Welcome back to the TRUCE Medical Minute. This is the second installment in the series and is on a popular topic, ORAL INGESTION of cannabis (alternate title…”Edibles: Why Am I So Stoned?”).
If you missed part one, here is the deal: This new series is intended to educate on various cannabis-specific medical issues. It will be hosted by medical professionals, and we will cover only medical topics. If there are any specific subjects or questions that you’d like to see covered, please comment here or message TRUCE privately if preferred. We’ll make every effort to discuss your submissions.
As always, comments and questions specific to each column are encouraged.
In Part 2 I am going to discuss some basic concepts of the oral route of administration of cannabis. This means any form of oral ingestion in which the medicine is swallowed. Oral administration is most commonly associated with cannabis “edibles”, foods that are made with cannabinoids. It also includes pills/tablets and tinctures (if swallowed…more on that later), or even decarboxylated flower.
Under HB3001, legal edibles MUST be “gelatinous cube, gelatinous rectangular cuboid, or lozenge in a cube or rectangular cuboid shape”. This means that they must be gummies or lozenges in a very specific shape. Rings, pucks, gummy bears, or other shapes technically are not legal. Nor are any infused baked goods (e.g.“brownies”), fruits, chocolates or other candies legal.
Edibles may be labeled with their cultivar/chemovar or strain (sic) but much more commonly are seen with simply the dose of THC and/or CBD they contain. They may be labeled as indica, sativa or hybrid dominant, though in my opinion this has very little meaning for edibles as the THC and CBD molecules are identical in each of these types of cannabis. Without full spectrum cannabis and “minor” compounds the various types of edibles should have little difference.
Oral ingestion may be a very attractive method for patients new to cannabis. In my experience many patients feel it to seem less “illicit-feeling” than the inhalation route. It requires no devices, is easy to dose, is quite discreet as there is hardly any odor. Patients can expect to begin to experience effects 1-3 hours after ingestion. At 6-8 hours duration these effects generally last much longer than inhalation. There are some potential problems with it though. The delayed onset can make it difficult to dose, and titration is risky as some inexperienced users may try to “re-dose” before the full effects have begun.
There is another, more serious concern that I have with oral administration: the enhanced psychoactive effects. Warning: Biochemistry ahead.
When cannabinoids are swallowed they are absorbed into the bloodstream, entering the hepatic portal system. This means that the blood flows first to the liver where the absorbed contents undergo “first pass metabolism”.
In this process the liver transforms most of the THC from its most commonly known form, called delta-9-THC, into 11-hydroxy THC (11-OH-THC). This also happens when delta-9-THC is inhaled, but it happens about 10 times more after ingestion. The reason this is important is that 11-OH-THC crosses the blood brain barrier far more easily than delta-9, making the 11-OH about 4-5 times more psychoactive than delta-9. This is not necessarily a bad thing, it just may be an issue if not anticipated. Becoming densely stoned likely causes significant impairment in functioning, the opposite of what I am seeking for my patients in chronic pain.
My advice to my patients is to generally avoid oral use of THC during the daytime because of its impairing effects and duration. It is excellent though for nighttime (or bedtime) use for patients with pain and difficulty sleeping. Depending on timing and effects desired, for most patients probably a multi-pronged approach is best… one that involves a little bit of both inhalation or sublingual administration and oral ingestion.
By no means do I intend to condemn oral use of cannabinoids, just to point out that impairment is not my intention for patients in pain as I seek to help them maximize their function.
I’d love to hear about your experiences with oral ingestion of cannabinoids, if you are willing to share. Thanks for tuning in.
Andrew Talbott, MD
TRUCE Medical Advisor
Board Certified in Anesthesiology and Pain Medicine