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Legal Marijuana States Had Fewer Vaping-Related Lung Injuries, Study Finds

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People in states where recreational marijuana is legal were significantly less likely to experience vaping-related lung injuries than those in states where cannabis is prohibited, according to a new study published in an American Medical Association journal.

The finding seems to affirm what many reform advocates said during the peak of the e-cigarette or vaping product use-associated lung injury (EVALI) crisis last year. With thousands being hospitalized over EVALI, it became clear that contaminated vape cartridges were the source and that contamination was more common in illicit, unregulated markets where consumers can’t walk into retail stores and buy tested and labeled marijuana products.

By analyzing Centers for Disease Control and Prevention (CDC) data on EVALI cases, the prevalence of e-cigarette use and the population in each state from June 2019 to January 2020, researchers were able to confirm that.

The research letter, published by the JAMA Network Open on Monday, shows that states with recreational marijuana shops had 1.7 EVALI cases per million population compared to 8.1 cases per million in prohibition states. There was no statistically significant difference between criminalized and medical cannabis states, which experienced 8.8 cases per million population.

“The data suggest that EVALI cases were concentrated in states where consumers do not have legal access to recreational marijuana dispensaries,” the letter states. “This association was not driven by state-level differences in e-cigarette use, and EVALI case rates were not associated with state-level prevalence of e-cigarette use. One possible inference from our results is that the presence of legal markets for marijuana has helped mitigate or may be protective against EVALI.”

“Recreational marijuana states had among the lowest EVALI rates of all states.”

While the researchers said the reason for the association isn’t clear yet, they surmised that it’s “possible that in recreational states, people tend to purchase marijuana products at legal dispensaries, which may be less likely to sell the contaminated products that are thought to cause EVALI.”

That has been the working theory of many industry observers, who have argued that legalization is an important safeguard to public health by ensuring compliance with quality control standards in cannabis products. It should be noted, however, that there are select reports of instances where people seemed to develop a lung injury after obtaining marijuana vaping products from licensed dispensaries in Oregon.

“It appears states that have legal access to marijuana have lower rates of EVALI cases, which is consistent with the hypothesis that people have demand for marijuana products, and in states where they don’t have access to them in this regulatory fashion, they end up purchasing them elsewhere,” study co-author Alex Hollingsworth told MedPage Today.

NORML Executive Director Erik Altieri said the findings “come as little surprise.”

“In jurisdictions where cannabis is legally regulated, consumers gravitate toward the above-ground retail marketplace where they can access lab-tested products manufactured by licensed businesses,” he said. “Just like alcohol prohibition gave rise to the illicit production of dangerous ‘bathtub gin,’ marijuana prohibition provides bad actors, not licensed businesses, the opportunity to fulfill consumers’ demand—sometimes with tragic results.”

In a historical commentary on the new study also published by the American Medical Association Journal, a separate set of researchers drew a parallel to the era of alcohol prohibition—from which an underground industry of bootleggers emerged.

“Bootleggers fortified their distillates with methanol to increase apparent potency, causing blindness and death in unwary consumers,” they said, noting that industrial ethanol, which was exempt from prohibition, was sometimes used despite the fact that government officials directed it to be adulterated with poisonous substances to deter consumption. “The resulting concoctions, known as denatured alcohol, were responsible for thousands of deaths during the 14 years that Prohibition was in effect. The history of Prohibition thus serves as a cautionary tale about unintended and unforeseen consequences of legislation regulating substances that affect public health.”

“Bootlegging was rampant and criminal syndicates proliferated, fueling a wave of organized crime.”

EVALI similarly appears to be strongly associated with a specific contaminant in illicit markets, vitamin E acetate (VEA), which is used to dilute or stretch cannabis concentrates —”a scenario reminiscent of the unscrupulous bootleggers of the Prohibition era.”

“How could a state’s legalization of recreational marijuana inadvertently protect its citizens against EVALI? The obvious answer is that THC-containing vaping products in states where recreational marijuana is legal are uncontaminated with VEA. If so, another question follows: why would THC products in these states be less likely to be contaminated (ie, diluted) with VEA? One salient possibility is that there is less financial incentive to dilute THC concentrates in states where raw THC material is readily available without legal risk and compensatory markup.”

“If THC concentrates are transported from states where they are legal and can be relatively cheaply mass produced (like industrial ethanol stocks during Prohibition) to other states where they are illegal and must be guarded jealously as a rare and precious commodity, there may be a strong economic inducement to dilute them, thereby increasing profits. Thus, legalization of marijuana may have protective local effects but untoward collateral effects.”

President Trump also seemed to pick up on the failure of prohibition during a meeting on the vaping crisis last year. He acknowledged that simply banning the products wouldn’t work, as people would simply move on to the illicit market, where there aren’t regulations.

What’s worse, the conflict between state and federal marijuana laws actually inhibited research into how to address EVALI cases, complicating shipments of vaping specimens, a top CDC official said.

The same official also suggested that federal cannabis regulations could mitigate the vaping problem. Former Food and Drug Administration Commissioner Scott Gottlieb made a similar argument.

CBD Prescription Drug Is No Longer A Federally Controlled Substance, DEA Says

This story was updated to include comment from NORML.

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Science & Health

Epilepsy Patients Who Use ‘Artisanal CBD’ Have Higher Quality Of Life, Study Finds

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Epilepsy patients who used nonprescription CBD products reported a higher quality of life and better sleep than patients who did not take the cannabinoid, according to the results of a newly published study in the peer-reviewed journal Epilepsy & Behavior.

Patients who used CBD products also better tolerated epilepsy medications, used fewer prescription medications overall and experienced reduced psychiatric symptoms such as anxiety, the study found.

No significant differences in seizure control were observed between patients who used CBD and those who did not, but the study’s authors noted that “both groups included a high number of individuals with no past month seizures.”

“These findings further emphasize the need for controlled research to determine optimal CBD product types, doses, and concomitant use of other medications that maximize possible clinical benefit while minimizing potential risks,” the report says.

Healthcare utilization by Artisanal CBD product use. Plotted are the percentage of participants reporting use of prescription medications, over-the-counter medications, or the specified event in the past month or those using an artisanal CBD product (black bars) or not using an artisanal CBD product (white bars) in the baseline assessment. Artisanal refers to non-pharmaceutical (i.e., non-Epidiolex!) use. * p < .05; ** p < .01.

J.C. Strickland, H. Jackson, N.J. Schlienz et al., Cross-sectional and longitudinal evaluation of cannabidiol (CBD) product use and health among people with epilepsy, Epilepsy & Behavior.

The study, “Cross-sectional and longitudinal evaluation of cannabidiol (CBD) product use and health among people with epilepsy,” was published Tuesday. It focuses specifically on what authors call “artisanal CBD”—alternatives to the prescription drug Epidiolex, which the U.S. Food and Drug Administration approved in 2018 to treat certain rare types of epilepsy.

“Pharmaceutical CBD is currently a restricted prescription medication, and insurance coverage is often limited to only those patients with the specific approved indications,” the report says. “As a result, a large number of patients with epilepsy elect to use alternative CBD products sold widely as dietary supplements by commercial vendors.”

The research was funded by Realm of Caring, a nonprofit foundation devoted to cannabinoid therapies that is sponsored by companies that make CBD products. The group conducted the study in collaboration with researchers at the Johns Hopkins University School of Medicine.

“Despite the widespread availability and variety of these alternative cannabinoid products—here referred to as artisanal CBD in contrast to pharmaceutical CBD—controlled studies evaluating their safety or efficacy are rare,” the authors write, “making conclusions about the clinical utility of these products uncertain.”

To arrive at their conclusions, researchers analyzed the results of surveys returned by 280 epilepsy patients who said they used so-called artisanal CBD products and 138 patients who used no cannabis products. The participants were selected using Realm of Caring patient registries and social media posts, and follow-up surveys were collected from a subset of 190 participants.

Most patients (74 percent) were white, and roughly half (55 percent) were female. The average age was 21 years old, and most (90 percent) reported no history of non-medical or recreational cannabis use. A majority (93 percent) reported epilepsy as their primary condition, while the other 7 percent developed epilepsy related to cancer, autoimmune or neuropsychiatric conditions, sleep disorders or other conditions.

Although those who took CBD products reported fewer seizures than those who did not, the difference was not statistically significant and may be due to random chance.

Other measures of well being, however, were higher in patients who took CBD. Participants filled out standardized questionnaires on quality of life, pain, anxiety and depression and sleep.

While some indicators, such as pain, did not meaningfully differ between the groups, artisanal CBD users reported greater health satisfaction. Sleep was significantly better among CBD users, and patients who used CBD were also less likely to meet the clinical threshold for anxiety.

Epilepsy medication adverse effects. Plotted are group mean scores on the Liverpool Adverse Events Profile on total scores (top panel) and individual items (bottom panel). Controls (white bars) and participants using an artisanal CBD product (black bars) are plotted. Error bars are standard error of the mean. A clinical cutoff of greater than 45 is also presented in the top panel in the dotted line). Artisanal refers to non-pharmaceutical (i.e., non-Epidiolex!) use. Individual items available in the Supplemental Materials.

J.C. Strickland, H. Jackson, N.J. Schlienz et al., Cross-sectional and longitudinal evaluation of cannabidiol (CBD) product use and health among people with epilepsy, Epilepsy & Behavior.

Those who used CBD also had lower odds of having gone to the emergency room or calling in sick to work or school during the past month.

“Generally, higher quality of life, lower psychiatric symptom scores and improved sleep were observed among people using an artisanal CBD product based on both cross-sectional and longitudinal comparisons,” the study says. “Artisanal CBD Users reported significantly better epilepsy medication tolerability, a lower odds of prescription medication use and traditional anticonvulsant use, and reduced healthcare utilization compared with Controls.”

“These findings are consistent with research indicating that practitioners recommending CBD in clinical care for epilepsy report integrating the use of CBD both as a means to improve patient quality of life and as well as for seizure reduction,” the researchers noted.

Other patients—about 1 in 5 of the survey participants—reported adverse effects from CBD. These included drowsiness (11 percent), apparent worsening of epilepsy symptoms (4 percent), high or prohibitive cost of CBD products (4 percent), worries over legality (3 percent) and either concerns about or experienced interactions with other drugs.

CBD dosing didn’t seem to significantly impact the outcomes, although higher doses of CBD were associated with higher quality of life scores and lower odds of a past-month outpatient visit. In general, participants reported using a median dose of 1.4 milligrams of CBD per kilogram of body weight, which authors note “is well below the dose commonly associated with pharmaceutical products (e.g., 10 mg/kg/day is the current recommended maintenance dose for pharmaceutical CBD).”

Authors acknowledge there are a number of limitations to the study, for instance the fact that it’s drawn from self-reported data. “These limitations mean that we are not able to directly verify epilepsy characteristics and did not have control over factors like CBD dose or frequency of administration,” they wrote. Moreover, participants were drawn from Realm of Caring’s patient registry, “which may not generalize to the broader population of patients with epilepsy. Of note, the nature of the sample means that there is a possible referral bias and related increases in expectation for clinical benefit.”

Some of the authors also have links to the commercial cannabis industry, according to a study disclaimer. Of the study’s eight named co-authors, one, Ryan Vandrey, has received compensation as a consultant or advisory board member from Canopy Growth, MyMD Pharmaceuticals, WebMD and Syqe Medical. Another, Marcel O. Bonn-Miller, is an employee of Canopy Growth and a past director at AusCann Group Holdings.

Overall, the study says, the findings “highlight real-world evidence for the possible utility of artisanal CBD products in a diverse and heterogenous population of patients with epilepsy. Although the lack of a placebo control group precludes determination of efficacy, the consistent observation of clinically meaningful differences between groups at baseline and with Controls who initiated artisanal CBD product use over time suggests that use of these products can improve health and quality of life for patients with epilepsy.”

Congress To Vote On Marijuana, Psychedelics And CBD Amendments This Week Following Committee Action

Photo by Kimzy Nanney

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Surgeon General Says Stop Locking People Up For Marijuana

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The nation’s top doctor said on Sunday that it’s time to stop incarcerating people for marijuana use.

“When it comes to decriminalization, I don’t think that there is value to individuals or to society to lock people up for marijuana use,” Surgeon General Vivek Murthy said in a CNN appearance. “I don’t think that serves anybody well.”

Murthy was answering a question about a new draft federal marijuana legalization bill that was circulated last week by Senate Majority Leader Chuck Schumer (D-NY) and other top senators.

While the surgeon general stopped short of endorsing full-scale commercial cannabis legalization, his comments do indicate support for an approach that would at least decriminalize low-level possession.

President Joe Biden, who opposes broad legalization, campaigned on a platform of incremental decriminalization and expunging past records, but has taken no steps to follow through on those promises since taking office.

“When it comes to marijuana, I think we have to let science guide us,” Murthy said in the CNN interview. “And we know that the science tells us that there are some benefits to marijuana from a medical perspective but there are also some harms that we have to consider—and we have to put those together as we think about the right policy.”

Murthy, who previously served as surgeon general under the Obama administration, said he is concerned about the effort to change cannabis laws getting ahead of the science.

“In terms of our approach to marijuana, I worry when we don’t let science guide our process and policymaking,” he said in the latest comments. “And as surgeon general that’s my role, is to work with policymakers who work with members in the community and the general public to help people understand what science tells us and where you gaps, to help fill those gaps with research and with honest inquiry.”

Previously, in 2015, Murthy said there is “preliminary data showing that for certain medical conditions and symptoms, that marijuana can be helpful.”

But in 2018, the doctor said he is “concerned about how rapidly states have been legalizing marijuana” because there are a “lot of unknowns” about its effects.

Top Maryland Lawmaker Pledges To Put Marijuana Legalization On 2022 Ballot

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Testing People For Marijuana Impairment Based On THC Levels Is ‘Not Reliable,’ Federally Funded Study Finds

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The amount of THC in a person’s system after consuming marijuana is not an accurate predictor of impairment, a federally funded study has determined.

The research, backed by a grant from the National Institute of Justice (NIJ), involved 20 people who either ate or vaporized cannabis with varying levels of THC. They were then tested with basic field sobriety and cognitive tests.

While the groups that received doses higher than 5mg of THC were all “negatively impacted” and experienced observable psychomotor impairment, the RTI International researchers found that “THC levels in biofluids were not reliable indicators of marijuana intoxication for their study participants.”

“Researchers investigated how marijuana affects skills required for safe driving and found that biofluid levels of THC did not correlate with field sobriety test performance or marijuana intoxication, regardless of how the cannabis was ingested.”

That raises questions about “per se” laws that are in place in several states, barring people from driving if they have more than a certain amount of THC in their blood.

“These important findings come as no surprise,” NORML Deputy Director Paul Armentano said. “Despite a handful of states imposing per se THC thresholds as part of their traffic safety laws, there exists no science demonstrating that these arbitrary limits are reliable predictors of either recent cannabis exposure or impairment.”

The study, which was published last year and promoted by NIJ in a tweet on Thursday, also found that various tests, including standing on one leg, balancing and walking and turning, “were not sensitive to cannabis intoxication for any of the study participants.”

Throughout the tests, participants’ blood, urine and oral fluid were collected and then sent to forensic laboratories.

“Results from the toxicology tests showed that the levels of all three targeted cannabis components (THC, cannabidiol, and cannabinol) in blood, urine, and oral fluid did not correlate with cognitive or psychomotor impairment measures for oral or vaporized cannabis administration,” NIJ said.

“Many of their study participants had significantly decreased cognitive and psychomotor functioning even when their blood, urine, and oral fluid contained low levels of THC,” the federal agency continued. “The researchers also observed that standardized field sobriety tests commonly used to detect driving under the influence of drugs or alcohol were not effective in detecting marijuana intoxication.”

In other words, THC does lead to impairment—but the concentration of that compound in bodily fluids does not accurately correlate with the extent to which a person is impaired. And in low doses, it seems some people are not negatively impacted, at least with respect to the standard tests that the researchers utilized.

Late last year, a different study published in the Journal of the American Medical Association found that low levels of CBD do not appear to have a significant impact on driving, and low-level THC consumption has an impact that is “modest in magnitude and similar to that seen in drivers with a 0.05%” blood alcohol concentration.

A a congressional research body also released a report in 2019 that found that evidence about cannabis’s ability to impair driving is currently inconclusive.

Researchers have found on several occasions that traffic fatalities do not increase after a state legalizes marijuana.

Of course, that doesn’t change the fact that both opponents and supporters of legalization generally caution against driving under the influence.

Mississippi Lawmakers Hold Medical Marijuana Hearing After Court Overturns Voter-Approved Law

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