Cannabis contaminants: sources, distribution, human toxicity and pharmacologic effects

"Like the Wild West": Health care provider perspectives on impacts of recreational cannabis legalization on patients and providers at a tertiary psychiatric hospital in Ontario, Canada

INTRODUCTION

Legalization has increased cannabis availability in Canada. Research shows complex relationships between cannabis use and mental health, and a need for health care providers to engage with patients about cannabis use. Providers have noted gaps in knowledge and research on the medical effects of cannabis as barriers to service delivery. It is unclear how providers and patients in mental health care settings have been impacted by legalization.

METHODS

From June 1 to July 2, 2021, we conducted a qualitative study involving semi-structured interviews with 20 health care providers in a range of roles (e.g., physicians, pharmacists, nurses) within a psychiatric hospital setting. Participants responded to open-ended questions with follow-up probes on various topics related to cannabis legalization. Topics included impacts on patient mental and physical health, clinical impacts, education and training, legal cannabis retail system and the medical cannabis access system.

RESULTS

Thematic analysis identified several themes in the data. Participants reported that legalization has had some positive impacts relating to clinical care and cannabis safety. They also expressed concerns with increased rates of cannabis use, risks to mental health and ongoing challenges engaging with patients about cannabis. Participants made recommendations for medical educators and regulators (e.g., updated curriculums, clinical guidelines), the mental health care sector (e.g., implementation of standardized screening), government (e.g., public health campaigns, safe use guidelines), the medical cannabis access system (e.g., increased regulation, research), and the legal cannabis system (e.g., zoning changes, point-of-sale information).

CONCLUSIONS

This study begins to address the paucity of data on impacts of legalization from mental health service delivery settings. Findings show that although legalization has had some positive impacts, there are ongoing patient concerns and unmet provider needs. More research is needed to understand the experiences of providers delivering care to populations experiencing mental health and/or substance use concerns who use cannabis in the post-legalization era.

Exclusive Therapeutic Use of Cannabis in a Large Sample of Daily Cannabis Users in France: A Cross-Sectional Survey

Many cannabis users report therapeutic benefits from cannabis consumption, even when not recommended by a physician. To date, few data on therapeutic users of cannabis in France are available. Using a cross-sectional survey held in 2020, we collected sociodemographic, health and substance use data from 4150 daily cannabis users in France. We used multivariable logistic regression to assess factors associated with exclusive therapeutic use of cannabis. Approximately 10% (n = 453) of the participants reported using cannabis exclusively for therapeutic purposes. Exclusive therapeutic users of cannabis differed from non-exclusive (i.e. recreational and mixed) users, especially regarding age (aOR [95%CI] = 1.01 [1.00-1.02]), employment (aOR = 0.61 [0.47-0.79]), urban area of residence (aOR = 0.75 [0.60-0.94]), physical (aOR = 2.95 [2.34-3.70]) and mental health condition (aOR = 2.63 [1.99-3.49]), mode of cannabis administration (non-smoked, aOR = 1.89 [1.22-2.95); smoked with little tobacco, aOR = 1.39 [1.09-1.76]), frequency of cannabis use (aOR = 1.04 [1.01-1.06]), home cultivation (aOR = 1.56 [1.13-2.15]), at-ridsk alcohol use (aOR = 0.68 [0.54-0.84]), and previous-month opiate use (aOR = 1.67 [1.22-2.30]). A greater understanding of the distinct profiles of regular cannabis users could inform harm reduction strategies and care access for this population. Further studies are needed to better understand the boundaries between therapeutic and recreational use.

'The wild west of medicine': A qualitative investigation of the factors influencing Australian health-care practitioners' delivery of medicinal cannabis

INTRODUCTION

Strong patient interest in the use of medicinal cannabis to treat various clinical indications has sparked global legislative changes. Practitioners are vital in implementing regulatory changes and facilitating patient access to medicinal cannabis, however, little is currently known about the factors influencing practitioners' uptake. Recent rapid increases in practitioner applications to prescribe medicinal cannabis in Australia provides a unique backdrop to examine the current factors influencing prescribing behaviours. This qualitative study examined Australian practitioners' perspectives on prescribing medicinal cannabis to provide a comprehensive exploration of the potential factors influencing uptake in clinical practice.

METHODS

Seventeen semi-structured interviews were conducted with Australian health-care practitioners. Transcripts were analysed using the Framework approach to thematic analysis and cross-mapped to appropriate domains of the Theoretical Domains Framework.

RESULTS

We identified four themes related to the barriers and facilitators to prescribing medicinal cannabis: (i) clinical capabilities needed to prescribe; (ii) prescribing an unapproved therapeutic good; (iii) negative attitudes towards prescribers in the medical community; and (iv) divergent beliefs about clinical utility.

DISCUSSION AND CONCLUSIONS

Practitioners face multiple pervasive barriers to prescribing medicinal cannabis. Beliefs about clinical utility appear to be highly influential in shaping prescribing behaviours. Moreover, our findings suggest that a medicinal cannabis 'specialisation' has emerged within the Australian medical community. Findings demonstrate that a range of complex and multifaceted factors influence practitioners' medicinal cannabis prescribing behaviours. We highlight several considerations for policy and practice to support safe and appropriate patient access to medicinal cannabis in this emerging area of clinical practice.

Cannabinoid products for pain management: recommendations from the São Paulo State Society of Anesthesiology

There is growing interest in using cannabinoids across various clinical scenarios, including pain medicine, leading to the disregard of regulatory protocols in some countries. Legislation has been implemented in Brazil, specifically in the state of São Paulo, permitting the distribution of cannabinoid products by health authorities for clinical purposes, free of charge for patients, upon professional prescription. Thus, it is imperative to assess the existing evidence regarding the efficacy and safety of these products in pain management. In light of this, the São Paulo State Society of Anesthesiology (SAESP) established a task force to conduct a narrative review on the topic using the Delphi method, requiring a minimum agreement of 60% among panelists. The study concluded that cannabinoid products could potentially serve as adjuncts in pain management but stressed the importance of judicious prescription. Nevertheless, this review advises against their use for acute pain and cancer-related pain. In other clinical scenarios, established treatments should take precedence, particularly when clinical protocols are available, such as in neuropathic pain. Only patients exhibiting poor therapeutic responses to established protocols or demonstrating intolerance to recommended management may be considered as potential candidates for cannabinoids, which should be prescribed by physicians experienced in handling these substances. Special attention should be given to individual patient characteristics and the likelihood of drug interactions.

Interconnected environmental challenges: heavy metal-drug interactions and their impacts on ecosystems

Industrial expansion and inadequate environmental safety measures are major contributors to environmental contamination, with heavy metals (HMs) and pharmaceutical waste playing crucial roles. Their negative effects are most noticeable in aquatic species and vegetation, where they accumulate in tissues and cause harmful results. Interactions between HMs and pharmaceutical molecules result in the production of metal-drug complexes (MDCs), which have the potential to disturb diverse ecosystems and their interdependence. However, present studies frequently focus on individual pollutants and their effects on specific environmental parameters, leaving out the cumulative effects of pollutants and their processes across several environmental domains. To address this gap, this review emphasizes the environmental sources of HMs, elucidates their emission pathways during anthropogenic activities, investigates the interactions between HMs and pharmaceutical substances, and defines the mechanisms underlying the formation of MDCs across various ecosystems. Furthermore, this review underscores the simultaneous occurrence of HMs and pharmaceutical waste across diverse ecosystems, including the atmosphere, soil, and water resources, and their incorporation into biotic organisms across trophic levels. It is important to note that these complex compounds represent a higher risk than individual contaminants.

Product labeling accuracy and contamination analysis of commercially available cannabidiol product samples

Background and objective: Commercially available cannabidiol (CBD) products are increasingly being used for medicinal purposes, including for the treatment of various neurological conditions, but there are growing concerns around adherence to quality control measures that protect consumers. This study was conducted to assess the purity and label accuracy of commercially available CBD products. Methods: Commercially available CBD products were chosen from the open stream of commerce in the United States based on formulations as a tincture, gummy, vape, or topical product. Cannabinoid concentrations were analyzed to verify label accuracy including "full spectrum," "broad spectrum," and "CBD isolate" claims on the product label. Analysis for the presence of contaminants included evaluation for heavy metals, pesticides, and residual solvents. Labeled and actual total amounts of CBD and levels of impurities such as heavy metals, residual solvents, and pesticides were measured. Results: A total of 202 CBD products (100 tinctures, 48 gummies, 34 vape products, and 20 topicals) were chosen to represent a broad sample in the United States. Of the products tested (full spectrum, n = 84; broad spectrum, n = 28; CBD isolate, n = 37), 26% did not meet the definition for product type claimed on the packaging. The majority of products (74%) deviated from their label claim of CBD potency by at least 10%. Heavy metals were detected 52 times across 44 of the 202 products tested, with lead being the most prevalent heavy metal. Residual solvents were detected 446 times across 181 of 202 products, with the highest concentrations reported for hexane, m/p-xylene, methanol, and o-xylene. Of 232 pesticides tested, 26 were found 55 times across 30 products. A total of 3% of heavy metals, 1% of residual solvents, and 1% of pesticides violated >1 regulatory threshold. Discussion: This study demonstrated that the majority of commercially available CBD products tested within the current study are inaccurately labeled. Heavy metals, residual solvents, and pesticides were found in several products, some of which violated regulatory thresholds. Thus, uniform compliance with CBD quality control measures is lacking and raises consumer protection concerns. Improved regulatory oversight of this industry is recommended.

Analytical techniques for screening of cannabis and derivatives from human hair specimens

Cannabis and associated substances are some of the most frequently abused drugs across the globe, mainly due to their anxiolytic and euphorigenic properties. Nowadays, the analysis of hair samples has been given high importance in forensic and analytical sciences and in clinical studies because they are associated with a low risk of infection, do not require complicated storage conditions, and offer a broad window of non-invasive detection. Analysis of hair samples is very easy compared to the analysis of blood, urine, and saliva samples. This review places particular emphasis on methodologies of analyzing hair samples containing cannabis, with a special focus on the preparation of samples for analysis, which involves screening and extraction techniques, followed by confirmatory assays. Through this manuscript, we have presented an overview of the available literature on the screening of cannabis using mass spectroscopy techniques. We have presented a detailed overview of the advantages and disadvantages of this technique, to establish it as a suitable method for the analysis of cannabis from hair samples.

Trace element levels: How Substance Use Disorder (SUD) contributes to the alteration of urinary essential and toxic element levels

Increasing illicit drug use is one of the main problems in most countries or societies. Monitoring heavy metals and trace elements in this vulnerable group seems to be necessary. Therefore, we assessed the urinary trace element and toxic metals/metalloids concentrations (Zinc (Zn), Iron (Fe), Copper (Cu), Chromium (Cr), Lead (Pb), Cadmium (Cd), Arsenic (As), Nickel (Ni), and Mercury (Hg)) in opium, tramadol, and cannabis users compared to healthy subjects. In this cross-sectional study, patients with substance use disorder (SUD) (n = 74) were divided into four groups: cannabis, tramadol, opium, and mixed (simultaneous use of more than one of the three studied substances), along with a healthy group (n = 60). Urine samples were prepared by dispersive liquid-liquid microextraction method so that heavy metals/metalloids could be measured by ICP-MS. The mean urinary concentration of Cu (48.15 vs. 25.45; 89.2%, p<0.001), Hg (1.3 vs. 0.10; 1200%, p < 0.001), and Zn (301.95 vs. 210; 43.8%, p < 0.001) was markedly lower among patients with SUD. The mean urinary concentration of other elements including As (1.9 vs. 4.1; 115.8%), Cd (0.1 vs. 1.10; 1000%), Cr (6.80 vs. 11.65; 71.3%), Ni (2.95 vs. 4.95; 67.8%), and Pb (1.5 vs. 7.9; 426.6%) were significantly higher among patients with SUD compared to healthy subjects. When sub-groups were compared, no significant differences were observed between their trace element levels (Kruskal-Wallis test, p > 0.05). This can be an indication that regardless of the type of drug, the levels of trace elements are changed with respect to healthy individuals. Our results showed that illicit drug use causes changes in urinary trace element/heavy metal/metalloid levels and highlights the need for monitoring heavy metals and trace elements in individuals with substance use disorder. Assessment of different elements in biological samples of drug dependents may be useful for implementing new prevention and treatment protocols. In case of changes in their levels, complementary recommendations, attention to diet, and periodic assessment of toxic metal levels within treatment programs will be needed.

External hair contamination from cannabis and "light cannabis" delivered by smoking and vaping: An in vitro study

External contamination of hair by cannabis smoking requires a careful evaluation in forensic toxicology. Medical and recreational cannabis are increasingly consumed by e-cigarettes, which give rise to side-stream vapor. Moreover, products containing low Δ9-tetrahydrocannabinol (Δ9-THC) and rich in cannabidiol (CBD) started spreading legally. The goal of the present study was to assess whether hair analysis could allow to distinguish the type of delivered product, with low or high Δ9-THC, and the delivering mode, by smoking or vaping. Contamination of blank hair was mimicked by in vitro exposure to low- (0.4%) and high-Δ9-THC (9.7%) products delivered by smoking and vaping within a small confined system. Cannabis vaping extracts were prepared to deliver identical target Δ9-THC doses. Eighty samples were analyzed by ultrahigh-performance liquid chromatography mass spectrometry and quantified for Δ9-THC and CBD. After contamination by cannabis smoking, THC levels were in line with past in vitro and in vivo studies. Samples exposed to cannabis (169.30 ng/mg) showed significantly higher Δ9-THC than hair exposed to "light cannabis" (35.54 ng/mg), and the opposite was seen for the CBD/Δ9-THC ratio. Hair contaminated by vaping or smoking did not show a statistically different Δ9-THC content. Under our in vitro conditions, hair analysis might allow to discriminate whether external contamination is determined by products containing low or high Δ9-THC, but not the delivering mode. More research is needed in real-life conditions, to see whether the same also applies to the interpretation of forensic casework.

Cigarette Smoking, Risky Alcohol Consumption, and Marijuana Smoking among University Students in Germany: Identification of Potential Sociodemographic and Study-Related Risk Groups and Predictors of Consumption

(1) Background: Cigarette smoking, risky alcohol consumption, and marijuana smoking are the most common behaviors related to legal and illicit drug use worldwide, including among university students. To plan effective evidence-based programs to prevent the risky consumption of these substances among university students, the present study aimed to identify potential sociodemographic and study-related risk groups and predictors of consumption. (2) Methods: A cross-sectional online health survey with approximately 270 health-related items was conducted among students at the University of Mainz, Germany. Cigarette smoking, risky alcohol consumption (AUDIT-C score: female ≥ 4, male ≥ 5), and marijuana smoking were chosen as dependent variables. Of the 270 health-related items, 56 were chosen as independent variables and collated into five groups (sociodemographic, psychological, study-related psychosocial, general psychosocial and health behavior). The prevalence of cigarette smoking, risky alcohol consumption, and marijuana smoking was assessed using established and validated instruments. Pearson's chi-square test was used to analyze the differences in prevalence between the sociodemographic and study-related groups, and binary logistic regression was used for analyses with stepwise inclusion of the five variable groups. (3) Results: Of the 3991 university students who entered the analyses, 14.9% reported smoking cigarettes, 38.6% reported risky alcohol consumption, and 10.9% reported smoking marijuana. The prevalence of these differed between genders, fields of study, and aspired degree level, among other factors. Binary logistic regression analyses revealed nine significant predictors (p ≤ 0.05) of cigarette smoking (Nagelkerke R2 = 0.314), 18 significant predictors of risky alcohol consumption (Nagelkerke R2 = 0.270), and 16 significant predictors of marijuana smoking (Nagelkerke R2 = 0.239). (4) Conclusions: This study showed cigarette smoking, risky alcohol consumption, and marijuana smoking among university students in Germany to be associated with multiple factors, especially health behaviors. Furthermore, each of the substances was highly associated with each of the two other substances we examined. Other variable groups, such as psychological or psychosocial variables, seemed to play a rather minor role. Therefore, our recommendation for future prevention programs is that substance use among university students should be addressed as a whole, not just in terms of specific substances.

Blood-lead level in humans and drug addiction: a comprehensive study in Iran

Drug abuse has a high prevalence worldwide and causes many health-related disorders. There are limited human exposure studies on establishing lead exposure levels and their propensity for drug addiction. In the present study, blood samples were tested for lead (Pb) concentrations in illicit drug users together with the related symptoms in comparison with control group of non-drug users. The study was performed on 250 volunteers divided equally in four drug groups, namely, opioids, hashish, methadone, and methamphetamine, and one control group of non-drug users. Participants were recruited from drug addiction clinics and camps in Kashan city, Iran, who were using drugs continuously for more than 1 year. Control group was recruited from companions of the patients with no drug use history. In the investigated groups of drug users, the highest blood-lead level (BLL) concentrations were observed in the opioid group (mean 37.57 µg/dL) with almost 3.7 times higher than in the control group (mean 3.39 µg/dL). In the methamphetamine group, type of occupation had the significant association with BLL concentrations. The positive correlation was revealed in the opioid and methadone groups for BLL concentrations and the duration of drug usage. In the opioid group, the highest BLL concentrations were observed among users who used both methods of drug use: smoking and eating. Also, several behavioral and life-style factors were identified which influence the blood-lead concentration in the drug users. The results of our study revealed that the BLL concentrations in investigated drug users' groups were significantly higher than in the control group (P < 0.001). That can be related with the Pb contents in illicitly used drugs. Apart other adverse health effects, long-term illicit drug use might cause to lead poisoning.

Using Detached Industrial Hemp Leaf Inoculation Assays to Screen for Varietal Susceptibility and Product Efficacy on Botrytis cinerea

In greenhouse production, grey mould caused by Botrytis cinerea Pers. is one of the most widespread and damaging diseases affecting medicinal cannabis (MC). Fungicide options to control this disease are extremely limited due to the regulations surrounding fungicides and chemical residues as the product end users are medical patients, often with compromised immune systems. Screening for alternative disease control options, such as biological and organic products, can be time-consuming and costly. Here, we optimise and validate a detached leaf assay as a quick and non-destructive method to evaluate interactions between plants and pathogens, allowing the assessment of potential pathogens' infectivity and product efficacy. We tested eight industrial hemp varieties for susceptibility to B. cinerea infection. Using detached leaves from a susceptible variety, we screened a variety of chemical or organic products for efficacy in controlling the lesion development caused by B. cinerea. A consistent reduction in lesion growth was observed using treatments containing Tau-fluvalinate and Myclobutanil, as well as the softer chemical alternatives containing potassium salts. The performance of treatments was pH-dependent, emphasizing the importance of applying them at optimal pH levels to maximise their effectiveness. The detached leaf assay differentiated varietal susceptibility and was an effective method for screening treatment options for diseases caused by Botrytis. The results from the detached leaf assays gave comparable results to responses tested on whole plants.

The Exploration of Cannabis and Cannabinoid Therapies for Migraine

PURPOSE OF REVIEW

There is increasing interest in the use of cannabis and cannabinoid therapies (CCT) by the general population and among people with headache disorders, which results in a need for healthcare professionals to be well versed with the efficacy and safety data. In this manuscript, we review cannabis and cannabinoid terminology, the endocannabinoid system and its role in the central nervous system (CNS), the data on efficacy, safety, tolerability, and potential pitfalls associated with use in people with migraine and headache disorders. We also propose possible mechanisms of action in headache disorders and debunk commonly held myths about its use.

RECENT FINDINGS

Preliminary studies show that CCT have evidence for the management of migraine. While this evidence exists, further randomized, controlled studies are needed to better support its clinical use. CCT can be considered an integrative treatment added to mainstream medicine for people with migraine who are refractory to treatment and/or exhibit disability and/or interest in trying these therapies. Further studies are warranted to specify appropriate formulation, dosage, and indication(s). Although not included in guidelines or the AHS 2021 Consensus Statement on migraine therapies, with the legalization of CCT for medical or unrestricted use across the USA, recent systematic reviews highlighting the preliminary evidence for its use in migraine, it is vital for clinicians to be well versed in the efficacy, safety, and clinical considerations for their use. This review provides information which can help people with migraine and clinicians who care for them make mutual, well-informed decisions on the use of cannabis and cannabinoid therapies for migraine based on the existing data.

Appetite stimulation with cannabis-based medicine and methods for assessment of glomerular filtration in older patients with medical illness: A study protocol

BACKGROUND AND AIM

Malnutrition in older patients is linked to poor appetite. Cannabis-based medicine may have orexigenic properties in older patients, but this has to our knowledge never been investigated. In older patients, uncertainty applies to the accuracy of estimated glomerular filtration rate (eGFR) based on creatinine, which is crucial for medication prescribing. In older patients with poor appetite, the study aims (1) to assess the efficacy of Sativex® (8.1-mg delta-9-tetrahydrocannabinol [THC] and 7.5-mg cannabidiol [CBD]) to stimulate appetite and (2) to compare the performance of various GFR-estimates and measured-GFR (mGFR) for determining gentamicin clearance utilizing population pharmacokinetic (popPK) modelling methods.

METHODS AND OBJECTIVES

This study is composed of two substudies. Substudy 1 is an investigator-initiated single-center, double-blinded, randomized, placebo-controlled, superiority, cross-over study. Substudy 1 will recruit 17 older patients with poor appetite, who will also be invited to substudy 2. Substudy 2 is a single-dose pharmacokinetics study and will recruit 55 patients. Participants will receive Sativex® and placebo in substudy 1 and gentamicin with simultaneous measurements of GFR in substudy 2. The primary endpoints are as follows: Substudy 1-the difference in energy intake between Sativex® and placebo conditions; substudy 2- the accuracy of different eGFR equations compared to mGFR. The secondary endpoints include safety parameters, changes in the appetite hormones, total ghrelin and GLP-1 and subjective appetite sensations, and the creation of popPK models of THC, CBD, and gentamicin.

Clinical outcome data of anxiety patients treated with cannabis-based medicinal products in the United Kingdom: a cohort study from the UK Medical Cannabis Registry

RATIONALE

Cannabis-based medicinal products (CBMPs) have been identified as novel therapeutics for generalised anxiety disorder (GAD) based on pre-clinical models; however, there is a paucity of high-quality evidence on their effectiveness and safety.

OBJECTIVES

This study aimed to evaluate the clinical outcomes of patients with GAD treated with dried flower, oil-based preparations, or a combination of both CBMPs.

METHODS

A prospective cohort study of patients with GAD (n = 302) enrolled in the UK Medical Cannabis Registry prescribed oil or flower-based CBMPs was performed. Primary outcomes were changes in generalised anxiety disorder-7 (GAD-7) questionnaires at 1, 3, and 6 months compared to baseline. Secondary outcomes were single-item sleep quality scale (SQS) and health-related quality of life index (EQ-5D-5L) questionnaires at the same time points. These changes were assessed by paired t-tests. Adverse events were assessed in line with CTCAE (Common Terminology Criteria for Adverse Events) v4.0.

RESULTS

Improvements in anxiety, sleep quality and quality of life were observed at each time point (p < 0.001). Patients receiving CBMPs had improvements in GAD-7 at all time points (1 month: difference -5.3 (95% CI -4.6 to -6.1), 3 months: difference -5.5 (95% CI -4.7 to -6.4), 6 months: difference -4.5 (95% CI -3.2 to -5.7)). Thirty-nine participants (12.9%) reported 269 adverse events in the follow-up period.

CONCLUSIONS

Prescription of CBMPs in those with GAD is associated with clinically significant improvements in anxiety with an acceptable safety profile in a real-world setting. Randomised trials are required as a next step to investigate the efficacy of CBMPs.

Early onset frontotemporal dementia following cannabis abuse: a case report

BACKGROUND

Frontotemporal disorders (FTD) are the consequence of impairment to neurons in the frontal and temporal lobes of the brain. Also, no definitive treatment has been found for FTD. Cannabinoid products can be used to manage treatment-resistant behavioral variants of Frontotemporal dementia (bvFTD).

CASE PRESENTATION

We describe the case of 34 years old male with two years of marijuana abuse. At first, he presented with symptoms of apathy and bizarre behavior, which became more severe, and led to disinhibition. The clinical symptoms and imaging findings made FTD probable for him, which was very interesting to report.

CONCLUSIONS

While cannabis has demonstrated potential in managing behavioral and mental symptoms of dementia, the presented case highlights the profound impact of cannabis consumption on brain structure and chemistry, including the potential for neurodegenerative disorders like FTD.

Reasonable access: important characteristics and perceived quality of legal and illegal sources of cannabis for medical purposes in Canada

BACKGROUND

Throughout the past two decades of legal medical cannabis in Canada, individuals have experienced challenges related to accessing legal sources of cannabis for medical purposes. The objective of our study was to examine the sources of cannabis accessed by individuals authorized to use medical cannabis and to identify possible reasons for their use of illegal sources.

METHODS

Individuals who participated in the Cannabis Access Regulations Study (CANARY), a national cross-sectional survey launched in 2014, and indicated they were currently authorized to use cannabis for medical purposes in Canada were included in this study. We assessed differences between participants accessing cannabis from only legal sources versus from illegal sources in relation to sociodemographic characteristics, health-related factors, and characteristics of medical cannabis they considered important. A secondary analysis assessed differences in satisfaction with various dimensions of cannabis products and services provided by legal versus illegal sources.

RESULTS

Half of the 237 study participants accessed cannabis from illegal sources. Individuals accessing cannabis from illegal sources were significantly more likely to value pesticide-free products, access to a variety of strains, ability to select strain and dosage, ability to observe and smell cannabis, availability in a dispensary, and availability in small quantities than did individuals accessing cannabis from only legal sources (all p < 0.05). Additionally, participants gave significantly higher satisfaction scores to illegal sources than to legal sources on service-related dimensions of cannabis access (all p < 0.05).

CONCLUSION

Our findings contribute to an understanding of reasonable access to medical cannabis from a patient perspective and how to assess whether it has been achieved. Characteristics of cannabis products and services valued by patients and appropriate to their needs should be incorporated into legal medical cannabis programs to promote the use of legal medical sources. While pertaining specifically to medical use of cannabis in Canada, the findings of this study may also be instructive for understanding the use of illegal cannabis sources for non-medical purposes in Canada and provide insight for other jurisdictions implementing cannabis regulations for both medical and non-medical purposes.

Medicinal Cannabis Guidance and Resources for Health Professionals to Inform Clinical Decision Making

PURPOSE

Interest in the use of cannabis as a medicine has markedly increased during the last decade, with an unprecedented number of patients now seeking advice or prescriptions for medicinal cannabis. Unlike other medicines prescribed by physicians, many medicinal cannabis products have not undergone standard clinical trial development required by regulatory authorities. Different formulations with varying strengths and ratios of tetrahydrocannabinol and cannabidiol are available, and this diversity of medicinal cannabis products available for a myriad of therapeutic indications adds to the complexity. Physicians face challenges and barriers in their clinical decision making with medicinal cannabis because of current evidence limitations. Research efforts to address evidence limitations are ongoing; in the interim, educational resources and clinical guidance are being developed to address the gap in clinical information and support the needs of health professionals.

METHODS

This article provides an overview of various resources that health professionals may use when seeking information about medicinal cannabis in the absence of high-quality evidence and clinical guidelines. It also identifies examples of international evidence-based resources that support clinical decision making with medicinal cannabis.

FINDINGS

Similarities and differences between international examples of guidance and guideline documents are identified and summarized.

IMPLICATIONS

Guidance can help guide physicians in the individualized choice and dose of medicinal cannabis. Before quality clinical trials and regulator-approved products with risk management programs, safety data require clinical and academic collaborative pharmacovigilance.

Cannabis-Induced Anxiety Disorder in the Emergency Department

BACKGROUND

In December 2018, Michigan became the 10th state to legalize marijuana for adults. Since this law took effect, increased availability and use of cannabis in Michigan have led to increased emergency department (ED) visits associated with the drug's psychiatric effects.

OBJECTIVES

To describe cannabis-induced anxiety disorder's prevalence, clinical features, and disposition in a community-based study.

METHODS

This was a retrospective cohort analysis of consecutive patients diagnosed with acute toxicity related to cannabis use (ICD-10 code F12). Patients were seen at seven EDs over a 24-month study period. Data collected included demographics, clinical features, and treatment outcomes in ED patients who met the criteria for cannabis-induced anxiety disorder. This group was compared to a cohort experiencing other forms of acute cannabis toxicity. Chi-squared and t-tests were used to compare these two groups across key demographic and outcome variables.

RESULTS

During the study period, 1135 patients were evaluated for acute cannabis toxicity. A total of 196 patients (17.3%) had a chief complaint of anxiety, and 939 (82.7%) experienced other forms of acute cannabis toxicity, predominantly symptoms of intoxication or cannabis hyperemesis syndrome. Patients with anxiety symptoms had panic attacks (11.7%), aggression or manic behavior (9.2%), and hallucinations (6.1%). Compared to patients presenting with other forms of cannabis toxicity, those with anxiety were likelier to be younger, ingested edible cannabis, had psychiatric comorbidities, or had a history of polysubstance abuse.

CONCLUSIONS

Cannabis-induced anxiety occurred in 17.3% of ED patients in this community-based study. Clinicians must be adept in recognizing, evaluating, managing, and counseling these patients following cannabis exposure.

Association Between Markers of Vulnerability for Cannabis-Related Harms and Source of Supply: Secondary Analysis of a Representative Population Survey

OBJECTIVE

In 2018, the sale of non-medical cannabis was authorized in the province of Quebec in Canada, within a public monopoly under the Société Québécoise du Cannabis (SQDC). The objective of this study was to offer a description of the cannabis-using population regarding the sources of cannabis supply and to explore whether at-risk individuals are purchasing cannabis at SQDC.

METHOD

We used data from a cross-sectional, representative population survey (age >18 years, n = 1799), the Enquête Québécoise sur le Cannabis, which was completed between February and June 2019. Analyses involved adjusted binary logistic regressions, incorporating population weights, to assess 7 potential indicators of harm.

RESULTS

The vulnerability profiles of SQDC consumers (47.8%) and those acquiring their cannabis elsewhere (52.2%) were similar in terms of frequency of cannabis use (adjusted odds ratio [aOR] = 0.46; 95% confidence interval [CI] = 0.12-1.67), motivation to use (aOR = 0.62; 95% CI = 0.16-2.46), concomitant consumption of other substances (aOR = 0.80; 95% CI = 0.14-4.75), cannabis-impaired driving behaviours (aOR = 0.93; 95% CI = 0.26-3.36), psychological distress (aOR = 0.99; 95% CI = 0.26-3.79), and problematic cannabis use (aOR = 0.46; 95% CI = 0.13-1.64). However, SQDC consumers were more likely to be aware of the cannabinoid content of the product purchased compared to those who acquired their cannabis from other sources (aOR = 4.12; 95% CI = 1.10-15.40).

CONCLUSIONS

No association was detected between the source of cannabis supply and potential vulnerability indicators of cannabis-related harms, but SQDC consumers were more aware of the cannabinoid content of the products purchased. These results suggest that the regulated government supply in Quebec is reaching a substantial portion of those with potential high vulnerability to harm. Whether this knowledge translates into a reduction in the negative consequences related to consumption is still to be determined.

Therapeutic use of cannabis in the US

ABSTRACT

NPs are likely to encounter patients using cannabis with therapeutic intent, with or without legal authorization. During the clinical history and assessment process, NPs need to engage in frank discussion about cannabis therapeutics, including the risks and benefits, evidence for use, dosing considerations, potential drug interactions, and harm reduction.

Complementary and alternative therapies in the palliative setting

Complementary and alternative medicine (CAM) encompasses a wide range of medication, herbal, dietary and physical therapies that are not usually considered within the realm of conventional therapeutics. Approximately two thirds of the Australian population use CAMs and only around half of this number will discuss their use of these products with their doctor. Clinical use is commonly seen in patients with life-limiting illness, often because they experience a high burden of symptoms. However, it is also the case that many of these therapies do not have demonstrated efficacy, particularly for the often broad list of conditions and symptoms for which they are chosen to be used. Further, depending on whether they are sold as medications, sold as food supplements or imported illegally and distributed via nonstandard therapeutic channels, several products have had reports of toxicity, severe adverse effects, batch irregularities and drug interactions with other therapies. This awareness, together with lack of standardisation of products and lack of interchangeability between brands has made prescribers unwilling to put patients at risk of harm by supporting their use. In this article, we cover general pharmacological principles around use of a small selection of chemicals used in a medical setting to enable some guidance for use.

Comparison of State-Level Regulations for Cannabis Contaminants and Implications for Public Health

BACKGROUND

The presence of contaminants in cannabis presents a potential health hazard to recreational users and susceptible patients with medical conditions. Because of the federally illegal status of cannabis, there are no unified regulatory guidelines mitigating the public health risk of cannabis contaminants.

OBJECTIVE

To inform further research and provide solutions to the public health risk of cannabis contaminants at a national level, we examined the current landscape of state-level contaminant regulations, and cannabis contaminants of concern, as well as patient populations susceptible to contaminants.

METHODS

We examined the regulatory documents for medical and recreational cannabis in all legalized U.S. jurisdictions and compiled a complete list of regulated contaminants, namely, pesticides, inorganics, solvents, microbes, and mycotoxins. We data mined the compliance testing records of 5,654 cured flower and 3,760 extract samples that accounted for ∼6% of California's legal cannabis production in 2020-2021. We also reviewed the publicly available medical cannabis use reports to tabulate the susceptible patient populations.

RESULTS

As of 18 May 2022, 36 states and the District of Columbia listed a total of 679 cannabis contaminants as regulated in medical or recreational cannabis, including 551 pesticides, 74 solvents, 12 inorganics, 21 microbes, 5 mycotoxins, and 16 other contaminants. Different jurisdictions showed significant variations in regulated contaminants and action levels ranging up to four orders of magnitude. A failure rate of 2.3% was identified for flowers and 9.2% for extracts in the California samples. Insecticides and fungicides were the most prevalent categories of detected contaminants, with boscalid and chlorpyrifos being the most common. The contaminant concentrations fell below the regulatory action levels in many legalized jurisdictions, indicating a higher risk of contaminant exposure. Cannabis use reports indicated usage in several patient populations susceptible to contamination toxicity, including cancer (44,318) and seizure (21,195) patients.

DISCUSSION

Although individual jurisdictions can implement their policies and regulations for legalized cannabis, this study demonstrates the urgent need to mitigate the public health risk of cannabis contamination by introducing national-level guidelines based on conventional risk assessment methodologies and knowledge of patients' susceptibility in medical use. https://doi.org/10.1289/EHP11206.

Cannabinoids and solid organ transplantation: Psychiatric perspectives and recommendations

Cannabinoid use in patients seeking solid organ transplantation (SOT) is an important and unsettled matter which all transplantation clinicians regularly encounter. It is also a multifaceted, interprofessional issue, difficult for any specialty alone to adequately address in a research article or during clinical care. Such uncertainty lends itself to bias for or against cannabinoid use accompanied by inconsistent policies and procedures. Scientific literature in SOT regarding cannabinoids often narrowly examines the issue and exists mostly in liver and kidney transplantation. Published recommendations from professional societies are mosaics of vagueness and specificity mirroring the ongoing dilemma. The cannabinoid information SOT clinicians need for clinical care may require data and perspectives from diverse medical literature which are rarely synthesized. SOT teams may not be adequately staffed or trained to address various neuropsychiatric cannabinoid effects and risks in patients. In this article, authors from US transplantation centers conduct a systematized review of the few existing studies regarding clinician perceptions, use rates, and clinical impact of cannabinoid use in SOT patients; collate representative professional society guidance on the topic; draw from diverse medical literature bases to detail facets of cannabinoid use in psychiatry and addiction pertinent to all transplantation clinicians; provide basic clinical and policy recommendations; and indicate areas of future study.

Expert advice for prescribing cannabis medicines for patients with epilepsy-drawn from the Australian clinical experience

There is international interest for consensus advice for prescribers working in the field of drug resistant epilepsy intending to trial potential therapies that are nonregistered or off‐label. Cannabinoids are one such therapy. In 2017, the New South Wales State Government (Australia) set up a cannabinoid prescribing guidance service for a wide variety of indications, based on known pharmacology together with the relevant new literature as it became available. Increasing interest in cannabis medicines use outside this State over the following 5 years together with a paucity of registration‐standard clinical trials, lack of information around dosing issues, drug interactions and biological plausibility meant there remained a large unmet need for such advice. To address the unmet need in epilepsy, and until medicines were registered or regulator quality data were available, it was agreed to bring together a working group comprising paediatric and adult epilepsy specialists, clinical pharmacists., clinical pharmacologists and cannabis researchers from across Australia to develop interim consensus advice for prescribers. Although interim, this consensus advice addresses much of the current practice gap by providing an informed overview of the different cannabis medicines currently available for use in the treatment of epilepsy in paediatric and adult settings, with information on dose, drug interactions, toxicity, type of seizure and frequency of symptom relief. As such it supplements the limited evidence currently available from clinical trials with experience from front‐line practice. It is expected that this consensus advice will be updated as new evidence emerges and will provide guidance for a subsequent Guideline.

Cannabis, cannabidiol and tetrahydrocannabinol in sport: An overview

The World Antidoping Agency now allows cannabidiol (CBD) to be taken in elite sport but has retained all other cannabinoids on its banned list. This, together with liberalisation of cannabis laws have led to an increasing interest in its use in sport. This includes commercial sponsorship of sporting events and highlights the need for accurate information to be readily available to athletes and their advisers. This narrative review confirms that CBD and tetrahydrocannabinol (THC) do not enhance performance. CBD possesses anti-inflammatory and analgesic properties which have not been adequately evaluated in the area of sport. Some formulations of CBD contain THC or other cannabinoids that may result in a positive drug test. This article is protected by copyright. All rights reserved.

Analysis of cannabidiol (CBD) and THC in nonprescription consumer products: Implications for patients and practitioners

PURPOSE

Cannabidiol products remains largely unregulated in the US. Unlike the Rx formulation of CBD [Epidiolex^R], little information is available regarding labeling accuracy (does the product contain what the label says it does), lot to lot variability, nor long-term product stability. Understanding these properties are fundamental if these products are to be used in patients with epilepsy, where product variability of traditional AEDs has been suspected to result in inadequate seizure control. Therefore, we analyzed commercial CBD products, including oils, aqueous products (i.e., beverages), and various Other products for cannabinoid content vs label claims and stability under United States Pharmacopeia (USP) standards.

METHOD

Samples were diluted and analyzed by HPLC for CBD, THC, and CBN concentrations in order to assess product label accuracy. Products with <90% of label claim CBD were denoted over-labeled, products with >110% of label claim CBD were denoted under-labeled, and products between 90% and 110% of label claim CBD were denoted appropriately labeled, per USP standards.

RESULTS

Among commercial CBD Oils (n = 11), mean CBD concentration vs label claim was 91.56% [95% CI, 66.02-117.10%], although 18.18% of oils (n = 2) made nonspecific label claims of "hemp extract" in lieu of CBD. Among all oils, 36.36% (n = 4) were appropriately labeled, another 36.4% (n = 4) of all oils were under-labeled, maximum 128.3% label claim, and finally, 9.09% (n = 1) of oils were over-labeled. The remaining 18.18% (n = 2) of oils lacked specific CBD label claims, minimum of 0.3 mg CBD per 1-ml "dose". THC was detected in 54.55% (n = 6) of oils with a maximum concentration of 0.2% w/v and a minimum concentration of 0.036% w/v. Cannabinol was detectable in only 9.1% (n = 1) of products at a concentration of 0.00465% w/v. Among aqueous products (n = 21) tested, only 66.67% (n = 14) gave specific CBD label claims, with mean CBD concentration vs label claim of 59.93% [95% CI, 38.24-81.63%]. Only 7.14% (n = 1) of aqueous products with a label claim were appropriately labeled, 14.29% (n = 2) were found to be under-labeled, and 78.57% (n = 11) over-labeled. THC was detected in 23.81% (n = 5) of aqueous products tested with a maximum THC concentration of 0.0005% w/v, and a minimum concentration of 0.0002% w/v. Cannabinol was detected in 9.52% (n = 2) of aqueous products, both at a concentration of 0.0015% w/v. "Other" products (n = 7) tested ranged from chocolate bars to transdermal patches. Some 42.86% (n = 3) gave specific CBD label claims, with mean CBD concentration vs label claim of 67.01% [95% CI, 0.87-133.14%]. Among these three "Other" products with specific label claims, 33% (n = 1) was appropriately labeled, and 66.67% (n = 2) were over-labeled, with CBD concentrations vs label claim ranging from a minimum of 39.30% to a maximum of 101.99%. The remaining 57.14% (n = 5) of "Other" products tested made nonspecific CBD label claims, denoting CBD content in terms of "full spectrum hemp extract" or "activated cannabinoids". One such product was labeled with a "40-50-mg CBD" range instead of a single, specific value. Tetrahydrocannabinol was detected in 71.43% (n = 5) of Other products tested with a maximum concentration of 0.0046% w/w, and a minimum concentration of 0.0008% w/w. Cannabinol was detected in 14.3% (n = 1) of Other products at a concentration of 0.0001% w/w.

CONCLUSION

We demonstrate that commercial CBD products, especially aqueous beverages, can show inconsistent labeling, vary largely from their label claims should they make them, and show lot-to-lot variability making dosing unpredictable.

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.

In vitro metabolism of tebuconazole, flurtamone, fenhexamid, metalaxyl-M and spirodiclofen in Cannabis sativa L. (hemp) callus cultures

BACKGROUND

Cannabis sativa L. (hemp) is a medicinal plant producing various cannabinoids. Its consumption is legalized for medical use due to the alleged positive health effects of these cannabinoids. To satisfy the demand, C. sativa plants are propagated in contained growth chambers. During indoor propagation, pesticides usually are used to ensure efficient production. However, pesticide registration and safe application in C. sativa has not been investigated in detail.

RESULTS

With this study the metabolic degradation of pesticides in recently established C. sativa callus cultures was examined. Tebuconazole, metalaxyl-M fenhexamid, flurtamone and spirodiclofen were applied at 10 μm for 21 days. Results were compared with metabolism data obtained from Brassica napus L., Glycine max (L.) Merr., Zea mays L. and Tritium aestivum L. callus cultures as well as in metabolism guideline studies. The successfully established C. sativa callus cultures were able to degrade pesticides by oxidation, demethylation, and cleavage of ester bonds in phase I, as well as glycosylation and conjugation with malonic acid in phase II and III. Initial metabolites were detected after Day (D)7 and were traced at D21.

CONCLUSION

The resulting pathways demonstrate the same main degradation strategies as crop plants. Because metabolites could be the main residue, the exposure of consumers to these residues will be of high importance. We present here an in vitro assay for a first estimation of pesticide metabolism in C. sativa. © 2021 The Authors. Pest Management Science published by John Wiley & Sons Ltd on behalf of Society of Chemical Industry.

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.

The potential of cannabinoids and inhibitors of endocannabinoid degradation in respiratory diseases

The global incidence of respiratory diseases and complications is increasing. Therefore, new methods of treatment, as well as prevention, need to be investigated. A group of compounds that should be considered for use in respiratory diseases is cannabinoids. There are three groups of cannabinoids - plant-derived phytocannabinoids, synthetic cannabinoids, and endogenous endocannabinoids including the enzymes responsible for their synthesis and degradation. All cannabinoids exert their biological effects through either type 1 cannabinoid receptors (CB₁) and/or type 2 cannabinoid receptors (CB₂). In numerous studies (in vitro and in vivo), cannabinoids and inhibitors of endocannabinoid degradation have shown beneficial anti-inflammatory, antioxidant, anti-cancer, and anti-fibrotic properties. Although in the respiratory system, most of the studies have focused on the positive properties of cannabinoids and inhibitors of endocannabinoid degradation. There are few research reports discussing the negative impact of these compounds. This review summarizes the properties and mechanisms of action of cannabinoids and inhibitors of endocannabinoid degradation in various models of respiratory diseases. A short description of the effects selected cannabinoids have on the human respiratory system and their possible use in the fight against COVID-19 is also presented. Additionally, a brief summary is provided of cannabinoid receptors properties and their expression in the respiratory system and cells of the immune system.

Analysis of cannabis seizures by non-targeted liquid chromatography-tandem mass spectrometry

Due to the popularity of recreational cannabis use, contamination of this drug with diverse classes of chemicals, including pesticides, mycotoxins, and synthetic cannabinoids, has been identified as major threat for public health. For the detection of these compounds in seized cannabis, a screening workflow involving non-targeted liquid chromatography-tandem mass spectrometry (LCMS/MS) was developed. A Quick, Easy, Cheap, Effective, Rugged and Safe (QuEChERS) method was used for the extraction of small bioorganic molecules from ground dried material. Instrumental analysis involved chromatographic separation of compounds and subsequent mass spectrometric detection. Collection of MS and MS/MS information was accomplished by data-dependent acquisition. Compound identification was primarily based on matching acquired MS/MS-spectra to several thousands of reference spectra stored in multiple libraries. Additionally, for selected cannabinoid and pesticide standards, a retention time library was developed. Performance of the workflow was evaluated for 182 pesticides. All tested pesticides were detectable at 5000 μg/kg, 94 % at 500 μg/kg, and 50 % at 50 μg/kg. The workflow was applied to the screening of seized cannabis samples. 41 out of 93 analysed samples (44 %) were tested positive for one or more contaminants impairing quality and/or safety of the material. The detected contaminants included a synthetic cannabinoid (5F-MDMB-PINACA), fifteen pesticide residues (boscalid, carbendazim, chlorantraniliprole, chlorpyrifos, chlorotoluron, cyprodinil, diflubenzuron, ethiofencarb sulfoxide, hexythiazox, iprodione, metalaxyl, pyrimethanil, terbutryn, thiophanate methyl, and trifloxystrobin), and a mycotoxin (sterigmatocystin).

A narrative review on environmental impacts of cannabis cultivation

Interest in growing cannabis for medical and recreational purposes is increasing worldwide. This study reviews the environmental impacts of cannabis cultivation. Results show that both indoor and outdoor cannabis growing is water-intensive. The high water demand leads to water pollution and diversion, which could negatively affect the ecosystem. Studies found out that cannabis plants emit a significant amount of biogenic volatile organic compounds, which could cause indoor air quality issues. Indoor cannabis cultivation is energy-consuming, mainly due to heating, ventilation, air conditioning, and lighting. Energy consumption leads to greenhouse gas emissions. Cannabis cultivation could directly contribute to soil erosion. Meanwhile, cannabis plants have the ability to absorb and store heavy metals. It is envisioned that technologies such as precision irrigation could reduce water use, and application of tools such as life cycle analysis would advance understanding of the environmental impacts of cannabis cultivation.

Toxicological aspects of cannabinoid, pesticide and metal levels detected in light Cannabis inflorescences grown in Italy

Recently, the cultivation of light Cannabis, with a total THC content less than 0.6%, has been encouraged due to its industrial and therapeutic potential. This has increased the consumption of hemp for both smoking purposes and food preparation. Even so, Cannabis inflorescences are not subject to EU regulations and standards provided for food and tobacco products. A study was carried out on thirty-one inflorescences samples, collected in different Italian regions, in order to determine cannabinoids, pesticides and metals and to evaluate the exposure of consumers to contaminants and ensure a safe consumption. Contents of THC were always below 0.5%, while CBD ranged between 0.3 and 8.64%. The determination of 154 pesticides showed that 87% of the samples contained fungicides and insecticides in the range 0.01-185 μg/g. The most found are spinosad and cyprodinil. The concentration of metals ranged from 1 to more than 100 μg/g and As, Cd, Co, Cr, Hg, Cu, Mo, Ni and V exceeded the regulatory US limits for inhaled Cannabis products, while Pb exceeded them for both oral and inhaled products. These contaminants are intrinsically toxic and may affect public health. Actions are needed to establish regulatory measures and reduce the adverse effects caused by contaminants in Cannabis.

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.

Dabbing-Induced Hypersensitivity Pneumonitis

Dabbing has been gaining popularity among young people in recent years due to its ability to deliver a high concentration of tetrahydrocannabinol. When produced illegally, it is usually contaminated by toxic substances and associated with multiple health hazards. We present the case of a 66-year-old woman who developed hypersensitivity pneumonitis after dabbing butane hash oil for the first time and was successfully treated with corticosteroids with complete resolution of her symptoms. This case report emphasizes the respiratory complications associated with using a noxious substance like butane hash oil and gives physicians an insight into the diagnosis and management of dabbing-induced hypersensitivity pneumonitis.

Determination of eighty-two pesticides and application to screening pesticides in cannabis growing facilities

Determination of pesticides in cannabis facilities is increasingly important as medicinal and recreational uses of cannabis products expand rapidly. We report a method involving wipe sampling, liquid chromatography separation, and tandem mass spectrometry, which enables determination of 82 pesticides out of the 96 regulated by Health Canada. To demonstrate an application of the method, we sampled and measured pesticides in two cannabis growing facilities, representing a non-certified and a certified site. We detected 41 pesticides in surface wipe samples at the non-certified site and 6 at the certified site. This study provides the first evidence showing pesticide occurrence on common surfaces in cannabis growing facilities and points to a need for routine monitoring and strict control of pesticide use in cannabis facilities.

Chronic Cannabis Users: A New Special Population to Consider for Drug Development

The use and acceptance of cannabis, either medically or recreationally, has substantially outpaced the collection of data necessary to evaluate its use in any population. However, the mere widespread availability does not imply the absence of risk or confirmation of efficacy and should not be treated as such. There is enough data to suggest that not only does the potential for pharmacokinetic and metabolic interactions exist, but also that baseline characteristics for a given population could be different in chronic cannabis users. Either or both of these may impact the safety and efficacy profile for any new drug in development. As such, we encourage drug developers to consider that the cannabis user may very well be a special population that warrants its own clinical pharmacology evaluation.

Cannabis dabbing: An emerging trend

ABSTRACT

Cannabis dabbing refers to the recreational inhalation of extremely concentrated tetrahydrocannabinol, the main psychotropic cannabinoid derived from the marijuana plant. The practice carries significant health and legal risks. This article discusses what nurses need to know about dabbing and how they can educate patients who may be engaging in risky behavior.

Using Therapeutic Drug Monitoring and Pharmacovigilance to Overcome Some of the Challenges of Developing Medicinal Cannabis from Botanical Origins

PURPOSE

Plants belonging to the genus Cannabis have been domesticated and used by humans for millennia. Thought to have originated from central Asia, cannabis has been harnessed for its nutritional, therapeutic, and psychoactive properties, and as a source of fiber (Office of Medicinal Cannabis. Analytical Monograph Cannabis Flos. Den Haag, The Netherlands: Office of Medicinal Cannabis; 2014). Human use of cannabis is not novel; however, its medicalization offers a new pharmacotherapeutic frontier.

METHODS

The authors recently reported a systematic review of the contaminants of cannabis (National Academies of Sciences Engineering, and Medicine. The health effects of cannabis and cannabinoids: the current state of evidence and recommendations for research. Washington, DC; 2017). This article draws on the research limitations identified by that review and examines a collection of the relevant literature to provide an appreciation of the current evidence base.

RESULTS

The review explores the current status of cannabis in medical use, the drug development aspects that apply when taking a plant through to pill development, and the roles that therapeutic drug monitoring and pharmacovigilance have to guide practice until the drug development information on medicinal cannabis preparations is complete.

CONCLUSIONS

A surge of public and clinical interest in the possible therapeutic applications of constituent cannabinoids has potentiated global legislative and policy reform. However, our understanding of its properties, optimized use, and harmful effects remains incomplete (Therapeutic Goods Administration. Guidance for the use of medicinal cannabis in Australia In: Department of Health Department, editor. Woden ACT Australian Government 2017; Dryburgh LM, Bolan NS, Grof CP, Galettis P, Schneider J, Lucas CJ, et al. Cannabis contaminants: sources, distribution, human toxicity and pharmacologic effects. Brit J Clin Pharm. 2018;84(11):2468-2476). In particular, a comprehensive appreciation of its toxicity profile is lacking.

Regulatory Status of Pesticide Residues in Cannabis: Implications to Medical Use in Neurological Diseases

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Movement disorders are the most common neurological category of qualifying conditions in the U.S.

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The number and action levels of regulated pesticides in cannabis differ vastly in 33 states and Washington, D.C.

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Network analysis reveals potential interactions of insecticides, cannabinoids, and seizure at a functional level.

Medical cannabis represents a potential route of pesticide exposure to susceptible populations. We compared the qualifying conditions for medical use and pesticide testing requirements of cannabis in 33 states and Washington, D.C. Movement disorders were the most common neurological category of qualifying conditions, including epilepsy, certain symptoms of multiple sclerosis, Parkinson’s Disease, and any cause of symptoms leading to seizures or spasticity. Different approaches of pesticide regulation were implemented in cannabis and cannabis-derived products. Six states imposed the strictest U.S. EPA tolerances (i.e. maximum residue levels) for food commodities on up to 400 pesticidal active ingredients in cannabis, while pesticide testing was optional in three states. Dimethomorph showed the largest variation in action levels, ranging from 0.1 to 60 ppm in 5 states. We evaluated the potential connections between insecticides, cannabinoids, and seizure using the Comparative Toxicogenomics Database. Twenty-two insecticides, two cannabinoids, and 63 genes were associated with 674 computationally generated chemical-gene-phenotype-disease (CGPD) tetramer constructs. Notable functional clusters included oxidation-reduction process (183 CGPD-tetramers), synaptic signaling pathways (151), and neuropeptide hormone activity (46). Cholinergic, dopaminergic, and retrograde endocannabinoid signaling pathways were linked to 10 genetic variants of epilepsy patients. Further research is needed to assess human health risk of cannabinoids and pesticides in support of a national standard for cannabis pesticide regulations.

A systematic review of the label accuracy of cannabinoid-based products in regulated markets: is what's on the label what's in the product?

OBJECTIVES

To review the literature regarding label accuracy and contamination of medical cannabinoid-based products.

METHODS

A systematic review with meta-analysis following PRISMA guidelines. This study is registered with PROSPERO (CRD42019131565).

RESULTS

Five studies reported label accuracy data ranging between 17% and 86%. Four studies reported contaminants, including pesticides, solvents and AB-FUBINACA. Meta-analysis was limited to the proportion of pesticide-contaminated samples found in two studies (0.25 (95% CI [0.10, 0.40])) and displayed significant heterogeneity.

CONCLUSIONS

Label inaccuracies and contaminants are found across a spectrum of cannabinoid-based products. The review highlights the paucity and heterogeneity of research relating to cannabinoid-based products in light of changing global legislation. Further robust research is required to support ongoing pharmacovigilance and patient safety.

Controlled administration of cannabis to mitigate cannabis-attributable harm among recreational users: a quasi-experimental study in Germany

Background: New approaches are required to slow down or reverse increasing trends of levels of delta-9-tetrahydrocannabinol (THC) and cannabis-attributable hospitalizations in Germany. Legal access to cannabis may constitute one viable effective policy response; however, available evidence does not suffice to inform a regulation model for Germany. The proposed study aims to reduce harm for cannabis users through legal access to herbal cannabis through pharmacies.

Protocol: A quasi-experimental study comparing cannabis users with legal access to herbal cannabis (Berlin, intervention group) to those without legal access (Hamburg, control group) (total N=698). As the primary outcome, we hypothesize that: 1) illegal THC consumption will reduce by at least 50% in the intervention group and 2) total THC exposure in the intervention group will be reduced by at least 10% lower than that of the control group, taking into account baseline values. Secondary outcomes comprise measures of frequency of use, THC-impaired driving, and mode of administration. Paired t-tests and multilevel regression models will be performed for statistical analyses.

Discussion: This study proposal is currently being reviewed by the ‘Federal Institute for Drugs and Medical Devices’ – the body responsible for approving research studies on classified substances, including cannabis. Upon approval and prior to the start of the study, a full ethical review will be undertaken. Results may inform a regulation model for Germany and other jurisdictions and are expected to deepen the understanding of the effects of legal access to cannabis.

Pre-registration: German Clinical Trials Register (DRKS), DRKS00020829