What Are Health Risks of Vaping CBD?

By Roger Chriss, PNN Columnist

An outbreak of lung illnesses linked to vaping is raising important questions about the safety of vaping cannabis products. The cause is still unclear, but the CDC reports about 76% percent of the patients who became ill vaped products containing THC – the psychoactive ingredient in cannabis. Only about 17% reported vaping a cannabidiol (CBD) product.

At present, very little is known about CBD vaping safety. The World Health Organization’s 2017 report on cannabidiol looked at oral, sublingual and intranasal routes of administration. When the WHO wrote that “CBD is generally well tolerated with a good safety profile,” it was not considering vaping at all.

The Food and Drug Administration still considers CBD in food and drugs sold commercially to be illegal, unless the product falls under the Food, Drug and Cosmetic Act. Vaping CBD does not, and so there has been no testing or regulatory action.

There have been no good human studies on CBD vaping. Research generally looks at CBD in edibles and liquids, or smoked using traditional means.

It is not known what happens to CBD under vaping temperatures, if there are thermal degradants, or important chemical reactions between CBD and other ingredients in vaping liquids or other drugs.

A recent lung tissue study found concerning results about inhaling CBD while using steroids. CBD helps reduce inflammation, but “acts as an antagonist with steroids, overriding the anti-inflammatory potential of steroids when used in combination.”

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Last year Vice reported on public health warnings in North Carolina after 90 people became sick with headaches, nausea, hallucinations and other health problems after vaping CBD products. Adulterants appear to have been the problem, and Vice noted that vape oils are poorly regulated and sometimes contain chemicals that “when heated in a vape and inhaled, can cause serious lung irritation.”

A recent study on the quality of CBD liquids used in e-cigarettes is also concerning, finding that “the quality control of manufacturers and the relative safety of these products is uncertain.”

An AP investigation last month found that in lab tests on 30 CBD vape products, ten samples contained synthetic marijuana such as K2 or spice, while others had no CBD at all.

Some states with legalized cannabis do require testing of CBD vapes. But it’s not clear what to test for, and even the lab methods for testing have yet to be validated. It is also not known which cutting agents, adulterants and contaminants should be cause for concern. Lung tissue is fragile, vulnerable in ways the GI tract is not, and not well studied. So testing regimes may ultimately require information we currently lack.

Oversight of cannabis testing is limited. California’s Sequoia Analytical Labs was found to be falsifying lab results last year. Plus, many CBD vapes come from the gray or black markets, or are home-brewed, making attempts at quality control irrelevant. As a result, CBD vaping safety is an open question, assuming it is even possible to make a safe CBD vape.

Fortunately, new research may help. Researchers are testing vaporized cannabis extracts on rats. This will allow for studying the effects of THC and CBD in animal models in a way that closely mimics human behavior.

Such information is urgently needed. Animal studies on vaping are raising concerns about lung cancer risk, but such research may not be representative of how humans vape, limiting their value.

There is ongoing debate on what CBD is good for. And now we also have to consider how CBD should be administered. It may be possible to create a low-risk CBD vape product. But at present we don’t really know how to do it.

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Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society.

Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Has Vaping Hysteria Gone Too Far?

By Anna Maria Barry-Jester and Jenny Gold, Kaiser Health News

On Sept. 16, Tulare County in California announced the nation’s seventh death from vaping-related illness. Its advisory warned about “the dangerous effects of using electronic cigarettes, or e-cigarettes.”

As federal and state health officials struggle to identify what exactly is causing the deadly outbreak, vaping advocates are stepping into the void and crafting an alternative narrative that is being echoed broadly in online communities.

The people getting sick, according to their version of events, all vaped THC — the psychoactive ingredient in cannabis — using products bought on an illicit black market. They also contend federal officials have seized on the crisis to crack down on a nicotine vaping culture they don’t appreciate or understand, a culture proponents insist has helped them and millions of others quit smoking.

As of Oct. 1, the federal Centers for Disease Control and Prevention had identified more than 1,000 cases of vaping-related lung illness in 48 states. Eighteen people have died, including two in California. Of the 578 patients who have reported using specific products, most said they had vaped THC, but a significant portion — 17% — said they had used only nicotine.

CDC officials maintain they can’t identify one product or chemical culprit, and while they recently began emphasizing the risks of vaping THC, they continue to warn against any vape use at all.

Meanwhile, cities and states have responded with a divergent mix of warnings and bans. Michigan, New York and Rhode Island have moved to ban most flavored nicotine vaping products. The California Department of Public Health recently warned against all vaping devices, and the governor of Massachusetts issued a four-month ban on all vaping products.

The actions have sparked a backlash among hundreds of thousands of people who say they’ve been vaping for years without a problem. Compounding their distrust: the political calls to ban flavored nicotine products even though the vast majority of illnesses identified appear to involve people who were vaping THC.

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They see a government out to quash nicotine vaping because its popularity with teens has caused a public outcry, ignoring the adults who find it a pleasing alternative to cigarettes. When it comes to vaping, they have stopped looking to the CDC for advice.

Debbye Saladine-Thompson is a registered nurse in Michigan who was a smoker for 32 years before she switched to vaping. She now manages the Michigan Facebook page for Consumer Advocates for Smoke-Free Alternatives Association (CASAA), a nonprofit that advocates for access to e-cigarettes and receives industry funding.

“I do not trust the CDC. Not anymore” Saladine-Thompson said. “I cannot trust an agency that says the product that I and so many people have been using for 10 years and hasn’t caused one death is now causing hundreds of illnesses. No, I do not believe that.”

Online vaping forums are roiling with accusatory messages suspicious of the government response. In Facebook groups, including one called ‘BLACK MARKET THC CARTRIDGES CAUSED THIS QUIT LYING ABOUT VAPOR PRODUCTS,’ vapers have expressed outrage over the bans on nicotine products while cigarettes remain readily available. They’re organizing phone calls to legislators and rallies at state capitols.

“We’re living and dying by these decisions,” said Kristin Noll-Marsh, the member coordinator for CASAA who moderates the group’s national Facebook group. “This vaping panic of 2019 is gonna go down in the history books as being like flat Earth, bloodletting and burning witches.”

CDC Messaging Criticized

Throughout the outbreak, the CDC has said that people who vape to quit smoking should not return to cigarettes. But the emphasis on all vaping devices drowns out that warning, said Dr. Michael Siegel, a professor at Boston University and proponent of e-cigarettes as a smoking cessation tool.

“In an outbreak investigation like this one, you have to be as specific as possible if you want people to listen. If you say ‘Just don’t vape,’ that’s not telling anyone anything they don’t already know.”

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Many also are critical of the messaging used by the CDC, states and some media outlets, saying they are out of touch with vaping culture and its terminology. Public officials often use one word — e-cigarettes — to describe what to people who vape is a wide range of products with different names.

People who see headlines about illnesses linked to “e-cigarettes” may not know it applies to them, said Jim McDonald, a journalist with Vaping360, a consumer news site. “Cannabis vapers don’t use the term e-cigarettes. They never, never use that term.”

Even among e-cigarettes, a term many equate with nicotine delivery devices, people differentiate between cartridge-based devices like Juul and the handheld “mods,” which tend to be larger and produce more vapor. E-liquids can come prepackaged in ready-to-use form or can be mixed in stores or at home. Whether cannabis is legal and regulated also varies among states.

The problem with the alternative narrative, say doctors who are treating patients, is that it’s not clear whether only illicit THC is to blame. Dr. Dixie Harris, a critical care pulmonologist with Intermountain Healthcare in Utah, has been reporting five to seven cases a week for the past six weeks. While many patients have reported using illicit THC, she also has had patients who have fallen ill after using products purchased at licensed medical dispensaries in states where cannabis is regulated.

A new study looking at lung tissue samples from 17 patients found the damage resembled chemical burns and included two samples from people who fell ill before the outbreak. The findings cast doubt on a popular theory that vitamin E oil, which has been used as a thickening agent in THC oil, is the culprit.

The investigation is challenging on many fronts. Vaping — both legal and illicit, nicotine and cannabis — has exploded in the past few years with little regulation. There are hundreds of products, do-it-yourself kits and home brews. The potential culprits are many: popular flavorings in nicotine vapes never tested for inhalation. Oils used to dilute THC. Contaminants. Pesticides. Possible toxic residue from the containers themselves.

The CDC is grappling with a dearth of information. The process of alerting the many agencies and entities involved — doctors, hospitals, law enforcement, public health departments — has been slow.

Among 86 cases in Illinois and Wisconsin, where the outbreak first was identified and investigators are further along in their work, people reported using 234 different products involving both nicotine and cannabis, according to a report published last month. Those products, in turn, involved a variety of brands, numerous supply chains and packaging without listed ingredients.

Dr. Anne Schuchat, principal deputy director of the CDC, said the agency wasn’t narrowing the investigation only to cannabis, stressing it needed to “have an open mind” to understand the possible risks.

“Personally, with all the data that I’ve been seeing,” Schuchat said Friday, “I don’t know what ‘safe’ is right now.”

Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

The Risks of Vaping THC

By Roger Chriss, PNN Columnist

An outbreak of vaping-associated pulmonary illness is getting national attention. Over 800 people have been sickened and 12 have died.

The CDC reported last week that vaping products containing tetrahydrocannabinol (THC) -- the psychoactive compound in marijuana – were involved in 77 percent of the illnesses. Several states responded with bans on vaping products and health alerts on vaping THC.

What do we know about the risks of vaping?

Vaping THC is so new that there is very little research. An animal study on vaping THC was published earlier this year. Performed on male and female rats, the study found that “repeated THC vapor inhalation in adolescent rats results in lasting consequences observable in adulthood."

Specifically, both sexes became tolerant to THC and male rats ate more. Interestingly, THC use did not change oxycodone self-administration in either sex, but increased fentanyl self-administration in female rats. There is no mention of lung effects.

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While vaping with e-cigarettes is relatively new, inhaling THC via cannabis smoking is old. And there is an extensive literature on multiple harms.

A recent study of nearly 9,000 people found that regular cannabis use was significantly associated with greater risk of respiratory diseases such as asthma, chronic obstructive pulmonary disease (COPD) and pneumonia. The study used blood work to confirm use and had a control group, making its results more reliable than a simple population survey.

According to the National Institute on Drug Use, cannabis smoke contains multiple carcinogens and inhalation causes lung inflammation, increased airway resistance and hyperinflated lungs, a symptom of COPD

Josh Bloom at the American Council of Science and Health writes that the solubility and boiling point of THC and CBD in cannabis vaping products may play a role in the lung illnesses.

But complicating matters is the presence of other subtsances in vaping liquids and in the devices themselves. A newly published study in Scientific Reports on aerosols in tank-style e-cigarettes found levels of chromium, lead and nickel, all known carcinogens, in excess of OSHA permissible exposure limits.

Most cases of vaping-associated pulmonary illness involve illicit products. But one fatal case in Oregon involved someone who bought vaping products at two state-licensed cannabis dispensaries.

Some vaping illnesses involve people who report no use of THC products at all, though investigators are finding that these self-reports are not necessarily accurate. According to STAT News, eight patients in Wisconsin initially said they didn’t use THC products, but were later found to have used the drug.

In other words, we may not know what people were really vaping. Given that vaping THC is federally illegal and only marginally regulated in states where cannabis is legal, investigating the role of THC in the vaping outbreak is challenging.

But the emerging risks have led states like Washington to ban all flavored vaping products. And the FDA has asked the DEA to pursue criminal charges against anyone who sells illicit vaping products.

For patients who use cannabis products for pain relief, there are better alternatives than vaping. The Arthritis Foundation recently released new guidelines that recommend CBD oils and tinctures that can be taken orally.

It is not clear what this means for the cannabis industry. But Joe Tierney, known as the "Gentleman Toker,” told the Washingtonian that he would be shutting down his cannabis website.

“I don’t feel good about the industry any longer,” Tierney said. “I don’t think it’s safe to consume cannabis anywhere after all of my travels.”

Sorting out the risks of THC vaping will take time. At present there is only circumstantial evidence and intriguing ideas. It is possible that THC is one of several different causes or is just guilty by association. Beyond that, we have the unknowns of vaping itself, which may be too novel for anyone to fully understand the risks.

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Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.