Interlude in our vaping related illness series: A new weekly Sunday feature coming to the TRUCE blog begins, appropriately with a column on cannabis inhalation. This first installment is written by TRUCE’s Medical Board Advisor, Dr. Andrew Talbott….

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Thank you for reading “TRUCE Medical Minute”.

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. We’ll make every effort to discuss your submissions.

As always, comments and questions specific to each column are encouraged.

Today we are covering basics of the inhalational route of administering cannabinoids: specifically vaporization (“vaping”) and combustion (or smoking). Before getting into the nuts and bolts, we need to remind you that smoking cannabis (or cannabis concentrates) remains illegal in Utah under HB3001, so DO NOT SMOKE CANNABIS in Utah.

Inhalation is one route of administration for cannabinoids, in addition to many others (sublingual, oral/ingestion, topical, etc.) and has both pros and cons. It works nearly instantly, lasts just a couple of hours (at the most), is fairly easy to titrate, but can be expensive (if using a flower vaporizer).

It also has several negative health impacts. Additionally, I have found that many new cannabis users consider inhalation to feel stigmatized because of their preconceptions, valid or not.

Smoking is, of course, the most storied, traditional method of using cannabis. It involves heating the cannabis (usually with a flame) to around 1000-2000 degrees F and causing it to burn. The smoke is then inhaled into the lungs where the contents rapidly pass into the bloodstream.

Unfortunately, in addition to its illegal status in Utah, smoking produces harmful polycyclic aromatic hydrocarbons (PAH), carbon monoxide (CO), tar, and potential thermal injuries to the respiratory epithelial surface. It wastes the product, losing around 30-50% of the flower, and potentially destroys the terpenes and flavonoids.

Some proponents argue that the flavor and ritual of the smoking act balance out these negatives. It certainly is a reliable, time proven method though.

Vaping involves heating the product only to the boiling point of the active medical compounds in cannabis, which can vary between 320-540 degrees F. The compounds are released from the plant/product as vapor that is far cooler than smoke.

Like smoking, the vapor is inhaled and pass quickly into the bloodstream. This method drastically decreases (but does not eliminate) PAH, with few of the other harmful side effects of smoking. It preserves the product better than smoking, is less wasteful and also produces slightly higher blood levels of cannabinoids after use than smoking does.

Vaping can be done either with dry, raw flower or with cannabis concentrates. Most cannabis dispensaries carry inexpensive rechargeable or disposable “vape pens” that have a standardized, threaded cartridge containing concentrated cannabis oils.

These are also often found on the black market, which should be avoided at all costs due to the potential for harmful contaminants.

Vaping flower is also done with the aid of a vaporizing device, which can vary significantly in size/portability, ability to adjust temperature, and cost.

Neither inhalational route has ever been proven to cause lung cancer or emphysema, though chronic cannabis smoking is clearly associated with bronchitis, coughing and increased phlegm production.

For cannabis inhalation, Drs. MacCallum and Russo* suggest an initial dosing regimen to start with 1 inhalation and then wait 15 minutes. Then, patients may increase by 1 inhalation every 15–30 min until desired symptom control has been achieved (or side effects are encountered). This advice to “start low and go slow(ly)” should allow the new user to safely titrate their medicine to effect.

Currently my advice to my patients is to avoid combustion altogether given the illegality and harmful effects. I believe that vaporization is superior to combustion in every possible way, save for the expense and convenience of a power or “dry herb” vaporizer.

The recent spate of mysterious respiratory illnesses among vaporizer users causes some alarm. While the cases seem to be most closely linked to illegally purchased and untested concentrate vaporizer cartridges, I am advising patients to avoid using them until the cause has clearly been identified and their products deemed safe.

If inhalation is the desired route of administration then my advice is for patients to use vaporization of raw flower. This seems to be the best and safest inhalational delivery method at the current time.

Andrew Talbott, MD
TRUCE Medical Advisor
Board Certified in Anesthesiology and Pain Medicine

*”Practical considerations in medical cannabis administration and dosing”
MacCallum, Caroline A. et al.
European J. of Internal Medicine, Vol. 49, 12 – 19