The Ultimate Medical Cannabis Resourse

Vaporized state

Photo Alexa Ace

While counterfeit cannabis cartridges have been a blight on the industry for years, a recent spate of severe lung illnesses have brought vaping into a harsh spotlight.

Late this spring, young adults began filling emergency rooms in Wisconsin and Illinois with complaints of an acute but puzzling respiratory illness. By mid-summer, enough clinicians had reported cases of the mystery illness that health authorities had launched a coordinated public health investigation, and the first reported Oklahoma case was announced the last week of September. The common denominator? Recent usage of e-cigarettes or “vapes.”

In a report filed by Centers for Disease Control and Prevention (CDC), this outbreak of “lung injury associated with e-cigarette usage — more commonly called “vaping illness” — has continued to spread, resulting in 1,080 cases across 48 states by Oct. 1. Eighteen deaths have been confirmed: two in California and Kansas and one each in Alabama, Delaware Florida, Georgia, Illinois, Indiana, Minnesota, Mississippi,  Missouri, Nebraska, New Jersey , Oregon and Virginia

While symptoms vary a bit, many victims of this mystery illness report a gradual onslaught of respiratory symptoms, from breathing difficulty to shortness of breath that can sometimes advance into moderate gastrointestinal symptoms like vomiting and nausea. Doctors and researchers are working around the clock to determine the actual causes; however, a common obvious factor in all cases is the usage of e-cigarettes — a large percentage of the e-cigarette used contained black-market THC concentrates.

Oklahoma opened its medicinal cannabis market last year with dozens of vaporizer cartridge brands available on dispensary shelves. It should be pointed out that there has been no link between licensed Oklahoma cannabis companies and this mysterious illness.

OSDH officials continue to review medical records, gather data and conduct patient interviews.

“We are committed to working with our state and federal partners to learn everything we can about this investigation in order to prevent further injury and potential death,” commissioner of health Gary Cox said in a news release. “E-cigarettes are unregulated, and of great concern is the significant number of young people using the products. The public is advised to consider refraining from using all e-cigarette and vaping products while the investigation is ongoing.”

Nationwide, about 77 percent of victims reported using THC-containing products and 36 percent reported exclusive use of THC-containing products, while about 57 percent reported using nicotine-containing products and 16 percent reported exclusive use of nicotine-containing products, according to the CDC.

A study compiled by The New England Journal of Medicine determined all affected patients had a history of e-cigarette usage within the 90 days before the onset of their symptoms.

“Most patients … reported at least daily e-cigarette use,” the study said. “Of the 41 patients who were extensively interviewed, 61 [percent] reported use of nicotine products, 80 [percent] reported use of THC products, and 7 [percent] reported use of CBD products.”

While the surveyed patients reported using a variety of THC brands and flavored nicotine products, “the most common THC product that was reported was marketed under the ‘Dank Vape’ label,” the report stated.

In addition to its rapid rise, another frightening aspect of this vaping illness is how it largely targets young people, with two-thirds of the victims aged 18 to 34 years old. By the end of September, the number of national cases involving minors accounted for 16 percent of all cases.

“In the case series presented here,” the study said, “the population was generally young and healthy, yet acute severe pulmonary disease developed and resulted in critical care and respiratory support. Given the disparate nature of e-cigarette–associated illnesses that have been reported in the literature, it is notable that case patients in Wisconsin and Illinois presented with similar clinical findings and progression of disease, which suggests a similar pathophysiological mechanism of lung injury.”

Dubious packaging

Examples of black-market vape cartridge packaging. The majority of cases of vaping illness have been tied to carts in Dank Vapes packaging. | Photo provided

What makes it particularly difficult to trace the source of the cartridges responsible for the majority of these vaping illness cases is that brands like Dank Vapes are not actually sourced from a single manufacturer but rather are packaging available to purchase online.

A Google search revealed a number of Chinese websites that offered the packaging, some offering it for as little as 14 cents per package. They are still available, though more reputable retailers like Amazon have deleted sale listings.

Further complicating matters, additional brands like Mario Carts, Exotic Carts and many others are also available online, though the sources of these are dubious as well.

“Dank Vapes was just some packaging that showed up early on, for people who were trying to get quick, fast packaging or just package their black-market stuff. It’s all riddled with famous Nabisco and Kraft icons. I would imagine that they don’t have the trademarks or licensing for any of that stuff,” said Derek Kern, co-owner of Mammoth Processing in Oklahoma City.

The only way most cannabis patients and consumers can know that they are purchasing vape cartridges that are unlikely to cause vaping illness is to purchase lab-tested products from companies doing business in the states in which they reside, like Mammoth.

“When we extract, our methodology is really quite simple,” Kern said. “It goes through the CO2 machine. I run it at its parameters, using a little bit of heat and a little bit of pressure. The oil comes out. It does have lots of fats, lipids and waxes. So I winterize it, filter off those fats, lipids and waxes, and then that oil, 100 percent, just goes right into a cartridge or into a syringe.”

While Mammoth uses a process that does not destroy terpenes, many distillate companies do and then reintroduce “food-grade” terpenes back into them before sale.

“Most of the distillate cartridges have never been OK’d by the FDA to vaporize ever. Most of these food-grade terpenes too, and most of these companies who are now cannabis terpene companies, they were selling limonene and stuff like that to industrial cleaning companies before,” Kern said. “That’s how these food-grade terpenes were being used, and so now they’re in your vapes. Is that safe? Probably not. Same thing goes with these people who are steam-distilling cannabis-derived terpenes. Terpenes are a very, very light molecule, so riddle me this. How are you taking steam and distilling it and keeping the molecular integrity of a terpene? That’s not a terpene anymore.”

Another big concern for Kern is inhaling oils or distillates that have not been winterized.

“We should be all worried about lipoid pneumonia from the dab culture, and that also goes for live rosin cards or any of these carts with sauce and where they don’t actually winterize the product and then you just smoke it,” he said. “When we smoke flower, it has fats, lipids and waxes in it, obviously. The plant naturally does, but in the flower form, we’re talking about parts per million. Once people like myself concentrate it down, now we’re talking about parts per thousand. That’s a way different scenario. Now you’re coating your lungs with fats, lipids and waxes.”

Potential cause

After a summer of hand-wringing speculation among vape users, a potential culprit emerged this September when researchers were able to isolate the presence of vitamin E acetate used to dilute the THC in many of the tainted cartridges. While this has been theorized as one potential factor in the illness, a wide range of tests from U.S. Food & Drug Administration has questioned the theory, stating in a report that, “No one substance has been identified in all of the samples tested,” but the report went on to state the agency was committed to hunting down all potential leads, “including the presence of vitamin E acetate found in many of the samples containing THC.”

Even though the jury’s still out on vitamin E acetate and other potential causes, researchers at University of Utah might have hit on a promising diagnostic tool. A recent report from the university revealed that researchers have been able to isolate a previously unrecognized trait in the lungs of all vaping illness victims: large immune cells containing numerous oily droplets called lipid-laden macrophages. Being able to quickly locate and identify these macrophages could expedite the diagnosis and treatment of victims, potentially saving countless lives.

“While it is too soon to be sure, these lipid-laden macrophages may turn out to be useful to confirm or rule out this disease,” said the study’s senior author, Scott Aberegg, M.D., a critical care pulmonologist at University of Utah Health. “They may also be helpful in understanding what is causing this illness.”

Tests commissioned by NBC News in late September found, in addition to vitamin E acetate in 13 out of the 15 black market brands tested, that 10 of 10 brands tested for fungicide containing myclobutanil, which can turn into hydrogen cyanide when burned.

Placing blame

Nicotine vape companies, many of which have been in business for years without any such negative side effects, are being caught in the crossfire of the vaping illness outbreak. Without knowing a precise cause of the illness, many entrepreneurs feel like they are caught in the middle of a scare campaign that is being used to unjustly target their businesses.

Ryan Vicedomini founded and sold Vapor World before launching CBD Plus USA. He said vaping illness is being used as another excuse to crack down on the nicotine vaping industry.

“It’s the biggest crock of shit I’ve ever heard of because it’s still all about big tobacco,” Vicedomini said. “They basically found a reason to exploit the flavors somehow and pushed on it, and now this is this is what you’ve got. They’re going to win either way. Juul or Marlboro is going to win either way. Juul took away their flavors six months ago. They knew this was coming. All they needed was something to start, and now all they’re doing is pushing it to the finish line. It’s a scary thought that you can make something and end up inhaling cutting agent that could affect your life. … They’ve isolated it, they’ve addressed it and now what they want to do is use it as a scapegoat to take out the vape industry.”

The owner of Liquid Vapor Lounge, 6608 N. May Ave., feels the same way. Craig Majors said that — not accounting for other factors like the Oklahoma State Fair — his business has been down approximately 20 percent in the latter part of September when vaping illness became daily news.

“Now everybody associates vaping with people who want to quit smoking, and they’re using regular, traditional vape products. So when they say vaping is killing, they may throw in every once in a while the three letters THC. It’s just killing us,” Majors said. “They’re leaving it very murky for a reason, I feel. The CDC hates vaping. The FDA doesn’t hate vaping, but they have a whole bunch of influence from other outside parties that do not care for vaping at all. So the FDA has come out with a little bit more clear of a message than the CDC. I would say one out of five customers come in very concerned. Two out of five customers mentioned something about it, but one of them is, like, ‘Legitimately, I don’t even know if I should be here right now. I just need some information.’”

Some states have already used this illness as a reason to crack down on nicotine vaping preemptively.

Majors feels like his industry is being dealt blow after blow, with more regulation upcoming.

“We get a whole lot of flack about not being FDA-regulated and so forth, which in fact, is complete, utter bullshit. We are very, very regulated by the FDA,” Majors said. “Matter of fact, August 8th of 2016, we were stymied. We were now no longer able to put new e-liquids on the market. Now, what a lot of companies did is whenever it was August of 2016, they registered a whole bunch of recipes. They may have even bought some old recipes from a company that went out of business, but they registered that shit and put names to it. And then they had to upload their labels, they had to upload any kind of advertising that had been done with that brand or that name. They also had to later upload an updated label that had FDA-suggested warnings on it, which we all had to comply to, then we had to give them every one of our proprietary recipes. … We don’t want a company that is in bed with big tobacco and big pharmacy having our recipes.”

CDC recommendations

For now, the CDC has recommended that people refrain from using e-cigarettes or vaping products. While this is good advice, practically speaking, for those continuing to vape, it offers the following advice: Anyone who uses an e-cigarette or vaping product should only purchase tested, regulated medical cannabis products from legal stores, avoid purchasing any off the street and should not modify or add any other substances to these products.

If you are an adult who uses e-cigarettes because you have quit cigarette smoking, do not return to smoking cigarettes.

The center further recommends that users experiencing an abnormal cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, fatigue, fever or abdominal pain should see a health care provider immediately and call the poison control center at 1-800-222-1222. 

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