A sudden wave of vaporizer-related illnesses have hit the United States. A physician weighs in on the knowns and unknowns.
When patients ask what the best method to take cannabis is, I cannot really answer. I tell them that the reason there are so many ways to take cannabis is that there is no perfect way to take cannabis. Each method has plusses and minuses. With education and a little bit of trial and error, each cannabis patient can decide which method works best for the symptoms being treated, fits into their lifestyle and has acceptable levels of risk.
One somewhat recent entry into the battle of methods is vaporizing. Vaporizers have been around for many decades but really hit the U.S. marketplace in 2007. Vaporizing is the process of heating a substance, but not to the point of combustion, in order to inhale the vapors that are created. There are many different types of vaporizers on the market. The primary difference in them is either using a vaporizer to heat the actual cannabis flower (dry herb) or using a vaporizer that heats a liquid that contains cannabis or cannabis extracts, often in cartridge form.
Vaping entered the scene and quickly became a contender as one of the popular methods. Like smoking, by using the lungs, the medication can enter the bloodstream rapidly. The user can control this effect with the number of puffs taken; because of the rapid onset, the effect can be easily titrated. For new users, this helps to avoid guessing a dose and hoping it was correct later when the effect starts, as with other methods. It is cleaner than smoking. By not actually combusting the product, the user avoids inhaling combustion particles and tar. The user is inhaling a vapor with the active molecules along for the ride.
Despite those benefits, there has been an ongoing concern. We simply do not have any long-term studies showing how safe it is as a method. Medicine is riddled with history of things seeming like a good idea until a period of time shows us the error in our ways that was not apparent at first.
For vaping, this is possibly happening right now. Case reports of vaporizer-related illnesses have been published occasionally in the medical literature for several years. However, over the past few months, an outbreak of these respiratory illnesses linked to vaping has occurred. This is beginning to be called vaporizer associated lung injury (VAPI), although it is not yet a recognized syndrome. To make matters worse, these illnesses are attacking otherwise healthy young people and can be very severe. As of Oct. 1, 18 deaths have been reported so far, and there are still many more questions than answers. We’ll look at what is known thus far to allow those of you using vaporizers to decide if this risk is worth taking.
We are all finding it frustrating that there are so few answers, but there are reasons for this. Unlike many outbreaks, this has not been attributed to a single product, manufacturing process, location or contaminant. In fact, the issue appears to be occurring with nicotine and cannabis products, although more commonly with cannabis. It appears to be more likely in illegally obtained or adulterated products but is not exclusive to those. It seems to be happening more frequently in new users who rapidly increased their use, but not all are new users. Vapor-izers adulterated with vitamin E have been blamed as a possible culprit, but again, not all have been found to contain vitamin E.
Compounding our confusion with the cause of this illness is the fact that the symptoms and clinical findings are also different. Most start with a nonproductive cough, shortness of breath and sometimes chest pain. Some have gastrointestinal symptoms like vomiting or diarrhea first. A few only develop mild symptoms that resolve. Many get severe symptoms, drop their oxygen levels and require being placed in an intensive care unit with a ventilator. Doctors are finding that the presentations can vary, with four different types of noninfectious pneumonia being found. Some have hemorrhaged into the lungs. Others have lipoid pneumonia, which is characterized by lipid (fat) globules within the cells. Others have eosinophilic pneumonia similar to what can sometimes be seen with parasitic illness. Finally, others have an organizing pneumonia. This just reflects inflammation in the small airways of the lungs, which can occur with a wide variety of causes.
In summary, at this point, all we really know is that we have a severe disease that affects young healthy people in several different ways with no distinct cause found other than the use of some type of vaporizer in the past 90 days. How frustrating for the medical and vaping communities. There has also been a rapid escalation in cases after several years of vaporizer use. Pinpointing one reason has thus far been unsuccessful.
With incomplete information and an escalating report of cases, the current recommendation from the Centers for Disease Control and Prevention is for people to “consider not using e-cigarettes.” An editorial in The New England Journal of Medicine went a step further and made blanket statement that physicians should recommend that patients not use e-cigarettes at all. All guidance is recommending that people avoid buying from the streets/illicit sources, not to alter the product and not to start using if not already a user.
The CDC has reports from 48 states, including four Oklahoma cases. There are more than 1,000 potential cases at the current reporting time. The small number of cases in Oklahoma, given the enormous increase in the medical cannabis industry since State Question 788 passed, is a pleasant surprise. Whether this is because of Oklahoma’s somewhat restrictive laws that require Oklahoma residency to process cannabis in the state or simply luck is not known. There also have not been any cases in Canada or the United Kingdom despite extensive vaporizer use in those countries. It’s a true medical mystery.
What do I tell patients at this point? Much like I treat nearly all areas of controversy in medicine, I explain the facts as well as I can and let the person make their own decision. If somebody is using a vaporizer and is happy and stable on their therapy, it might be unwise to change due to this risk. After all, 1,080 cases have been found, yet millions have been using vapes for many years without this issue. Four have occurred locally. On the other hand, being that it seems to occur more prominently in new users, this might not be a wise time to start use.
How big is the risk? Honestly, at this point, it is small but growing. There are approximately 10 million adults in the US that vaporize THC. For people using vaporizers for relief of symptoms like severe pain, disabling anxiety or inability to sleep, that risk is probably reasonable. Another way to avoid the risk is the use of a dry herb vaporizer, as all the cases thus far have been with concentrate or vaping liquid.
The understanding of this process is certainly still in evolution with new information trickling out daily. Vaporizers have been in use for several years, and these conditions were not widespread. There also appears to be increased incidence in certain geographic areas. These facts make me suspect that a change in processing or some type of adulteration has occurred. Hopefully that can soon be sorted and the issue resolved. If not and this issue continues to spread and vaporization becomes considered too risky, other methods will become available because inhalation as a method of ingestion has benefits over oral use. Cannabis inhalers would be the likely replacement. While they lose some of the cool factor that a vape has, inhalers are starting to hit the market and would be readily available to deliver the medication. In addition, they have a long history of safe use for other indications.
At this point, the mystery continues, but the public health authorities are pretty incredible at their jobs. Most likely, we will have a better answer in the near future.
Dr. Steven Ross is a physician who has practiced and taught medicine in several countries worldwide and is now a practicing cannabis clinician and founder of MMDOKC in Oklahoma City. He has a passion for assisting patients with cannabis recommendations and guidance for medical use.