A double-blind, randomized, placebo-controlled study of the safety and effects of CBN with and without CBD on sleep quality

The present study sought to determine the effects of cannabinol (CBN) alone and in combination with cannabidiol (CBD) on sleep quality. This was a double-blind, randomized, placebo-controlled study conducted between May and November 2022. Participants were randomized to receive either (a) placebo, (b) 20 mg CBN, (c) 20 mg CBN + 10 mg CBD, (d) 20 mg CBN + 20 mg CBD, or (e) 20 mg CBN + 100 mg CBD for seven consecutive nights. Participants were 18-55 years of age who self-rated sleep quality as "very poor" or "poor." The primary endpoint was sleep quality, while secondary endpoints included sleep onset latency, number of awakenings, wake after sleep onset (WASO), overall sleep disturbance, and daytime fatigue. In a modified intent-to-treat analyses (N = 293), compared to placebo, 20 mg CBN demonstrated a nonsignificant but potentially meaningful effect on sleep quality (OR [95% CI] = 2.26 [0.93, 5.52], p = .082) and significantly reduced number of awakenings (95% CI [-0.96, -0.05], p = .025) and overall sleep disturbance (95% CI [-2.59, -0.14], p = .023). There was no difference from placebo among any group for sleep onset latency, WASO, or daytime fatigue (all p > .05). Individuals receiving 20 mg CBN demonstrated reduced nighttime awakenings and overall sleep disturbance relative to placebo, with no impact on daytime fatigue. The addition of CBD did not positively augment CBN treatment effects. No differences were observed for latency to sleep onset or WASO. Findings suggest 20 mg of CBN taken nightly may be helpful for improving overall sleep disturbance, including the number of times one wakes up throughout the night, without impacting daytime fatigue. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Examination of the effects of cannabidiol on menstrual-related symptoms

Some individuals attempt to alleviate menstrual-related symptoms (MRS) by using cannabis and report having expectations that cannabis can improve MRS; however, no study has examined the effect of cannabinoids on MRS. The present study is a pre-post, randomized, open-label trial that aimed to examine the effects of oral cannabidiol (CBD) isolate for alleviating MRS. Participants were assigned randomly to one of two open-label dosing groups of CBD softgels (160 mg twice a day, BID, n = 17; 320 mg BID, n = 16) and completed a 1-month baseline period. Following baseline, participants were instructed to consume CBD starting the first day they believed they experienced symptoms each month and to take their assigned dose daily for 5 consecutive days for three CBD-consumption months. We examined differences in MRS and related outcomes between baseline and 3 months of CBD consumption. Results revealed reductions (in both dosing groups) in MRS, irritability, anxiety, global impression of change, stress, and subjective severity scores when comparing baseline to all 3 months of CBD consumption. Depression scores did not change in either dosing group. Findings suggest that CBD may have the potential for managing MRS. Importantly, changes in symptoms appeared in the first month of CBD consumption and persisted over the 3 consumption months. Further research is warranted comparing the effects of CBD to placebo (a limitation of the study) and examining the potential to optimize CBD consumption for reducing MRS (e.g., combining CBD with terpenes; varying routes and timing of administration). (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Serum Markers of Bone Turnover Following Controlled Administration of Two Medical Cannabis Products in Healthy Adults

Introduction: Cannabidiol (CBD) has been shown to maintain bone integrity in pre-clinical models, but little is known about the effects of delta-9-tetrahydrocannabinol (THC) on bone turnover. In this study we explored the effects of two oral medical cannabis products on normal bone homeostasis through evaluation of markers of bone resorption (carboxyl-terminal collagen crosslinks, CTx) and bone formation (procollagen type 1 N-terminal propeptide, P1NP; alkaline phosphatase, ALP). Methods: This study is an analysis of secondary data from two Phase 1 double-blind, placebo-controlled trials of Spectrum Yellow (0.9 mg THC, 20 mg CBD/mL of oil) and Spectrum Red (2.5 mg THC, 0.3 mg CBD/softgel). Healthy participants (n=38 men, 45 women) were randomized to receive 5-20 mg THC (CBD levels varied as a function of administered product) or placebo daily (BID) for 7 days. Bone markers were assessed at baseline, upon completion of product administration (day 8), and after a 5-day washout (day 13). Results: All bone markers were significantly higher in men at baseline (p≤0.008). For CTx, there was a significant day×group interaction (F=3.23, p=0.04); CTx levels were significantly lower in participants treated with Spectrum Red (b=-164.28; 95% confidence interval [CI], -328 to -0.29; p=0.04) and marginally lower in participants treated with Spectrum Yellow (b=-157.31; 95% CI, -323 to 8.68; p=0.06) versus placebo on day 8. For P1NP and ALP, there were no significant differences between treatments across study days. Bone marker values outside the reference range (RR) were observed; CTx > RR (n=71) was predominantly (85.9%) observed in male participants, whereas P1NP > RR (n=100) was more evenly distributed between sexes (53.0% in men). These were not considered clinically significant and did not differ between treatment groups. Conclusions: These are the first interventional human data on the effect of cannabinoids on biomarkers of bone turnover. Short-term treatment with CBD- or THC-dominant medical cannabis products resulted in attenuation of a marker of bone resorption. Although the attenuation was not clinically significant, this finding may be indicative of protective properties of cannabinoids in bone. Further research over longer dosing durations in individuals exhibiting bone-specific conditions (e.g., osteoporosis) is warranted. ClinicalTrials.gov IDs: ACTRN12619001723178 and ACTRN12619001450101.

A randomized, double-blind, placebo-controlled, repeated-dose pilot study of the safety, tolerability, and preliminary effects of a cannabidiol (CBD)- and cannabigerol (CBG)-based beverage powder to support recovery from delayed onset muscle soreness (DOMS)

BACKGROUND

Cannabinoid-containing products are marketed to athletes as promoting recovery, in spite of a lack of data on their safety and effects. This randomized, double-blind, placebo-controlled, repeated-dose pilot study tested the safety, tolerability, and preliminary effects on recovery of a formulation containing cannabidiol (CBD; 35 mg), cannabigerol (CBG; 50 mg), beta caryophyllene (BCP; 25 mg), branched-chain amino acids (BCAAs; 3.8 g), and magnesium citrate (420 mg).

METHODS

Exercise-trained individuals (N = 40) underwent an experimental induction of delayed onset muscle soreness (DOMS) and completed follow-up visits 24-, 48-, and 72-hours post-DOMS. Participants were randomized to active or placebo formulation, and consumed the formulation twice per day for 3.5 days.

RESULTS

There was one adverse event (AE) in the active group (diarrhea) and two AEs in placebo (dry mouth; eye rash/swollen eye). There was 100% self-reported compliance with formulation consumption across the two groups. For the primary outcome of interest, the estimate of effect for ratings of average soreness/discomfort 72 hours post-DOMS between active and placebo groups was -1.33 (85% confidence interval = -2.55, -0.10), suggesting moderate evidence of a treatment difference. The estimate of effect for the outcome of ratings of interference of soreness, discomfort, or stiffness on daily activities at work or home 48 hours post-DOMS was -1.82 (95% confidence interval = -3.64, -0.01), indicating a treatment difference of potential clinical importance. There was no significant effect between active and placebo groups on objective measures of recovery, sleep quality, or mood disturbance.

CONCLUSIONS

The tested formulation reduced interference of DOMS on daily activities, demonstrating its improvement on a functional aspect of recovery.

A Two-Phase, Dose-Ranging, Placebo-Controlled Study of the Safety and Preliminary Test of Acute Effects of Oral Δ8-Tetrahydrocannabivarin in Healthy Participants

Introduction: Tetrahydrocannabivarin (THCV) is an understudied cannabinoid that appears to have effects that vary as a function of dose. No human study has evaluated the safety and nature of effects in a wide range of THCV doses. Methods: This was a two-phase, dose-ranging, placebo-controlled trial of the Δ8 isomer of oral THCV in healthy adults. Phase 1 utilized an unblinded, single-ascending dose design (n=3). Phase 2 used a double-blind, randomized, within-participant crossover design (n=18). Participants received single acute doses of placebo and 12.5, 25, 50, 100, and 200 mg of THCV. Safety measures and subjective and cognitive effects were assessed predose and up to 8 h postdose. Results: Most adverse events (AEs; 55/60) were mild. Euphoric mood was the most common AE. The 12.5, 25, and 200 mg doses produced significantly lower minimum times to complete the digit vigilance test (ps=0.01). The 25 mg dose showed elevations on mean ratings of "energetic" at 1-, 2-, and 4-h postdose, but the maximum postdose rating for this dose did not achieve statistical significance relative to placebo ([95% confidence interval]=3.2 [-0.5 to 6.9], p=0.116). The 100 and 200 mg doses showed elevations on ratings of "feel a drug effect" and "like the drug effect." Almost all urine drug screens (78/79) at 8 h postdose in the active THCV conditions tested positive for tetrahydrocannabinol (THC). Conclusion: All THCV doses displayed a favorable safety profile. Several THCV doses showed a preliminary signal for improved sustained attention, but the effect was not dose dependent. Though mild and not associated with impairment, THC-like effects were observed at higher THCV doses. Oral THCV-containing products could lead to positive urine drug screens for THC. ClinicalTrials.gov ID: NCT05210634.

Oral Cannabidiol Treatment in Two Postmenopausal Women with Osteopenia: A Case Series

Introduction: Cannabidiol (CBD), a nonintoxicating cannabinoid, may be involved in bone remodeling, but human studies are limited. In this case series, we explored the effects of oral CBD administration on bone turnover. Materials and Methods: Two postmenopausal women with osteopenia (T-score=-1 to -2.5) were randomized to receive 100 or 300 mg CBD daily (oral, bis in die [twice per day]) for 12 weeks. Serum markers of bone resorption (carboxyl-terminal collagen crosslinks [CTx]) and bone formation (procollagen type 1 N-terminal propeptide [P1NP], bone-specific alkaline phosphatase [BSAP], and osteocalcin [OC]); safety measures; plasma concentrations of CBD and metabolites; sleep disturbance; symptoms of depression, anxiety, and stress; and quality of life, were assessed. Results: CBD was well tolerated, with no clinically significant change in vital signs, hematology, chemistry, or urinalysis, and no adverse events reported. Reductions (% change vs. baseline) in CTx (-8.5%, -28.1%), P1NP (-9.9%, -39.5%), BSAP (-12.7%, -74.8%), and OC (-16.0%, -6.7%) were observed after 12 weeks of oral administration of 100 or 300 mg CBD daily, respectively. The two participants self-reported consuming 95.3% and 98.8% of CBD doses, respectively. CBD and select metabolites were measurable in plasma after 4 and 12 weeks of CBD treatment. No notable changes in sleep disturbance, depression, anxiety, stress, or quality of life were observed. Conclusions: CBD was well tolerated after 12 weeks of twice-daily oral administration and was associated with reduction in measured markers of bone turnover. Compliance with CBD treatment was good. Large-scale randomized clinical trials into the bone protective effects of CBD in postmenopausal women are warranted.

Sex Differences in the Safety and Subjective Effects of Two Oral Δ9-Tetrahydrocannabinol-Containing Cannabis Products over Multiple Doses Among Healthy Adults

Introduction: A growing number of females report consuming cannabis products. There is a paucity of data on sex differences in safety and subjective effects after repeated use of varying oral doses of Δ9-tetrahydrocannabinol (THC; the primary psychoactive constituent of cannabis). Materials and Methods: Data were from two randomized, double-blind, placebo-controlled, multiple-dose, between-subject trials of two THC-containing oral cannabis products. Healthy adults received placebo, low-dose THC (∼2.5 or ∼5 mg per dose), or high-dose THC (∼7.5 or ∼10 mg per dose) twice daily for 7 days. There were 38 males (8 placebo, 17 low-dose THC, 13 high-dose THC) and 46 females (8 placebo, 17 low-dose THC, 21 high-dose THC). Analyses compared adverse events (AEs) and subjective effects between males and females, by THC dose. Results: In the placebo and low-dose THC groups, there were no sex differences in the relative rate of AEs. In the high-dose THC group, females versus males reported 3.08 (95% confidence interval [CI]=1.31-8.33) times as many AEs. There were no significant interactions of sex×low-dose THC group for any subjective effect. In the high-dose THC group, females versus males reported greater "relaxed" ratings (b=15.14, 95% CI=1.44-28.84, p=0.027), whereas in the placebo group, males versus females reported greater ratings of "liking the effect" (b=-30.01, 95% CI=2.77-57.26, p=0.028). Although analyses were underpowered to assess the sex×THC dose×day interaction, the initial sex disparity in AEs and some subjective effects in the high-dose THC group appeared to shrink after the first day. Conclusions: In this exploratory analysis, sex differences in some responses to oral THC were nuanced. Females appeared more sensitive than males to AEs and some subjective effects at higher but not lower doses. Males reported higher ratings than females on some subjective effects in response to placebo. Initial sex differences in response to higher doses of oral THC tended to diminish over 7 days of dosing. If replicated, findings could help inform sex-specific dosing strategies of medical cannabis products and could help educate medical cannabis patients on any temporality of effects.

Sex Differences in the Pharmacokinetics of Cannabidiol and Metabolites Following Oral Administration of a Cannabidiol-Dominant Cannabis Oil in Healthy Adults

Introduction: Oral cannabidiol (CBD) product use is increasingly growing among women; however, there is a lack of data on sex differences in the pharmacokinetics (PKs) of CBD and its primary metabolites, 7-hydroxy-CBD (7-OH-CBD) and 7-carboxy-CBD (7-COOH-CBD), after repeated doses. Materials and Methods: The present study is a secondary analysis of data from a randomized, double-blind, placebo-controlled multiple-dose trial of a commercially available, CBD-dominant oral cannabis product. Healthy participants (n=17 males and 15 females) were randomized to receive 120 to 480 mg of CBD daily for 7 days. Dosing groups were pooled for all analyses due to sample size limitations. Analyses compared plasma PK parameters by sex, day, and sex×day. Results: For raw PK parameters for CBD and metabolites, there were no statistically significant effects of sex×day or sex (all p-values >0.05). For metabolite-to-parent ratios (MPRs) of AUC_0-t, there were significant effects of the sex×day interactions for 7-OH-CBD (F=6.89, p=0.016) and 7-COOH-CBD (F=5.96, p=0.021). For 7-OH-CBD, follow-up analyses showed significant simple effects of day within females (t=4.13, p<0.001), but not within males (t=0.34, p=0.73), such that 7-OH-CBD MPRs increased significantly from day 1 to 7 for females, but not for males. For 7-COOH-CBD, follow-up analyses revealed significant simple effects of day within females (t=8.24, p<0.001) and males (t=5.20, p<0.001), therefore 7-COOH-CBD MPRs increased significantly from day 1 to 7 in both sexes, but the increase was significantly greater among females than among males. Within dosing days, there were no statistically significant simple effects of sex on MPRs of 7-OH-CBD or 7-COOH-CBD. Conclusions: Females exhibited greater relative exposure to CBD metabolites in plasma over time, which may reflect sex differences in CBD metabolism or elimination. Further research assessing the safety implications of higher relative exposure to CBD metabolites over longer periods of time is warranted to mirror typical consumer use patterns.

A crowdsourcing survey study on the subjective effects of delta-8-tetrahydrocannabinol relative to delta-9-tetrahydrocannabinol and cannabidiol

Delta-8-tetrahydrocannabinol (Δ8-THC) has emerged as a new retail cannabinoid product in the U.S. This study queried Δ8-THC users about product use characteristics and self-reported drug effects. Participants were recruited via a large online crowdsourcing platform (Amazon Mechanical Turk). Adults (N = 252) with past year Δ8-THC use (35% with at least weekly use) completed surveys and open-ended questions related to their reasons for using and past experiences with Δ8-THC-containing retail products. Participants with past year use of Δ9-tetrahydrocannabinol (Δ9-THC) and/or cannabidiol (CBD; 81% and 63%) compared the effects of Δ8-THC to those of Δ9-THC and/or CBD by rating drug effects on a visual analog scale from -50 to + 50 where negative scores indicated Δ8-THC effects are weaker, positive scores indicated Δ8-THC effects are stronger, and a score of 0 indicated equal effects to Δ9-THC or CBD. Compared to Δ9-THC, self-reported ratings for "Drug effect," "Bad effect," "Sick," "Anxiety," "Paranoia," "Irritability," "Restlessness," "Memory Problems," and "Trouble Performing Routine Tasks" were lower for Δ8-THC (d = -0.21 to -0.44). Compared to CBD, ratings for Δ8-THC effects were higher for "Drug effect," "Good effect," "High," "Relaxed," "Sleepy," "Hunger/Have the Munchies," "Memory Problems," "Trouble Performing Routine Tasks," and "Paranoia" (d = 0.27-1.02). Qualitative responses indicated that participants used Δ8-THC because it is perceived as (a) legal, (b) a substitute or similar to Δ9-THC, and/or (c) less intense than Δ9-THC. Δ8-THC is an understudied psychoactive component of cannabis that shares more characteristics with Δ9-THC than CBD and should be characterized further with human laboratory studies. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Effect of very low nicotine content cigarettes on alcohol drinking and smoking among adult smokers who are at-risk alcohol drinkers

Alcohol and tobacco use are interrelated. This study examined response to very low nicotine content (VLNC) and moderate nicotine content (MNC) cigarettes by problematic drinking. We utilized a double-blind, randomized, within-subjects crossover design of VLNC and MNC cigarettes in two groups of adult cigarette smokers: with at-risk drinking (ARD; n = 23) and without ARD (n = 24). Participants smoked only their assigned experimental cigarette in their home environment for 7 days, and completed laboratory visits, including ad libitum smoking of the assigned experimental cigarette, at the beginning and end of each experimental week. Participants smoked their usual cigarettes for 7 days between conditions. Participants provided daily reports of alcohol and cigarette consumption. Current Diagnostic and Statistical Manual of Mental Disorders-5th edition (DSM-5) alcohol use disorder (AUD) was assessed at baseline and the end of each experimental week. Compliance with smoking of experimental cigarettes was good. Adjusting for baseline drinking, there was no significant effect of experimental cigarette or ARD group on drinks per day or alcohol urges. There was no effect of experimental cigarette or ARD group on cigarettes per day, or on any puff topography outcome or postsmoking exhaled carbon monoxide during laboratory smoking. No participant had a change in AUD status or AUD severity. After 7 days of exposure to VLNC cigarettes, adult cigarette smokers with ARD did not show compensatory drinking or compensatory smoking behavior. A future policy change in the United States to reduce nicotine content in cigarettes may not produce unintended compensatory drinking or smoking among this vulnerable and prevalent population of smokers. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Medical cannabis authorization patterns, safety, and associated effects in older adults

Background

Use of medical cannabis is increasing among older adults. However, few investigations have examined cannabis use in this population.

Methods

We assessed the authorization patterns, safety, and effects of medical cannabis in a sub-analysis of 201 older adults (aged ≥ 65 years) who completed a 3-month follow-up during this observational study of patients who were legally authorized a medical cannabis product (N = 67). Cannabis authorization patterns, adverse events (AEs), Edmonton Symptom Assessment Scale-revised (ESAS-r), and Brief Pain Inventory Short Form (BPI-SF) data were collected.

Results

The most common symptoms for which medical cannabis was authorized were pain (159, 85.0%) and insomnia (9, 4.8%). At baseline and at the 3-month follow-up, cannabidiol (CBD)-dominant products were authorized most frequently (99, 54%), followed by balanced products (76, 42%), and then delta-9-tetrahydrocannabinol (THC)-dominant products (8, 4.4%). The most frequent AEs were dizziness (18.2%), nausea (9.1%), dry mouth (9.1%), and tinnitus (9.1%). Significant reductions in ESAS-r scores were observed over time in the domains of drowsiness (p = .013) and tiredness (p = .031), but not pain (p = .106) or well-being (p = .274). Significant reductions in BPI-SF scores over time were observed for worst pain (p = .010), average pain (p = .012), and overall pain severity (p = 0.009), but not pain right now (p = .052) or least pain (p = .141).

Conclusions

Overall, results suggest medical cannabis was safe, well-tolerated, and associated with clinically meaningful reductions in pain in this sample of older adults. However, the potential bias introduced by the high subject attrition rate means that all findings should be interpreted cautiously and confirmed by more rigorous studies.

Safety, Pharmacokinetics and Pharmacodynamics of Spectrum Red Softgels in Healthy Participants

Due to a lack of published pharmacokinetic (PK) and/or pharmacodynamic (PD) data, informed physician and patient decision-making surrounding appropriate dosing of cannabis for medical purposes is limited. This Phase 1, multiple-dose study evaluated the safety, tolerability, PK and PD of Spectrum Red softgels (2.5 mg Δ9-tetrahydrocannabinol (THC) and <0.25 mg cannabidiol (CBD)). Participants (n = 41) were randomized to one of five groups: 5 mg THC and 0.06 mg CBD daily (Treatment A), 10 mg THC and 0.12 mg CBD daily (Treatment B), 15 mg THC and 0.18 mg CBD daily (Treatment C), 20 mg THC and 0.24 mg CBD daily (Treatment D) or placebo. Study medication was administered in divided doses, every 12 h, ∼60 min after a standardized meal, for 7 consecutive days. All treatment-emergent adverse events (TEAEs) (65/65) were of mild-to-moderate severity; none was serious. The highest number of TEAEs (30/65) occurred on the first day of treatment. The most common TEAEs included somnolence, lethargy and headache (reported by eight, seven and five participants, respectively). On Day 7, maximum observed plasma concentration of 11-carboxy-THC increased by 2.0- and 2.5-fold as the dose doubled between Treatments A and B and between Treatments B and D, respectively. Mean peak post-treatment ratings of self-reported subjective effects of 'feel any effect' and 'dazed' differed between Treatment D and placebo on Days 1, 3 and 7. Over a week of twice-daily dosing of Spectrum Red softgels, daily doses of THC up to 20 mg and of CBD up to 0.24 mg were generally safe and became better tolerated after the first day of treatment. A prudent approach to improve tolerability with Spectrum Red softgels might involve initial daily doses no higher than 10 mg THC and 0.12 mg CBD in divided doses, with titration upward over time as needed based on tolerability.

Effect of Cannabidiol on the Long-Term Toxicity and Lifespan in the Preclinical Model Caenorhabditis elegans

Introduction: Despite widespread use of cannabidiol (CBD), no lifelong toxicity study has been published to date. Caenorhabditis elegans is often used in preclinical lifelong toxicity studies, due to an estimated 60-80% of their genes having a human ortholog, and their short lifespan of ∼2-3 weeks. In this study, we examined both acute and long-term exposure studies of CBD at physiologically relevant concentrations. Materials and Methods: Acute toxicity was determined by treating day 1 adults with a wide range of CBD concentrations (0.4 μM to 4 mM) and assessing mortality and motility compared to control animals. Thermotolerance was examined by treating adult animals with CBD (0.4 μM to 4 mM) and exposing them to 37°C for 4 h, and then scoring for the number of alive animals treated with CBD compared to controls. Long-term toxicity was assessed by exposing day 1 adults to 10, 40, and 100 μM CBD until all animals perished. Control animals had no active drug exposure. Results: We report both acute and long-term exposure studies of CBD to adult C. elegans at physiologically relevant concentrations. Acute toxicity results showed that no animal died when exposed to 0.4-4000 μM CBD. The thermotolerance study showed that 40 μM CBD, but not other treatment levels, significantly increased resistance to heat stress by 141% compared to the untreated controls. Notably, whole-life exposure of C. elegans to 10-100 μM CBD revealed a maximum life extension of 18% observed at 40 μM CBD. In addition, motility analysis of the same groups revealed an increase in late-stage life activity by up to 206% compared to controls. Conclusion: These results serve as the only CBD lifelong exposure data in an in vivo model to date. While further research into the lifelong use of CBD should be carried out in mammalian models, the C. elegans model indicates a lack of long-term toxicity at physiologically relevant concentrations.

Pharmacokinetics of cannabichromene in a medical cannabis product also containing cannabidiol and Δ9-tetrahydrocannabinol: a pilot study

Purpose

Cannabichromene (CBC) is a phytocannabinoid commonly found in cannabis, yet its acute post-dose pharmacokinetics (PK) have not been examined in humans. This is a secondary data analysis from a trial investigating Spectrum Yellow oil, an oral cannabis product used for medical purposes that contained 20 mg cannabidiol (CBD), 0.9 mg Δ⁹-tetrahydrocannabinol (THC), and 1.1 mg CBC, per 1 mL of oil.

Methods

Participants (N = 43) were randomized to one of 5 groups: 120 mg CBD, 5.4 mg THC, and 6.6 mg CBC daily; 240 mg CBD, 10.8 mg THC, and 13.2 mg CBC daily; 360 mg CBD, 16.2 mg THC, and 19.8 mg CBC daily; 480 mg CBD, 21.6 mg THC, and 26.4 mg CBC daily; or placebo. Study medication was administered every 12 h for 7 days. Plasma CBC concentrations were analyzed by a validated two-dimensional high-performance liquid chromatography–tandem mass spectrometry assay.

Results

After a single dose and after the final dose, the C_max of CBC increased by 1.3–1.8-fold for each twofold increase in dose; the t_max range was 1.6–4.3 h. Based on the ratio of administered CBD, THC, and CBC to the plasma concentration, the dose of CBD was 18 times higher than the dose of CBC, yet the AUC_0–t of CBD was only 6.6–9.8-fold higher than the AUC_0–t of CBC; the dose of THC was similar to the dose of CBC, yet THC was quantifiable in fewer plasma samples than was CBC.

Conclusions

CBC may have preferential absorption over CBD and THC when administered together.

Trial Registration: Australian New Zealand Clinical Trials Registry #ACTRN12619001450101, registered 18 October 2019.

Supplementary information

The online version contains supplementary material available at 10.1007/s00228-021-03232-8.

Impact of smoked cannabis on tobacco cigarette smoking intensity and subjective effects: A placebo-controlled, double-blind, within-subjects human laboratory study

Co-users of cannabis and tobacco frequently use cannabis, then tobacco cigarettes, in a sequential pattern within an occasion, that is, they "chase" smoked cannabis with a tobacco cigarette. The objective of this placebo-controlled, double-blind, within-subjects human laboratory study was to gather preliminary data on how smoking active versus placebo cannabis impacts tobacco cigarette smoking behavior, craving, and subjective effects. Adult daily cannabis and tobacco co-users (N = 9) were randomly assigned to two experimental visit orders (i.e., active cannabis (5.2% THC) first visit and placebo cannabis second visit, or vice versa). Participants smoked one cannabis cigarette, and approximately 30 min later were given a 5-min ad libitum period to smoke one of their own brand of tobacco cigarette. As expected, boost in plasma THC levels and cannabis-related subjective effects differed between active and placebo cannabis conditions. Tobacco cigarette puff topography measures and tobacco craving did not differ between cannabis conditions, but there appeared to be between-participants heterogeneity in cumulative total puff volume. After smoking active versus placebo cannabis, the changes in subjective effects of tobacco smoking after adjusting for pretobacco smoking levels were not significant. Results do not support the notion that immediate effects of smoked cannabis change the behavior of tobacco smoking. The strong overlap between cannabis and tobacco smoking may not be explained by primarily pharmacological factors, but may be driven by more nuanced and complex mechanisms involving pharmacological processes as well as learning factors. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Authorization Patterns, Safety, and Effectiveness of Medical Cannabis in Quebec

Introduction: Despite increasing demand for data, little is known about the authorization patterns, safety, and effectiveness of medical cannabis products.

Materials and Methods: We conducted a 2 year observational study of adult patients who were legally authorized a medical cannabis product from a single licensed producer; we captured and analyzed authorized cannabis use patterns by cannabinoid profile (tetrahydrocannabinol [THC]-dominant; cannabidiol [CBD]-dominant; and balanced (THC:CBD) and clinical outcomes using standardized outcome measures every 3 months for 12 months at a network of medical cannabis clinics in Quebec, Canada.

Results: We recruited 585 patients (average age 56.5 years), of whom 61% identified as female and 85% reported pain as their primary complaint. Over 12 months, there was a significant increase in the number of products authorized (Z=2.59, p=0.01). The proportion of authorizations for a THC-dominant or CBD-dominant product increased relative to the proportion of authorizations for a balanced (THC:CBD) product (all p<0.01). Symptom improvement over time was observed for pain, tiredness, drowsiness, anxiety, and well-being. Patients authorized THC-dominant products exhibited less symptom improvement for anxiety and well-being relative to those authorized CBD-dominant or balanced (THC:CBD) products. Medical cannabis was well tolerated across all product profiles.

Conclusion: These real-world data reveal changes in medical cannabis authorization patterns and suggest that symptom improvement may vary by cannabinoid profile over 12 months of follow-up.

Safety, Pharmacokinetics, and Pharmacodynamics of Spectrum Yellow Oil in Healthy Participants

Due to a lack of published pharmacokinetic (PK) and/or pharmacodynamic (PD) data, decision-making surrounding appropriate dosing of cannabis used for medical purposes is limited. This multiple-dose study evaluated the safety, tolerability, PK, and PD of Spectrum Yellow oil [20 mg/mL cannabidiol (CBD)/<1 mg/mL ∆9-tetrahydrocannabinol (THC)]. Participants (N=43) were randomized to one of five groups: 120 mg CBD and 5.4 mg THC daily, 240 mg CBD and 10.8 mg THC daily, 360 mg CBD and 16.2 mg THC daily, 480 mg CBD and 21.6 mg THC daily, or placebo. Study medication was administered every 12 hours for seven consecutive days. Treatment-emergent adverse events (TEAEs); plasma and urine concentrations of THC, CBD, and metabolites; and self-reported subjective effects were collected. Nearly all TEAEs (44/45) were of mild or moderate severity; none was serious. The highest incidence of TEAEs (67%) was in the two higher-dose treatment groups. The highest number of TEAEs (17/45) occurred on the first treatment day. Steady-state plasma CBD concentrations were reached by Day 7. On Day 7, CBD exposure showed dose-proportionality (AUC0-t slope=1.03 [0.70, 1.36], Cmax slope=0.92 [0.53, 1.31]). Most plasma THC concentrations were below the limit of quantification. Across Days 1 and 7, there were no consistent differences in subjective effects between placebo and active study medication. A prudent approach to improve tolerability with Spectrum Yellow oil might involve initial doses no higher than 240 mg total CBD and 10.8 mg total THC daily in divided doses, with titration upwards over time as needed based on tolerability.

Withdrawal Symptoms From E-Cigarette Abstinence Among Former Smokers: A Pre-Post Clinical Trial

INTRODUCTION

The major aim of this study was to test whether abstinence from e-cigarettes causes withdrawal symptoms in former smokers.

METHODS

We conducted an unblinded, within-participants, pre-post clinical trial in which 109 former smokers who were current daily electronic cigarette (e-cigarette) users used their own e-cigarette for 7 days followed by 6 days of biologically confirmed abstinence engendered via an escalating contingency payment system. Participants monitored symptoms of nicotine withdrawal daily via an Interactive Voice Response system. They also attended three laboratory visits per week for carbon monoxide and cotinine testing to verify abstinence.

RESULTS

Half of participants completely abstained for a week. All the Diagnostic and Statistical Manual, Fifth Edition (DSM-5) tobacco withdrawal symptoms, craving for e-cigarettes, craving for tobacco cigarettes, and the four possible new withdrawal symptoms (anhedonia, impulsivity, mood swings, and positive affect) increased during abstinence. Weight increased and heart rate decreased with abstinence. Symptoms showed the prototypical inverted U time pattern of a withdrawal state. The magnitude of withdrawal appeared to be somewhat less than that in a prior study of abstinent daily tobacco cigarette smokers. More severe withdrawal on the first 2 days of abstinence did not predict abstinence on the last day of the study.

CONCLUSIONS

Former smokers who are daily e-cigarette users transfer physical dependence on tobacco cigarettes to dependence on e-cigarettes. The severity of withdrawal from e-cigarettes appears to be only somewhat less than that from daily tobacco cigarette use. Replication tests that include placebo controls, testing for pharmacological specificity, and including never-smokers, non-daily e-cigarette users and dual users are indicated.

IMPLICATIONS

Our results indicate e-cigarettes can maintain physical dependence. This adverse effect should be included in any risk vs. benefit calculation. Also, potential and current e-cigarette users should be informed that abrupt cessation of e-cigarettes can cause withdrawal symptoms.

TRIAL REGISTRATION

NCT02825459.

The state of clinical outcome assessments for cannabis use disorder clinical trials: A review and research agenda

There is considerable variability in the use of outcome measures in clinical trials for cannabis use disorder (CUD), and a lack of consensus regarding optimal outcomes may have hindered development and approval of new pharmacotherapies. The goal of this paper is to summarize an evaluation of assessment measures and clinical endpoints for CUD clinical trials, and propose a research agenda and priorities to improve CUD clinical outcome assessments. The primary recommendation is that sustained abstinence from cannabis should not be considered the primary outcome for all CUD clinical trials as it has multiple limitations. However, there are multiple challenges to the development of a reliable and valid indicator of cannabis reduction, including the lack of a standard unit of measure for the various forms of cannabis and products and the limitations of currently available biological and self-report assessments. Development of a core toolkit of assessments is needed to both allow flexibility for study design, while facilitating interpretation of outcomes across trials. Four primary agenda items for future research are identified to expedite development of improved clinical outcome assessments for this toolkit: (1) determine whether minimally invasive biologic assays could identify an acute level of cannabis use associated with psychomotor impairment or other cannabis-related harms; (2) create an indicator of quantity of cannabis use that is consistent across product types; (3) examine the presence of cannabis-specific functional outcomes; and (4) identify an optimal duration to assess changes in CUD diagnostic criteria.

Withdrawal Symptoms From E-Cigarette Abstinence Among Adult Never-Smokers: A Pilot Experimental Study

INTRODUCTION

Use of e-cigarettes among never-smokers has substantially increased; yet there are few descriptions of the consequences of such use. We assessed whether adult never-smokers can have withdrawal from cessation of e-cigarettes.

METHODS

In an un-blinded pre-post clinical trial, 30 never-smoker daily e-cigarette users used their own nicotine-containing e-cigarette for 7 days followed by 6 days of biologically confirmed abstinence. Participants monitored symptoms of nicotine withdrawal nightly via an Interactive Voice Response system. They attended three lab visits/week to provide expired carbon monoxide and urine samples to determine compliance.

FINDINGS

Abstinence increased all the DSM5 symptoms of tobacco withdrawal and this occurred in the majority of participants. The increase in severity of withdrawal was small and rarely impaired functioning.

CONCLUSIONS

Our finding suggests that withdrawal symptoms can occur in never-smokers who stop e-cigarettes abruptly. However, the severity of withdrawal appears to be small and may not be of clinical or regulatory significance. Although our sample size was small and thus replication tests of our results are indicated, it may be prudent to warn never-smokers that withdrawal symptoms may occur.

IMPLICATIONS

This study indicates that withdrawal symptoms can occur in never-smokers who are daily e-cigarette users. However, the severity of withdrawal from e-cigarette abstinence in never-smokers appears to be small and may not be of clinical or regulatory significance. Given our small sample size, replication of our results is warranted. Nevertheless, it might be prudent to warn never-smokers of addiction to e-cigarettes.Clinical Trial Registration = NCT02825459.

Blunt use and menthol cigarette smoking: An examination of adult marijuana users

INTRODUCTION

Use of menthol cigarettes remains highly prevalent among African American smokers and has increased among White and Hispanic/Latino smokers. Research is needed to examine if behavioral factors, such as marijuana use, are differentially associated with menthol cigarette use among racially/ethnically diverse samples of marijuana users.

METHODS

Using data from the 2017 National Survey on Drug Use and Health, this study examined the association between past month marijuana (blunt versus non-blunt) and cigarette (non-menthol cigarette versus menthol cigarette versus no cigarette) use, as well as racial/ethnic differences in this relationship.

RESULTS

Among all marijuana users (N = 5,137), 34.1% smoked blunts, 28.7% smoked non-menthol cigarettes and 18.0% smoked menthol cigarettes, with the highest rates of blunt (63.8%) and menthol cigarette (38.9%) use found among African American adults. Multinomial logistic regression analyses revealed a significant association between blunt use and non-menthol cigarette use (versus non-use) and menthol cigarette use (versus non-menthol cigarette and no cigarette use) among the full sample. When stratified by race/ethnicity, this finding was consistent for non-Hispanic White (n = 3,492) and partially consistent for Hispanic/Latino (n = 839) adults. However, among African American adults (n = 806), blunt use was not significantly associated with non-menthol cigarette use or menthol cigarette use.

DISCUSSION

Blunt use is associated with increased odds of non-menthol and menthol cigarette use, but only among Hispanic/Latino and White adults. Examining racial/ethnic differences in the association between marijuana and tobacco use is important to understanding disparities and informing prevention and treatment interventions and drug policies.

Chemical characterization of marijuana blunt smoke by non-targeted chemical analysis

Background: Marijuana blunts, which are tobacco cigar wrappers filled with marijuana, are commonly smoked in the US as a means of cannabis use. The use of marijuana blunts presents toxicity concerns because the smoke contains both marijuana-related and tobacco-related chemicals. Thus, it is important to understand the chemical composition of mainstream smoke (MSS) from marijuana blunts. This study demonstrates the ability to detect and identify chemical constituents exclusively associated with blunt MSS in contrast to tobacco cigar MSS (designated as 'new exposures') through non-targeted chemical analysis.Methods: Samples collected separately from blunt MSS and tobacco cigar MSS were analyzed using two-dimensional gas chromatography-time-of-flight mass spectrometry (GC × GC-TOFMS).Results and Discussion: Two new exposures, which likely represent only a subset of all new exposures, were identified by evaluating the data from thousands of detected signals and then confirming selected compound identities in analyses using authentic chemical standards. The two confirmed new exposures, mellein and 2-phenyl-2-oxazoline, are not cannabinoids and, to the best of our knowledge, have not been previously reported in association with cannabis, tobacco, or smoke of any kind. In addition, we detected and quantified three phenols (2-, 3-, and 4-ethylphenol) in blunt MSS. Given the toxicity of phenols, quantifying the levels of other phenols could be pursued in future research on blunt MSS.Conclusion: This study shows the power and utility of GC × GC-TOFMS as a methodology for non-targeted chemical analysis to identify new chemical exposures in blunt MSS and to provide data to guide further investigations of blunt MSS.

Cannabinoid effects on responses to quantitative sensory testing among individuals with and without clinical pain: a systematic review

There has been an explosion of interest in the utility of cannabinoids as potential analgesics. This systematic review critically synthesizes the evidence for cannabinoid analgesic effects on quantitative sensory testing outcomes in both healthy adults and patients with chronic noncancer pain. Our systematic review protocol is preregistered on PROSPERO (CRD42018117367). An electronic search was made in PsycINFO, Cochrane, Google Scholar, Embase, and Pubmed of all literature published until August 2018. Of the 1217 studies found from the search, a total 39 placebo-controlled studies that met the eligibility criteria were synthesized for this study. Because of substantial heterogeneity of study designs, populations, cannabinoid compounds, and quantitative sensory testing outcomes, meta-analysis was not conducted. More consistent evidence of cannabinoid analgesia was observed for inhaled cannabis than synthetic cannabinoids. Analgesic effects were most commonly observed in tests of cold pain sensitivity, and hyperalgesic effects were most commonly observed in tests of electrical stimulation. Patterns of findings from studies with healthy subjects did not substantively differ from those with chronic noncancer pain. However, these observations are qualified by the high degree of inconsistency across studies and methodological heterogeneity. We offer recommendations for future studies to improve study rigor and reproducibility.

Trends in and Characteristics of Marijuana and Menthol Cigarette Use Among Current Cigarette Smokers, 2005-2014

Background

Given increasing co-marijuana and tobacco use in the United States, this study aimed to explore the overlap between menthol cigarette use (MCU) and marijuana.

Methods

Data came from past month US cigarette smokers 12 years and older responding to the National Survey on Drug Use and Health between 2005 and 2014 (N = 51 500). Prevalence, demographics and substance use characteristics from 2013 to 2014 were assessed across four groups, based on past month marijuana and tobacco use: cigarette smokers with marijuana and MCU, with marijuana but no MCU, with no marijuana but MCU, and with use of neither. Multivariable logistic regression explored the relationship between MCU, marijuana, and dependence. Linear and quadratic trends were assessed using logistic regression with orthogonal polynomials.

Results

Past month marijuana/MCU among cigarette smokers was 8.3% in 2013-2014. Overall, marijuana/MCU was significantly higher among blacks versus whites (20.8% vs. 5.8%, p < .0001), though among 12-25 year olds, prevalence was significantly higher among whites versus blacks (6.3% vs. 0.9% for 12-17-year-olds; 39.2% vs. 26.8% for 18-25-year-olds). Marijuana/MCU increased significantly between 2005 and 2014 overall, and among whites and blacks. No adjusted associations were found between marijuana, MCU and nicotine or marijuana dependence.

Conclusions

Past month marijuana/MCU among cigarette smokers is increasing in the United States, with specific racial and age-based disparities. Research about the implications of consuming both marijuana and menthol, and the potential overlap in consumption of flavors across the products is warranted to better inform future preventive and treatment approaches.

Implications

This is the first study to assess the overlap between MCU and marijuana use among a nationally representative sample of US current smokers ages 12 and older. Findings from this study suggest that past month marijuana and menthol use among cigarette smokers is increasing in the United States, with specific racial/ethnic and age-based disparities. More research about the implications of consuming both marijuana and menthol, and the potential overlap in consumption of flavors in marijuana and tobacco products is warranted to better understand what preventive and treatment approaches may be needed.

Tobacco and cannabis co-use: Drug substitution, quit interest, and cessation preferences

The co-use of tobacco and cannabis is a common practice worldwide and carries with it substantial public health burden. Few interventions exist that target both substances and little is known about quit interest, treatment preferences, and drug substitution during past cessation attempts, which is critical to guide the development of treatment strategies. The goal of this study was to provide descriptive information regarding quit interest, treatment preferences, and perceived drug substitution among adult (age 18 +) cannabis-tobacco co-users. Participants (N = 282) from two independent survey samples (recruited from Amazon Mechanical Turk) from across the United States were combined. Among all participants, 57% were female, 79% were White, and average age was 33.31 (SD = 9.54) years old. Approximately 80% had tried to quit smoking cigarettes at least once, while 40% had tried to quit using cannabis at least once. Of those who tried to quit, 50% self-reported a perceived increase in their cannabis use during tobacco cessation and 62% self-reported a perceived increase in their tobacco use during cannabis cessation. Average quit interest (10-point scale) for cannabis was 2.39 (SD = 2.35) and for tobacco was 7.07 (SD = 2.90). Results of this study suggest that tobacco use should be addressed among cannabis-tobacco co-users, but interventions should consider lack of interest in cannabis cessation. Reduction-based strategies for cannabis use appear to be more acceptable to this nontreatment-seeking, co-using population. Drug substitution during quit attempts for one substance should be further explored as an important treatment consideration. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Prenatal Substance Use and Perceptions of Parent and Partner Use Using the 4P's Plus Screener

Background Prenatal substance use screening is recommended. The 4 P's Plus screener includes questions on perceived problematic substance use in parents and partner that are not considered in risk stratification. Objectives This research examined the: (1) prevalence of self-reported problematic parental and partner substance use and associations with biochemically-verified prenatal substance use; (2) utility of self-reported perceptions of parent/partner substance use as proxies for prenatal substance use; and (3) degree to which the sensitivity of the 4P's Plus can be augmented with consideration of parent/partner questions in risk stratification. Methods A convenience sample of 500 pregnant women was recruited between January 2017 and January 2018. Participants completed the 4P's Plus and provided urine for drug testing. Diagnostic utility of problematic parent/partner substance use questions was assessed, then compared to the 4P's Plus used as designed, and to the 4P's Plus used with these 2 questions included in risk stratification. Results Half (51%) of respondents reported either partner or parental problematic substance use. When partner or parent problematic substance use were considered as proxies for prenatal substance use, sensitivity was 65% and specificity was 55%. When used as intended, sensitivity was 94% and specificity was 29%. Including partner/parent questions increased sensitivity to 96% but lowered specificity (19%). Partner substance use and combined partner/parent use were associated with prenatal substance use [adjusted odds ratio (aOR): 2.0 (1.2, 2.4; p = 0.006); aOR = 1.6 (1.1, 2.5, p = 0.04)]. Conclusions for Practice Sensitivity of the 4P's Plus may improve with inclusion of self-reported problematic partner/parent substance use items in risk stratification.

Systematic review of outcome domains and measures used in psychosocial and pharmacological treatment trials for cannabis use disorder

Cannabis use disorder (CUD) is prevalent and demand for treatment is increasing, yet few individuals engage in formal treatment and the efficacy of established interventions for CUD is modest. Existing clinical trials evaluating psychosocial and pharmacological treatments for CUD have incorporated a wide variety of measures for assessing cannabis use outcomes, including abstinence, self-reported frequency and quantity used, withdrawal, use/dependence severity, and other psychosocial outcomes. The heterogeneity of measures and outcomes has limited quantitative analyses of the comparative effectiveness of existing interventions. The purpose of this systematic review is to: 1) identify and characterize approaches for measuring cannabis use in existing CUD intervention trials, including abstinence, frequency and quantity of use, and 2) summarize measures used to assess treatment efficacy in other outcome domains (e.g., cannabis use severity, psychosocial functioning, cannabis withdrawal), and provide a platform for future research to evaluate which outcome measures are most likely to reflect treatment efficacy and clinically significant improvement in other outcome domains.

Prevalence and Sociodemographic Correlates of Adolescent Use and Polyuse of Combustible, Vaporized, and Edible Cannabis Products

IMPORTANCE

Cannabis legalization and commercialization have introduced novel alternative cannabis products, including edible and vaporized cannabis that might appeal to youth and be associated with polyuse (ie, use of ≥2 different products).

OBJECTIVE

To investigate the prevalence, patterns, and sociodemographic correlates of cannabis product use across combustible, edible, and vaporized administration methods, including polyuse of cannabis via multiple administration methods.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional survey study included 10th-grade students from 10 Los Angeles, California, area high schools from January 2 through October 6, 2015. Students were recruited from respondents in the Happiness and Health Study, an ongoing prospective cohort study in the 10 high schools. Students not in school during administration of the pencil-and-paper survey completed abbreviated surveys by telephone, internet, or mail. Data were analyzed from July 17, 2017, through July 12, 2018.

EXPOSURES

Self-reported sex, race/ethnicity, and socioeconomic status (SES). Students with high SES had parents who attained college or a higher educational level and were ineligible for free or subsidized lunch; those with low SES had parents with lower educational attainment or were eligible for free or subsidized lunch.

MAIN OUTCOMES AND MEASURES

Self-report of ever use (yes or no) and past 30-day use (yes or no) status and frequency of use (days in past 30 days) of combustible, edible, and vaporized cannabis.

RESULTS

The sample included 3177 tenth-grade students (93.5% of study enrollees); among these students, 1715 (54.0%) were girls and the mean (SD) age was 16.1 (0.4) years. Among those with available demographic data, respondents were diverse in race/ethnicity (537 [17.2%] Asian; 149 [4.8%] black; 1510 [48.3%] Hispanic; 507 [16.2%] white; 207 [6.6%] multiethnic/multiracial; and 216 [6.9%] other) and included 1654 (60.1%) with a low SES. Prevalence of ever use was highest for combustible products (993 [31.3%]), followed by edible (676 [21.3%]) and vaporized (333 [10.5%]) products. A similar pattern was found for past 30-day use (426 [13.4%] for combustible, 249 [7.8%] for edible, and 156 [4.9%] for vaporized cannabis). Among participants who reported using cannabis in the past 30 days, mean frequency of use of combustible cannabis was higher by 2.65 days (95% CI, 1.40-3.91 days, P = .001) than the mean frequency of use for edible cannabis and 1.75 days higher (95% CI, 0.59-2.90 days, P = .003) than frequency of use for vaporized cannabis. Most cannabis users (665 [61.7%]) used multiple administration methods, and 260 (8.2%) used all 3 methods. Boys had higher prevalence of ever use for vaporized (170 [11.6%] vs 163 [9.5%]) but not combustible (459 [31.4%] vs 534 [31.1%]) or edible (303 [20.7%] vs 373 [21.7%]) cannabis. Respondents with low SES had higher prevalence of ever use for combustible (614 [37.1%] vs 242 [22.0%]) and edible (408 [24.7%] vs 166 [15.1%]) but not vaporized (186 [11.2%] vs 93 [8.5%]) cannabis.

CONCLUSIONS AND RELEVANCE

Among 10th-grade students in Los Angeles, use of cannabis via alternative administration methods was of appreciable prevalence, predominately reported in conjunction with other cannabis products and unequally distributed across sociodemographic strata. Prevention programs and regulatory restrictions addressing the spectrum of cannabis products might benefit pediatric public health.

Prevalence and associated birth outcomes of co-use of Cannabis and tobacco cigarettes during pregnancy

Use of Cannabis and use of tobacco overlap, and co-use of Cannabis and tobacco has increased over the past decade among adults. The current study aims to document the prevalence and correlates of co-use of Cannabis and tobacco cigarettes among adult pregnant women utilizing secondary data from a larger study that compared and validated screeners for illicit and prescription drug use during pregnancy. Pregnant women (N = 500; 71% African American; 65% never married, average age of 28 years) were recruited from two urban University obstetric clinics between January and December 2017. Participants self-reported demographic, Cannabis, and tobacco cigarette use characteristics, and provided urine and hair samples for drug testing. Within two weeks after due date, research staff reviewed participants' electronic medical records to collect birth outcome data. Results showed that 9.0% reported co-use of Cannabis and tobacco, 12.1% reported Cannabis only use, 7.8% reported tobacco cigarette only use, and 71.1% reported no Cannabis or tobacco cigarette use in the past month. The birth outcomes to emerge as significant correlates of co-use of Cannabis and tobacco cigarettes were small head circumference, and the occurrence of birth defects, with the co-use group having the highest odds of a small head circumference [aOR: 5.7 (1.1-28.9)] and birth defects [aOR: 3.1 (1.2-8.3)] compared with other use groups. The Cannabis only group had 12 times higher odds of a stillbirth or miscarriage (aOR = 12.1). Screening and interventions to address concurrent Cannabis and tobacco use during pregnancy are needed, particularly among subpopulations with higher co-use rates. It is imperative to further explore and highlight the possible health implications of maternal co-use given the high prevalence rates found in this study sample.

Cigar and Marijuana Blunt Use Among Pregnant and Nonpregnant Women of Reproductive Age in the United States, 2006-2016

OBJECTIVES

To assess trends in prevalence of cigar and blunt use in relation to cigarette use among pregnant and nonpregnant women of reproductive age.

METHODS

We used 2006 to 2016 data from the US National Survey on Drug Use and Health to assess past-month use of cigarettes, cigars, and blunts among a total of 8695 pregnant women and 162 451 nonpregnant women aged 18 to 44 years.

RESULTS

Cigarette use was more prevalent than cigar or blunt use in pregnant and nonpregnant women, with higher prevalence in nonpregnant women for each product. Among all women, cigarette use decreased and blunt use increased over time, whereas cigar use remained stable. Smoking prevalence was highest in the first trimester.

CONCLUSIONS

The health implications of the increase in blunt use are not well known in the scientific literature or by the general public. Given the rapid changes in state marijuana laws, this issue should be a public health priority.

Sweet flowers are slow, and weeds make haste: leveraging methodology from research on tobacco, alcohol, and opioid analgesics to make rapid and policy-relevant advances in cannabis science

The legalization of medical and recreational cannabis use has occurred ahead of science. The current evidence base has poor utility for determining if cannabis products can meet the standards of safety, efficacy, and quality intrinsic to modern medicine, and for informing regulation of cannabis as a legal intoxicant. Individual jurisdictions that pass cannabis reforms may not have adequate resources to support the level of new scientific research needed to inform regulatory actions; this could make it difficult to keep a rapidly growing multi-billion-dollar cannabis industry in check. Further, the present lack of evidence-based regulatory oversight for cannabis parallels the climates that gave rise to the tobacco and prescription opioid epidemics, suggesting that continued omission may result in negative public health consequences. However, translating a methodological framework developed through research on these compounds may promote rapid advances in cannabis science germane to regulatory knowledge gaps. The present review highlights specific advancements in these areas, as well as in alcohol regulation, that are prime for informing policy-relevant cannabis science, and also offers some recommendations for evidence-based regulatory policy. Resulting progress may directly inform both regulation of cannabis in both medical and licit recreational drug frameworks, and new cannabis-related public health initiatives.

Day-to-Day Variability in Self-Reported Cigarettes Per Day

Background and Aims

Nicotine addiction theory predicts small day-to-day variability in cigarettes/day (CPD) whereas social learning theory predicts large variability. A description of the variability in CPD over multiple days is not available.

Methods

We conducted secondary analyses of two natural history studies with daily smokers-one of smokers not intending to quit, and one of smokers intending to quit sometime in the next 3 months. In the former, smokers recorded their smoking during the day by Ecological Momentary Assessment, using a palm-top computer. In the latter, participants reported CPD nightly via a phone Interactive Voice Response system. Analyses were based on smokers who reported averaging ≥10 CPD, and on days in which there was no attempt to stop or reduce smoking.

Results

Across the two studies, on average, smokers had small changes in day-to-day CPD (mean changes were 2.2 and 2.9 CPD). However a minority averaged changing by ≥5 CPD from one day to the next (7% and 11%), and many changed by ≥5 CPD on at least 10 of the 90 days (8% and 31%). Neither smoking restrictions, dependence, stereotypy ratings, nor interest in quitting predicted variability.

Conclusion

Although on average, smokers have little change day-to-day CPD, a substantial minority of smokers often change by 5 CPD from day-to-day. We did not find potential causes of this variability.

Implications

Across day variability in CPD is larger than implied in prior studies. Determining causes of day-to-day variability should increase our understanding of the determinants of smoking.

Correlates and trends in youth co-use of marijuana and tobacco in the United States, 2005-2014

BACKGROUND

Past-month marijuana and tobacco use (co-use) are increasing among U.S. adults, but little is known about the prevalence of co-use among U.S. youth. This study uses nationally representative data to assess the prevalence, correlates, and trends in co-use of marijuana and tobacco, tobacco-only use, and marijuana-only use among U.S. youth.

METHODS

Data came from 176,245 youth ages 12-17 who responded to the National Survey on Drug Use and Health - a nationally representative, household interview survey - between 2005 and 2014. Prevalence, demographics and substance use characteristics from 2013 to 14 were assessed across three groups: past-month users of marijuana and tobacco (co-users), past-month tobacco-only users, and past-month marijuana-only users. Multinomial logistic regression was used to assess demographic correlates of each group. Linear and quadratic trends were assessed from 2005 to 2014 using logistic regression with orthogonal polynomials.

RESULTS

In 2013-14, 5.4% of youth reported past-month co-use of tobacco and marijuana, 2.2% reported marijuana-only use, and 3.9% reported tobacco-only use. Co-use was associated with higher prevalence of past year marijuana dependence (vs. marijuana-only users), and higher past-month risky alcohol and other illicit drug use (vs. both tobacco and marijuana-only use groups). Co-use did not increase significantly between 2005 and 2014; tobacco-only use declined, and marijuana-only use increased.

CONCLUSIONS

Co-use of marijuana and tobacco is more prevalent than tobacco-only or marijuana-only use in U.S. youth. Given changing tobacco and marijuana policies, ongoing surveillance and studies that seek to increase our understanding of co-use behaviors in youth are critical.

Comparison and validation of screening tools for substance use in pregnancy: a cross-sectional study conducted in Maryland prenatal clinics

INTRODUCTION

Prescription-drug use in the USA has increased by more than 60% in the last three decades. Prevalence of prescription-drug use among pregnant women is currently estimated around 50%. Prevalence of illicit drug use in the USA is 14.6% among pregnant adolescents, 8.6% among pregnant young adults and 3.2% among pregnant adults. The first step in identifying problematic drug use during pregnancy is screening; however, no specific substance-use screener has been universally recommended for use with pregnant women to identify illicit or prescription-drug use. This study compares and validates three existing substance-use screeners for pregnancy-4 P's Plus, National Institute on Drug Abuse (NIDA) Quick Screen/Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) and the Substance Use Risk Profile-Pregnancy (SURP-P) scale.

METHODS AND ANALYSIS

This is a cross-sectional study designed to evaluate the sensitivity, specificity and usability of existing substance-use screeners. Recruitment occurs at two obstetrics clinics in Baltimore, Maryland, USA. We are recruiting 500 participants to complete a demographic questionnaire, NIDA Quick Screen/ASSIST, 4 P's Plus and SURP-P (ordered randomly) during their regularly scheduled prenatal appointment, then again 1 week later by telephone. Participants consent to multidrug urine testing, hair drug testing and allowing access to prescription drug and birth outcome data from electronic medical records. For each screener, reliability and validity will be assessed. Test-retest reliability analysis will be conducted by examining the results of repeated screener administrations within 1 week of original screener administrations for consistency via correlation analysis. Furthermore, we will assess if there are differences in the validity of each screener by age, race and trimester.

ETHICS AND DISSEMINATION

This study is approved by the Institutional Review Board of the University of Maryland (HP-00072042), Baltimore, and Battelle Memorial Institute (0619-100106433). All participants are required to give their informed consent prior to any study procedure.

Marijuana and tobacco co-use among a nationally representative sample of US pregnant and non-pregnant women: 2005-2014 National Survey on Drug Use and Health findings

BACKGROUND

Marijuana and tobacco are the most commonly used illicit and licit drugs during pregnancy. This study aimed to examine a nationally representative sample of US pregnant women and to: (1) determine the prevalence of past month marijuana and tobacco co-use, (2) identify characteristics that distinguish marijuana and tobacco co-users from users of marijuana only, tobacco only, or neither, and (3) compare characteristics that differ between pregnant and non-pregnant co-users of marijuana and tobacco.

METHODS

Data were obtained from 497,218 US women (8721 pregnant) ages 12-49 who participated in the 2005-2014 National Survey on Drug Use and Health. Prevalence and demographic and substance use characteristics were compared across groups using weighted estimates and chi-squared tests. Multinomial logistic regression identified demographic and substance use correlates of co-use.

RESULTS

Co-use among pregnant and non-pregnant women was significantly more prevalent than marijuana-only use but was less common than tobacco-only use. In unadjusted frequencies, pregnant co-users significantly differed from non-pregnant co-users across several domains. Among pregnant women, multivariate correlates of co-use of tobacco and marijuana vs. tobacco-only use were ages 12-17, non-Hispanic black race, Hispanic ethnicity, and past month polytobacco, any alcohol, and other drug use (all adjusted odds ratios≥2.0).

CONCLUSIONS

In this first examination of the prevalence and correlates of co-use of marijuana and tobacco among a nationally representative group of pregnant women, pregnant co-users were more likely to report other high risk behaviors compared with non-pregnant co-users and users of a single substance, suggesting disparities worthy of further investigation.

Marijuana and tobacco cigarettes: Estimating their behavioral economic relationship using purchasing tasks

Although marijuana and tobacco are commonly coused, the nature of their relationship has not been fully elucidated. Behavioral economics has characterized the relationship between concurrently available commodities but has not been applied to marijuana and tobacco couse. U.S. adults ≥18 years who coused marijuana and tobacco cigarettes were recruited via Mechanical Turk, a crowdsourcing service by Amazon. Participants (N = 82) completed online purchasing tasks assessing hypothetical marijuana or tobacco cigarette puff consumption across a range of per-puff prices; 2 single-commodity tasks assessed these when only 1 commodity was available, and 2 cross-commodity tasks assessed these in the presence of a concurrently available fixed-price commodity. Purchasing tasks generated measures of demand elasticity, that is, sensitivity of consumption to prices. In single-commodity tasks, consumption of tobacco cigarette puffs (elasticity of demand: α = 0.0075; 95% confidence interval [0.0066, 0.0085], R² = 0.72) and of marijuana puffs (α = .0044; 95% confidence interval [0.0038, 0.0049], R² = 0.71) declined significantly with increases in price per puff. In cross-commodity tasks when both tobacco cigarette puffs and marijuana puffs were available, demand for 1 commodity was independent of price increases in the other commodity (ps > .05). Results revealed that, in this small sample, marijuana and tobacco cigarettes did not substitute for each other and did not complement each other; instead, they were independent of each other. These preliminary results can inform future studies assessing the economic relationship between tobacco and marijuana in the quickly changing policy climate in the United States. (PsycINFO Database Record

Marijuana and tobacco co-administration in blunts, spliffs, and mulled cigarettes: A systematic literature review

BACKGROUND

Blunts and spliffs/mulled cigarettes combine marijuana and tobacco for co-administration (use at the same time, in the same product). Co-administration of marijuana and tobacco presents significant potential for nicotine exposure, and may lead to exclusive tobacco use patterns, nicotine addiction, and compounded health effects. No review articles have summarized the number and nature of studies published on these co-administered products.

METHODS

Keywords "(blunt* OR spliff OR mull* OR joint) AND (tobacco OR smok* OR cigarette) AND (cannabis OR marijuana OR hashish)" were searched in the published literature. A total of 220 articles were considered for inclusion, 49 were reviewed by two independent qualitative coders, and 45 were included in this review.

RESULTS

Of the 45 articles, most (n=27) of studies were observational or descriptive; ten were qualitative, five employed causal designs, and three were mixed methods. A majority of the studies assessed blunts; only 11 studies assessed spliffs/mulled cigarettes. Many studies focused on sub-populations of youth, males, and African Americans. Use of co-administered marijuana and tobacco products was associated with several indicators of problematic use patterns, including perceptions of less risk, dependence on nicotine and marijuana, and greater subjective effects related to marijuana.

CONCLUSIONS

Literature on marijuana and tobacco co-administration comes largely from qualitative and observational/descriptive studies. In addition to continued surveillance, experimental research that directly assesses the smoking patterns of co-administered marijuana and tobacco products as compared with to those of marijuana and tobacco only products is needed to determine the potential long-term health consequences of using blunts, spliffs, or other co-administered products.

Tobacco assessment in completed lung cancer treatment trials

An effort over 3 years to conduct a data pooling project regarding the association between smoking and lung cancer treatment outcomes has shown that, of 32 completed studies of lung cancer treatments in 1 National Cancer Institute Cooperative Group, only a minority have usable data concerning smoking‐related variables. Clinical trials research is needed to inform patients with cancer and their physicians about the impact of smoking, and how smoking cessation may affect the course of their disease.

Does marijuana "blunt" smoking contribute to nicotine exposure?: Preliminary product testing of nicotine content in wrappers of cigars commonly used for blunt smoking

INTRODUCTION

An increasingly popular method of consuming marijuana is through the smoking of "blunts," cigar products in which some or all of the tobacco filler is removed and repacked with marijuana. Even if all tobacco filler is removed from the cigar product in the process of making blunts, nicotine may be present in the wrapper of the cigar product. This preliminary analysis quantified the nicotine content in wrappers of cigar products commonly used for blunt smoking.

METHODS

Five cigar products (3 large cigars, 2 cigarillos) were tested, yielding physical characteristics of cigar length, diameter, weight, and wrapper weight. Nicotine concentration in the wrapper of each cigar product was analyzed via gas chromatography/mass spectrometry. Total nicotine content in the wrapper of each cigar product was computed as the product of cigar wrapper weight and nicotine concentration in wrapper.

RESULTS

Depending on the product, the cigar wrapper contributed between 8 and 18% of the weight of the entire cigar article. Total nicotine content in the cigar wrapper ranged from 1.2 to 6.0mg per cigar.

DISCUSSION

All 5 tested cigar products had wrappers that contain quantifiable levels of nicotine, indicating that users of blunts may expose themselves to some degree of nicotine, the addictive component of tobacco. Future experimental studies that examine the efficiency of nicotine delivery from typical blunt smoking, as well as surveillance studies that quantify the number of blunts smoked by an individual per day, are needed to evaluate the contribution of blunt smoking to nicotine dependence.

Relationship of gambling with tobacco, alcohol, and illicit drug use among adolescents in the USA: Review of the literature 2000-2014

BACKGROUND AND OBJECTIVES

Adolescence is a time during which not only gambling, but also tobacco, alcohol, and illicit drug use, usually begin. The purpose of this paper is to provide an updated review of the literature on gambling and its associations with tobacco, alcohol, and illicit drug use among US youth.

METHODS

An electronic literature search of PubMed and PsycInfo was conducted for studies since 2000 using the keywords "smoking," "tobacco," "nicotine," "cigarette," "gambling," "adolescence," "adolescent," "alcohol," and "substance use." Ten articles with unique adolescent samples were located. Because the articles varied in regard to definitions of gambling, tobacco, alcohol, and drug use, we provide a qualitative review of included studies.

RESULTS

Gambling prevalence rates ranged from 44.3% to 68% in national telephone-based surveys, from 24.4% to 86% among students in school-based surveys, and from 22.5% to 47.4% in surveys of convenience samples. Significant associations were reported between gambling and tobacco use (4/7 articles), gambling and alcohol use (7/8 articles), and gambling and illicit drug use (7/8 articles).

CONCLUSIONS

The wide range in rates of gambling and problem gambling may be due in part to differences among the studies in participant samples, sampling techniques, assessment time frames, and definitions of gambling. Despite methodological differences, most studies showed significant associations of gambling with tobacco, alcohol, and other illicit drug use.

SCIENTIFIC SIGNIFICANCE

As accessibility to gambling increases, more research is needed to inform prevention efforts and identify youth at-risk for gambling and other high-risk behaviors.

Electronic cigarettes in adults in outpatient substance use treatment: Awareness, perceptions, use, and reasons for use

BACKGROUND AND OBJECTIVES

Most studies on e-cigarettes have come from population-based surveys. The current research aimed to provide initial data on e-cigarette awareness, perceptions, use, and reasons for use among adults seeking substance use treatment.

METHODS

A survey was conducted among 198 participants ≥18 years old in a community-based outpatient substance use treatment program.

RESULTS

Of the 198 participants, 69% currently smoked cigarettes, 92% were aware of e-cigarettes, and 58% had ever used e-cigarettes. The proportion of the number of participants who had ever used e-cigarettes to the number who currently smoked (89.7%) appeared higher than the corresponding proportion in the 2012-13 National Adult Tobacco Survey (78.3%). Almost half of the sample who reported ever using e-cigarettes endorsed quitting or reducing smoking as a reason for use, and 32% endorsed reasons for use relating to curiosity/experimentation. A greater likelihood of e-cigarette ever-use was significantly associated with younger age (adjusted odds ratio [AOR] = 0.94, 95%confidence interval [CI] = 0.90, 0.98) and perceptions related to using e-cigarettes in public places where smoking cigarettes is not allowed (AOR = 2.96, 95%CI = 1.18, 7.42) but was not associated with primary drug of choice.

DISCUSSION AND CONCLUSIONS

E-cigarette use in adults seeking substance use treatment appears higher than it is in the US general population of smokers. The high frequency of use may be due to curiosity/experimentation or attempts to quit or reduce smoking.

SCIENTIFIC SIGNIFICANCE

Future research may consider how e-cigarettes interact with other substance use and affect high rates of nicotine and tobacco use in this population.

Preliminary findings on the association between clients' perceived helpfulness of substance abuse treatment and outcomes: does race matter?

BACKGROUND

Few studies examine the helpfulness and effectiveness of substance abuse treatment from the clients' perspective.

METHODS

The current secondary analysis examined the perceived helpfulness of substance abuse treatment components and its relationship to treatment outcomes among 387 Black and White adults participating in a multisite randomized clinical trial (RCT) of Motivational Enhancement Therapy. Throughout the 16-week RCT, participants self-reported substance use. Upon completion of treatment, participants completed a self-report measure assessing the perceived helpfulness of treatment components.

RESULTS

Black participants rated 9 out of 12 treatment components (e.g., "learning skills that will help me cope with my problems") as being more helpful than their White counterparts, even after controlling for age, gender, employment status, primary drug type, and treatment assignment. However, perceived helpfulness ratings were not associated with substance use outcomes among Black or White participants.

CONCLUSIONS

Clients' perceived helpfulness of treatment components is an important factor to consider in improving the delivery of substance abuse treatment, especially for Black adults.

Delay discounting in adults receiving treatment for marijuana dependence

Delay discounting is an index of impulsive decision-making and reflects an individual's preference for smaller immediate rewards relative to larger delayed rewards. Multiple studies have indicated comparatively high rates of discounting among tobacco, alcohol, cocaine, and other types of drug users, but few studies have examined discounting among marijuana users. This report is a secondary analysis of data from a clinical trial that randomized adults with marijuana dependence to receive one of four treatments that involved contingency management (CM) and cognitive-behavioral therapy interventions. Delay discounting was assessed with the Experiential Discounting Task (Reynolds & Schiffbauer, 2004) at pretreatment in 93 participants and at 12 weeks posttreatment in 61 participants. Results indicated that higher pretreatment delay discounting (i.e., more impulsive decision-making) significantly correlated with lower readiness to change marijuana use (r = -0.22, p = .03) and greater number of days of cigarette use (r = .21, p = .04). Pretreatment discounting was not associated with any marijuana treatment outcomes. CM treatment significantly interacted with time to predict change in delay discounting from pre- to posttreatment; participants who received CM did not change their discounting over time, whereas those who did not receive CM significantly increased their discounting from pre- to posttreatment. In this sample of court-referred young adults receiving treatment for marijuana dependence, delay discounting was not strongly related to treatment outcomes, but there was some evidence that CM may protect against time-related increases in discounting.

A comprehensive examination of delay discounting in a clinical sample of Cannabis-dependent military veterans making a self-guided quit attempt

Delay discounting (DD), an index of impulsivity, reflects individuals' preference for smaller immediate rewards to larger delayed rewards. The current study examined (a) relations between DD and quantity, frequency, and severity of Cannabis use, as well as several other measures of co-occurring substance use and clinical severity, and (b) whether DD predicted Cannabis-cessation outcomes. Cannabis-dependent United States (U.S.) veterans (N = 72; 95% male) who were interested in making serious self-quit attempts were evaluated prior to their cessation attempts, during which they completed a computerized DD task, and were followed throughout six months postattempt. Results indicated that higher DD was significantly correlated with higher compulsive craving for Cannabis (ρ = .29, p < .05), younger age of first Cannabis use (r = -.32, p < .01), earlier commencement of regular Cannabis smoking (r = -.25, p < .05), and seeking professional help for a previous Cannabis quit attempt (ρ = .27, p < .05). DD did not significantly predict any Cannabis-cessation outcomes in the first week postattempt or during the 6-month follow-up. These results add to the literature on DD, which has focused on users of tobacco, alcohol, opioids, and cocaine, by demonstrating that DD is sensitive to developmental trajectories of Cannabis dependence, but does not reliably predict cessation outcomes. Results also suggest that DD may carry less relevance for Cannabis than for other substances of abuse.

Combining cognitive behavioral therapy and contingency management to enhance their effects in treating cannabis dependence: less can be more, more or less

AIMS

To evaluate reciprocal enhancement (combining treatments to offset their relative weaknesses) as a strategy to improve cannabis treatment outcomes. Contingency management (CM) with reinforcement for homework completion and session attendance was used as a strategy to enhance cognitive-behavioral therapy (CBT) via greater exposure to skills training; CBT was used as a strategy to enhance durability of CM with rewards for abstinence.

SETTING

Community-based out-patient treatment program in New Haven, Connecticut, USA.

DESIGN

Twelve-week randomized clinical trial of four treatment conditions: CM for abstinence alone or combined with CBT, CBT alone or combined with CM with rewards for CBT session attendance and homework completion.

PARTICIPANTS

A total of 127 treatment-seeking young adults (84.3% male, 81.1% minority, 93.7% referred by criminal justice system, average age 25.7 years).

MEASUREMENTS

Weekly urine specimens testing positive for cannabis, days of cannabis use via the time-line follow-back method.

FINDINGS

Within treatment, reinforcing homework and attendance did not significantly improve CBT outcomes, and the addition of CBT worsened outcomes when added to CM for abstinence (75.5 versus 57.1% cannabis-free urine specimens, F = 2.25, P = 0.02). The CM for abstinence condition had the lowest percentage of cannabis-negative urine specimens and the highest mean number of consecutive cannabis-free urine specimens (3.3, F = 2.33, P = 0.02). Attrition was higher in the CBT alone condition, but random effect regression analyses indicated this condition was associated with the greatest rate of change overall. Cannabis use during the 1-year follow-up increased most rapidly for the two enhanced groups.

CONCLUSIONS

Combining contingency management and cognitive-behavioural therapy does not appear to improve success rates of treatment for cannabis dependence in clients involved with the criminal justice system.