical cannabis or those conducting assessments to determine risk of impairment for safety-sensitive workplaces can utilize this framework to stratify patients' risk of impairment. Such assessments can inform patient-specific needs for support, education, and guidance, to ensure cannabis is used safely and responsibly.