Due to federal prohibition in the United States, the effectiveness of cannabis consumption in any of its forms is relatively unknown.
Those in Oklahoma who medicate with cannabis have an array of choice in what and how they consume, from gummies and lollipops to lotions and bath bombs.
There are a variety of reasons a patient might choose one method over another. Some are unable to smoke cannabis due to respiratory issues, while others choose not to because of the stigma associated with the practice.
Each product with a different delivery system affects the body in a different way — even those with identical chemical compounds. Making a decision on how to ingest cannabis should be considered carefully along with the particular strain you choose.
National Academy of Sciences has published a series of studies over the last several decades detailing the effects of cannabis on the human body as well as on some animals. The three studies were published over four decades, the first in 1982, followed by those in 1997 and 2017.
Each study suggests a range of potential ailments that could possibly be treated with cannabis, though recommendations have changed as its chemistry has become better understood.
The study from 1983 noted glaucoma and epilepsy as potential areas of study. In 1997, epilepsy was thought to be unrelated to cannabinoids, and researchers advised the connection be abandoned in favor of investigating the role of cannabis in muscle spasticity and the treatment of chronic pain.
Today, cannabis’s only empirically backed medical use in the United States is for treatment of children with epilepsy, though it is thought to alleviate symptoms from a variety of other conditions.
The first studies in 1983 and 1997 focused primarily on cannabis that was inhaled.
Inhaling cannabis means it is primarily processed by the lungs, or pulmonary system. The chemicals take effect only minutes after entering the body, and the high fades relatively quickly.
Inhaled cannabis allows for dose control in a way that pills do not. Instead of taking a premeasured amount, the patient is able to control the amount they use and how intense the effects will be — something particularly useful in the treatment of pain.
In the case of smoked cannabis, the process of combustion changes the substance that enters the body. Early research on medical cannabis struggled to draw conclusions on the effects of smoked cannabis because of the immense variation from joint to joint.
The ratio of THC to CBD had to be considered, but so did each individual cigarette — even those coming from the same source or batch. Any cannabis samples used in research in the United States comes from a facility run by the National Institute on Drug Abuse at the University of Mississippi. Even with this level of uniformity, drawing definitive conclusions was difficult.
Two joints rolled from the same batch could be packed more or less densely than one another or contain varying ratios of the plant itself. For example, the bud of the flower is the main source of the psychoactive compounds while the leaves and stems contain relatively little, so two joints rolled from the same plant might vary in the effects they produce.
“There is moderate evidence of no statistical association between cannabis use and incidence of lung, head, or neck cancers,” the most recent study, published in 2017 and titled The Health Effects of Cannabis and Cannabinoids found. “We really saw no adverse effects on the lungs of cannabis inhalation. Increased cough and mucus was all we found.”
Vaporized cannabis, or “vapes” are a newer form of inhaled cannabis. Though the intake method is the same as smoked cannabis, vaping differs substantially in key components.
Combustion is a chemical change, meaning the process of burning a substance alters its chemical compounds. Vaporization is a physical change. In addition to using less heat, the chemical compounds remain consistent throughout the process.
The substance used in vape cartridges is more consistent in terms of potency and THC to CBD ratios, eliminating the guesswork concerning which parts of the plant were used. The cannabis plant contains hundreds of different cannabinoid compounds, which are all present in a joint made from the dried plant.
Oil extracts can be measured for these compounds more carefully and contain a more precise mixture of cannabinoids than is possible using the bud of a whole plant — one of the reasons CBD oil can be sold over the counter while buds and flowers are only sold at dispensaries.
“We studied the Volcano vaporizer in healthy cannabis and compared vaporization to smoking a cigarette and found that they deliver the same amount of THC into the bloodstream and got people equally as high but with less expired carbon monoxide, suggesting that vaporization might be a safer delivery system. From that time on, we used the Volcano vaporizer in our trials,” study author Donald I. Abrams said.
However, he also said there is some uncertainty where vaping is concerned.
“I am rather conservative, and I do know the long-term effects of inhaling combusted plant products, but I don’t know the long-term effects of inhaling an oil,” Abrams said. “I worry about vape cartridges and what they’re going to do to people’s lungs if they’re inhaling oils.”
For some, inhaling cannabis is not practical. This could be due to muscle spasms, as seen in epilepsy and multiple sclerosis, or in patients with prior respiratory conditions such as chronic obstructive pulmonary disorder.
These people might not be able to hold or smoke a cigarette for long periods of time and need an alternative delivery method.
One specific form of oral cannabis has been available for more than two decades. Marinol, or Dronabinol, is a pill containing synthetic THC that was approved by the U.S. Food & Drug Administration for countering nausea in terminal cancer and to combat AIDS wasting syndrome.
The pill remains the only form of cannabis approved for medical use at the federal level. It was first approved by the FDA in 1985 and is considered a Schedule III substance, along with drugs such as codeine and ketamine.
The cannabis plant itself remains classified as a Schedule I narcotic, along with heroin, LSD and ecstasy.
Edibles — whether they are gummies, chocolate-covered pretzels or brownies — are primarily processed through the stomach and liver and end up in the bloodstream. Their effect is less immediate and longer-lasting, though that creates its own issues.
“I often see elderly women with cancer who believe that inhaling is bad and ingesting is good. So they go to a dispensary and are told to only eat a quarter of the cookie, and they do and nothing happens. They eat another quarter and nothing happens, so they eat another quarter and nothing happens. So they eat the whole cookie and then they call me three days later, possibly after a visit to the emergency room for a dysphoric reaction, saying they’re never going to do that again,” Abrams said.
Dr. Kent Hutchison, who also worked on the 2017 study, found that although patients who inhale and ingest experience the effects on a different time frame, they did not report feeling different effects from one method to another.
However, once cannabinoids enter the bloodstream, they can be difficult to measure.
“What is interesting about this is that blood levels do not correspond or correlate with the effects,” Hutchison said. “For example, blood level will peak within minutes after smoking, but you’ll still feel high an hour later or an hour and a half later.”
Cannabinoids are lipophilic, meaning they dissolve easily in fats. These compounds can linger in the fatty tissue of the body for hours or even days after the effects have passed, which makes testing for cannabis especially tricky.
“It doesn’t matter how high the blood levels go; it doesn’t really relate to how intoxicated a person is.”
— Kent Hutchison
“It doesn’t matter how high the blood levels go; it doesn’t really relate to how intoxicated a person is. … It’s very different than alcohol,” Hutchison said. “There’s no breathalyzer or blood alcohol test for marijuana.”
Though he does not use cannabis recreationally, Abrams said he is not very concerned for people who do.
“In general, I do believe cannabis is much healthier for people than alcohol,” he said. “I’ve been a physician now for 40 years, and I’ve admitted one patient to the hospital over 40 years with a potential adverse effect from cannabis. The number of patients I’ve admitted with potential adverse effects from alcohol, heroin, cocaine, speed [and] sugar is enormous.”
Abrams himself uses a topical cream to treat his arthritis.
Topical cannabis is absorbed through the skin, giving it the advantage of local application in the case of arthritis or joint pain. Less is known about topical administration, as it is still in relatively early stages of development.
“Many people say that cannabinoids are not absorbed topically, but I have a number of topical products myself that I use on my arthritis,” he said. “If they’re not absorbed, they’re certainly doing something.”
One of the reasons so little is known about the topical delivery system is that the cannabis plant remains classified as a Schedule I narcotic and can only be studied under very specific conditions.
Because all federally funded studies must use cannabis grown at the research institute of the University of Mississippi, there is a lack of data concerning the variety of products now available.
The government-provided cannabis is only available in flower form and relatively few strains. Recent studies have attempted to get around this issue in a variety of ways.
Abrams recently finished gathering data and is now analyzing the results of a study that aims to determine how and what products patients are using.
“The last thing I did was just an observational study because so many people are so crazy about CBD in the absence of any data to support it for anything but seizures in children,” Abrams said. “We asked people coming from integrative medicine clinics in San Francisco, San Diego and Chicago as well as three dispensaries in each of those cities who are using CBD-predominant products what they were using, how they were using it and if it worked.”
Hutchison has also been attempting to gather information on how people are using various forms of cannabis, though his methods are much different from Abrams’s.
Hutchison has a mobile laboratory that he moves from house to house, allowing him to target specific populations of those using cannabis.
“We focused on looking at the effects of the products people are actually buying in state regulated markets, so looking at flower, flower with CBD, looking at edibles, looking at concentrates,” Hutchison said. “Basically our strategy is to have the people buy their own products. We get the lab over to their house, they come down to the mobile lab, they get blood drawn, we do some motor tests, they go into their house, use the product, they come back to the van to do more testing, and we get a snapshot of the acute effects.”
He has examined cannabis use in populations of people with chronic pain and anxiety and is hoping to receive a grant to look into opioid-addicted populations as well.
“It’s kind of hard for people because they hear the word cannabis and they go to a dispensary and they realize there’s like a hundred different forms of cannabis, right?” Hutchison said. “Hopefully we’ll be able to identify the best formulation as the research goes forward.”