Vaping medical marijuana

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Vaping medical marijuana

Introduction
Marijuana is currently a prevalent recreational drug with millions of consumers throughout the world [1 Rong C, Lee Y, Carmona NE, et al. Cannabidiol in medical marijuana: research vistas and potential opportunities. Pharmacol Res. 2017;121:213–218.
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]. In the United States, around 20 million people acknowledged using marijuana during 2015 [2 Park JY, Wu LT. Prevalence, reasons, perceived effects, and correlates of medical marijuana use: a review. Drug Alcohol Depend. 2017;177:1–13.
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]. Derived from the plant Cannabis sativa, its two main ingredients, commonly termed cannabinoids, are tetrahydrocannabinol (THC) and phytocannabinoid cannabidiol (CBD) [1 Rong C, Lee Y, Carmona NE, et al. Cannabidiol in medical marijuana: research vistas and potential opportunities. Pharmacol Res. 2017;121:213–218.
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]. THC is psychoactive, and CBD has anti-oxidant and anti-inflammatory properties. Ideally, medical marijuana is a mix of components in a ratio, such that psychoactive effects are minimal and medicinal effects are maximized [3 The National Academies of Sciences E, and Medicine. The health effects of cannabis and cannabinoids. Washington (DC): THE NATIONAL ACADEMIES PRESS; 2017. [cited 2017 Aug 26].
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Beyond the personal and health-related benefits of marijuana, it can induce altered sensory perceptions, psychoses, or result in accidents or other difficulties. Long-standing consumption may cause decline in comprehension and judgment, along with an amotivational syndrome and cognitive deficits [2 Park JY, Wu LT. Prevalence, reasons, perceived effects, and correlates of medical marijuana use: a review. Drug Alcohol Depend. 2017;177:1–13.
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]. It can also prompt cannabis dependence, and if inhaled in smoke, chronic bronchitis [2 Park JY, Wu LT. Prevalence, reasons, perceived effects, and correlates of medical marijuana use: a review. Drug Alcohol Depend. 2017;177:1–13.
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]. Cannabis also reportedly results in neurodegenerative changes in the white matter areas of the brain [2 Park JY, Wu LT. Prevalence, reasons, perceived effects, and correlates of medical marijuana use: a review. Drug Alcohol Depend. 2017;177:1–13.
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]. The ill effects are particularly dangerous for children and young adults, during neurological development.

Otherwise, it can relieve spasticity and pain, even neuropathic pain syndromes caused by many different pathologies [4 Murnion B. Medicinal cannabis. Aust Prescr. 2015;38(6):212–215.
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]. It is also effective sometimes in the management of certain epilepsies and chemotherapy-induced nausea [5 Cranford JA, Bohnert KM, Perron BE, et al. Prevalence and correlates of “Vaping” as a route of cannabis administration in medical cannabis patients. Drug Alcohol Depend. 2016;169:41–47.
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]. Marijuana might decrease intraocular pressures on a short-term basis, but long-term efficacy is not substantiated [3 The National Academies of Sciences E, and Medicine. The health effects of cannabis and cannabinoids. Washington (DC): THE NATIONAL ACADEMIES PRESS; 2017. [cited 2017 Aug 26].
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]. A meta-analysis analyzed the health-related benefits of cannabinoids [6 Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA. 2015;313(24):2456–2473.
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]. This pooled data from 79 randomized control trials documented only modest evidence of effectiveness by marijuana in treating people with chronic pain and/or spasticity. Support for a role by marijuana in diminishing chemotherapy-associated emesis, insomnia, or Tourette’s syndrome is also limited [6 Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA. 2015;313(24):2456–2473.
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]. Inhaling aerosolizes marijuana induces a variety of benefits and risks.

Intake
California legalized medicinal marijuana in 1996. Currently, 28 states and Washington, DC, permit marijuana for therapeutic purposes [2 Park JY, Wu LT. Prevalence, reasons, perceived effects, and correlates of medical marijuana use: a review. Drug Alcohol Depend. 2017;177:1–13.
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]. Subsequent to lawful applications of medicinal marijuana, its utilization has increased; this results in a need to control its usage [1 Rong C, Lee Y, Carmona NE, et al. Cannabidiol in medical marijuana: research vistas and potential opportunities. Pharmacol Res. 2017;121:213–218.
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]. The drug can be incorporated into the body by inhalation, oral, or by topical means. Inhalation is accomplished via smoking or aerosolizing. Inhaling the aerosolized version is called ‘vaping’. Oral administration consists of tinctures, ingestible oils, or mixing it with food. Various modes of incorporating marijuana have different effects on the body [7 Schauer GL, King BA, Bunnell RE, et al. Toking, vaping, and eating for health or fun: marijuana use patterns in adults, U.S., 2014. Am J Prev Med. 2016;50(1):1–8.
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]. Smoking or vaping elevates THC levels in the bloodstream within minutes and the impact lasts for several hours [8 Varlet V, Concha-Lozano N, Berthet A, et al. Drug vaping applied to cannabis: is “Cannavaping” a therapeutic alternative to marijuana? Sci Rep. 2016;6:25599.
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]. Consumption of cannabis by mouth reduces the injurious respiratory effects of smoking, but results in a lower bio-availability and a delayed onset of action [7 Schauer GL, King BA, Bunnell RE, et al. Toking, vaping, and eating for health or fun: marijuana use patterns in adults, U.S., 2014. Am J Prev Med. 2016;50(1):1–8.
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]. It can sometimes be difficult for persons with nausea or vomiting to tolerate orally [9 Lee DC, Crosier BS, Borodovsky JT, et al. Online survey characterizing vaporizer use among cannabis users. Drug Alcohol Depend. 2016;159:227–233.
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]. Topical cannabis may be effective for neuropathic pain, as demonstrated in animal model research [10 Jorge LL, Feres CC, Teles VE. Topical preparations for pain relief: efficacy and patient adherence. J Pain Res. 2010;4:11–24.
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].

Vaping
Vaping is an informal term applied to this new, attractive method for getting the effect of marijuana into the body [8 Varlet V, Concha-Lozano N, Berthet A, et al. Drug vaping applied to cannabis: is “Cannavaping” a therapeutic alternative to marijuana? Sci Rep. 2016;6:25599.
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,9 Lee DC, Crosier BS, Borodovsky JT, et al. Online survey characterizing vaporizer use among cannabis users. Drug Alcohol Depend. 2016;159:227–233.
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]. Actually the inhaled marijuana is aerosolized into a combination of many different compounds; this mixture is not simply a water vapor. Aerosolized cannabis (and/or nicotine), when inhaled, is quickly incorporated into the brain [11 Budney AJ, Sargent JD, Lee DC. Vaping cannabis (marijuana): parallel concerns to e-cigs? Addiction. 2015;110(11):1699–1704.
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Although smoking and vaping are inhalational methods, they are quite different. Smoking marijuana refers to burning cannabis and inhaling smoky fumes, which contain several combustible products that are potentially toxic and/or carcinogenic [8 Varlet V, Concha-Lozano N, Berthet A, et al. Drug vaping applied to cannabis: is “Cannavaping” a therapeutic alternative to marijuana? Sci Rep. 2016;6:25599.
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]. Vaping entails electronically heating oils, wax, and/or plant material in a battery-powered vaporizer or atomizer. The heating generates an aerosolized mixture of water vapor, compounds derived from thermal decomposition of marijuana, and other chemical components [8 Varlet V, Concha-Lozano N, Berthet A, et al. Drug vaping applied to cannabis: is “Cannavaping” a therapeutic alternative to marijuana? Sci Rep. 2016;6:25599.
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]. This process is also called ‘cannavaping’, when specifically referring to cannabis inhalation. [8 Varlet V, Concha-Lozano N, Berthet A, et al. Drug vaping applied to cannabis: is “Cannavaping” a therapeutic alternative to marijuana? Sci Rep. 2016;6:25599.
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] Heating cannabis results in decarboxylation of the acidic cannabinoids. These naturally occurring compounds include delta-9-tetrahydrocannabinolic acid, and cannabichromenic acid, which are converted into THC and CBD [12 Romano LL, Hazekamp A. Cannabis Oil: chemical evaluation of an upcoming cannabis-based medicine. Cannabinoids. 2013;1(1):1–11.
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]. Higher temperatures increase the concentration of THC. Terpenes are also present in cannabis; they are responsible for the cannabis odor and might result in cannabinoid-effect augmentation. High temperatures decrease terpene concentrations [12 Romano LL, Hazekamp A. Cannabis Oil: chemical evaluation of an upcoming cannabis-based medicine. Cannabinoids. 2013;1(1):1–11.
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]. Vaping leads to a release of a higher concentrations of active ingredients and less carcinogens, in comparison to smoking, since the temperatures utilized by vaping are lower [9 Lee DC, Crosier BS, Borodovsky JT, et al. Online survey characterizing vaporizer use among cannabis users. Drug Alcohol Depend. 2016;159:227–233.
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]. The device refill materials may contain a wide range of contaminants and are under little governmental regulation or control. The dangers involved remain uncertain and safety is not documented [9 Lee DC, Crosier BS, Borodovsky JT, et al. Online survey characterizing vaporizer use among cannabis users. Drug Alcohol Depend. 2016;159:227–233.
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]. Cannabis oil is the most common source utilized in vaping and relies on several different solvents, such as naptha, petroleum ether, or olive oil for extraction. Some solvents are toxic and even small concentrations are not safe [12 Romano LL, Hazekamp A. Cannabis Oil: chemical evaluation of an upcoming cannabis-based medicine. Cannabinoids. 2013;1(1):1–11.
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Vaping instruments are available in the market with great variations, ranging from big devices, to small pen-like gadgets. Some allow the addition of flavoring substances [13 Giroud C, de Cesare M, Berthet A, et al. E-Cigarettes: a review of new trends in cannabis use. Int J Environ Res Public Health. 2015;12(8):9988–10008.
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]. Vaping induces psychoactive effects within minutes [7 Schauer GL, King BA, Bunnell RE, et al. Toking, vaping, and eating for health or fun: marijuana use patterns in adults, U.S., 2014. Am J Prev Med. 2016;50(1):1–8.
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]. In 2014, the Oxford Dictionary added the word ‘vape’, as the word of the year [11 Budney AJ, Sargent JD, Lee DC. Vaping cannabis (marijuana): parallel concerns to e-cigs? Addiction. 2015;110(11):1699–1704.
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]. One survey reported the prevalence of vaping marijuana involved nearly 11% of the US population [8 Varlet V, Concha-Lozano N, Berthet A, et al. Drug vaping applied to cannabis: is “Cannavaping” a therapeutic alternative to marijuana? Sci Rep. 2016;6:25599.
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]. Among people who are prescribed marijuana for medicinal purposes, 18% utilized vaping techniques, compared with 3% among recreational users. Vaping marijuana is more popular in states where medical prescribing of this drug is legal [7 Schauer GL, King BA, Bunnell RE, et al. Toking, vaping, and eating for health or fun: marijuana use patterns in adults, U.S., 2014. Am J Prev Med. 2016;50(1):1–8.
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].

Vaping is often claimed to be the best way to administer marijuana [7 Schauer GL, King BA, Bunnell RE, et al. Toking, vaping, and eating for health or fun: marijuana use patterns in adults, U.S., 2014. Am J Prev Med. 2016;50(1):1–8.
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]. It is believed to be safer than smoking. Surveys of people who vape report that this method yields efficacy at lower cannabis quantities; yet, this contention is not confirmed [14 Malouff JM, Rooke SE, Copeland J. Experiences of marijuana-vaporizer users. Subst Abus. 2014;35(2):127–128.
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]. It also decreases the amount of compounds that induce respiratory diseases, like chronic bronchitis, in comparison to the pulmonary pathology of smoking. Vaping avoids inhalation of smoke, ash, carbon monoxide, ammonia, hydrogen cyanide, and tar (i.e. phenols and carcinogens such as benzopyrene and benzanthracene). Vaping also reportedly might result in less passive inhalations by other people [5 Cranford JA, Bohnert KM, Perron BE, et al. Prevalence and correlates of “Vaping” as a route of cannabis administration in medical cannabis patients. Drug Alcohol Depend. 2016;169:41–47.
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]. Overall, it may reduce the morbidity and mortality of smoking [11 Budney AJ, Sargent JD, Lee DC. Vaping cannabis (marijuana): parallel concerns to e-cigs? Addiction. 2015;110(11):1699–1704.
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]. Other possible advantages could include reducing cannabis smoking and smoke-related sequelae [8 Varlet V, Concha-Lozano N, Berthet A, et al. Drug vaping applied to cannabis: is “Cannavaping” a therapeutic alternative to marijuana? Sci Rep. 2016;6:25599.
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]. Vaping is sometimes said to taste better, have a fast onset of action, and might even be utilizable in certain public places. Vaping is documented as less costly, compared to smoking marijuana [11 Budney AJ, Sargent JD, Lee DC. Vaping cannabis (marijuana): parallel concerns to e-cigs? Addiction. 2015;110(11):1699–1704.
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]. However, inhaling aerosolized marijuana, nicotine, or e-cigarette flavoring additives are not determined to be safe [11 Budney AJ, Sargent JD, Lee DC. Vaping cannabis (marijuana): parallel concerns to e-cigs? Addiction. 2015;110(11):1699–1704.
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]. Vaping aerosolized materials is so new that no one has experienced long exposures, and thus, the clinical safety of this technique is unknown.

One of the biggest problems with vaping marijuana is that while it does have health advantages, too many people mistakenly recognize it as safe. Market advertising focuses on the benefits. This might lead to more individuals trying marijuana, especially among younger persons, and that may result in increased usage. It is also feared that those who try marijuana as an experiment are more likely to transition to other drugs as a ‘gate-way’ mechanism [11 Budney AJ, Sargent JD, Lee DC. Vaping cannabis (marijuana): parallel concerns to e-cigs? Addiction. 2015;110(11):1699–1704.
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].

The aerosolizer devices come in different prices and some of them may emit more toxic products and health risks than others [11 Budney AJ, Sargent JD, Lee DC. Vaping cannabis (marijuana): parallel concerns to e-cigs? Addiction. 2015;110(11):1699–1704.
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]. Consequently vaping cannabis and/or nicotine may create difficulty for many people to terminate their usage. Since vaping is now more common, it becomes a matter of concern [9]; Lee DC, Crosier BS, Borodovsky JT, et al. Online survey characterizing vaporizer use among cannabis users. Drug Alcohol Depend. 2016;159:227–233.
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consumers are exposed to more toxicities. Those who vape marijuana might be more likely to utilize nicotine e-cigarettes, tobacco cigarettes, and/or other tobacco products and vice-versa [9 Lee DC, Crosier BS, Borodovsky JT, et al. Online survey characterizing vaporizer use among cannabis users. Drug Alcohol Depend. 2016;159:227–233.
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].

Impairment of cognition is another major adverse consequence of marijuana exposure. Long-term vaping marijuana, similar to smoking, predisposes users to cognitive and attitude concerns, with children and young adults especially at risk [15 Cox B. Can the research community respond adequately to the health risks of vaping? Addiction. 2015;110(11):1708–1709.
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]. These mental, brain-related issues can impair future intellectual and psychological function [15 Cox B. Can the research community respond adequately to the health risks of vaping? Addiction. 2015;110(11):1708–1709.
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]. Neurological and psychological functioning declines among marijuana users, especially if started at a young age; [16 Meier MH, Caspi A, Ambler A, et al. Persistent cannabis users show neuropsychological decline from childhood to midlife. Proc Natl Acad Sci U S A. 2012;109(40):E2657–E2664.
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] a higher decrement is documented in frequent consumers [16 Meier MH, Caspi A, Ambler A, et al. Persistent cannabis users show neuropsychological decline from childhood to midlife. Proc Natl Acad Sci U S A. 2012;109(40):E2657–E2664.
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Magnetic resonance imaging has imaged structural alterations resulting from marijuana use at a young age; the changes predominate in the nucleus accumbens and amygdala gray matter [17 Gilman JM, Kuster JK, Lee S, et al. Cannabis use is quantitatively associated with nucleus accumbens and amygdala abnormalities in young adult recreational users. J Neurosci. 2014;34(16):5529–5538.
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]. That marijuana induces deleterious effects has significant global support [17 Gilman JM, Kuster JK, Lee S, et al. Cannabis use is quantitatively associated with nucleus accumbens and amygdala abnormalities in young adult recreational users. J Neurosci. 2014;34(16):5529–5538.
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]. Short-term users may exhibit panic attacks, anxiety, and hallucinations. In the longer term, the development of psychotic symptoms or disorders, depression, suicidal tendencies, and cognitive deficits are sometimes observed [18 World Health Organization. The health and social effects of nonmedical cannabis use. Geneva: World Health Organization; 2016. [cited 2017 Aug 26]. Available from:
http://apps.who.int/iris/bitstream/10665/251056/1/9789241510240-eng.pdf?ua=1
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]. The degree of danger to neurological health of sustained marijuana vaping in children and young adults is still not fully determined. Research about the effect of marijuana on developing brains remains under investigation [11 Budney AJ, Sargent JD, Lee DC. Vaping cannabis (marijuana): parallel concerns to e-cigs? Addiction. 2015;110(11):1699–1704.
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]. Consumption of marijuana may similarly be dangerous for brain development during a gestation; pregnant women should be warned about this risk [19 Grant KS, Petroff R, Isoherranen N, et al. Cannabis use during pregnancy: pharmacokinetics and effects on child development. Pharmacol Ther. 2017 Aug 25. pii: S0163-7258(17)30224-3. [Epub ahead of print]. DOI:10.1016/j.pharmthera.2017.08.014
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].

Conclusion
Legalization of marijuana, coupled with the benefits for medical therapies, probably will increase consumption in coming years. Marijuana in any form has numerous potential ill effects. Besides short-term impairment of judgment and accidents or various somatic or psychiatric pathologies, vaping as a method to administer cannabis is not considered safe, especially risky for younger people. Similar danger applies to the unborn during a pregnancy. Even though it is not entirely safe, vaping may be preferable for users and the environment, in comparison to smoking cannabis. These aspects probably facilitate efforts at legalization.

Young persons and pregnant women must be strongly discouraged from marijuana consumption in any form. Physicians should discuss these risks with patients, families, and our wider society. Without a clear understanding about all of the physiological effects of marijuana consumption, physicians ought to provide warnings. More time and research could determine the advantages and disadvantages of using marijuana by any method.

Declaration of Interest
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

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