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MODERN CANNABISAND LUNG HEALTH
JEFF CALLARD PA-CEMERGENCY PHYSICIANS MEDICAL GROUP
ST JOSEPH MERCY HOSPITALLEAD APP
EMERGENCY MEDICINE FELLOWSHIP DIRECTOREMERGENCY PHYSICIANS MEDICAL GROUP
APRIL 28, 2018
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DISCLOSURES
NONE
But willing for the right price
SPECIAL THANKS
Jason Biehl MDSpectrum HealthMichigan State University College of Human Medicine
DEDICATED TO:
WHO CARES???
MAINE RESTAURANT SAYS THEY HUMANELY KILL LOBSTERS BY FIRST GETTING THEM HIGH ON MARIJUANA. BY BRIAN NEWLINPOSTED: 10:22 AM, SEPTEMBER 20, 2018 UPDATED: 10:22 AM, SEPTEMBER 20, 2018HTTPS://WWW.CLICKONDETROIT.COM/NEWS/NATIONAL/MAINE-RESTAURANT-SAYS-THEY-HUMANELY-KILLS-LOBSTERS-BY-FIRST-GETTING-THEM-HIGH-ON-MARIJUANA
MICHIGAN VOTERS TO DECIDE NOV. 6 WHETHER TO LEGALIZE RECREATIONAL MARIJUANA
GOALS/TOPICS• Changes in legislation Changes in use patterns• The “burning platform” for marijuana research• Current understanding of the pulmonary effects of cannabis use• Limitations to the current understanding• Limitations in the efficacy and safety of our current medicinal use• Future directions
SMOKING USE
SMOKING
• Water pipe and bongs: water filter
SMOKING
• Water pipe and bongs: water filter• Equal amount drug
• No decrease smoking risk
SMOKING
• Water pipe and bongs: water filter• Equal amount drug
• No decrease smoking risk
• Vaporizer
• Heat to combustion point• Lower tar level
• Fewer adverse respiratory symptoms
SMOKING• Vaporizer
• Heat to combustion point• Lower tar level
• Fewer adverse respiratory symptoms• BUT…..
• Increased ammonia
• Irritation increased
• CNS adverse effects
• Increase asthma/bronchospasms
WHAT DO WE – THINK – WE KNOW!
MARIJUANA: FACTS
• Cannabis comes from a flowering plant native to central Asia and the Indian sub continent.
MARIJUANA: FACTS
• Cannabis comes from a flowering plant native to central Asia and the Indian sub continent.
• Major active compounds
• Delta 9 Tetrahydrocannabinol (THC)
• Psychoactive component
MARIJUANA: FACTS
• Cannabis comes from a flowering plant native to central Asia and the Indian sub continent.
• Major active compounds
• Delta 9 Tetrahydrocannabinol (THC)
• Psychoactive component
• Cannabidiol (CBD)
• Modulates the THC• Pain
• Seizure control
MARIJUANA: FACTS
• Genus includes
• sativa-higher THC
• Indica-higher CBD
• Rudarlis-
• lowest THC
• Smells like skunk
MARIJUANA: FACTS
• Increase in allergy symptoms which is increasing in Colorado since legalization
• Increase users
• Increase exposure to non-users
• Ann Allergy Asthma Immunol 199(2017) 558-571.
MARIJUANA: FACTS• Good?
• Internet recommends cannabis• Pain control
• Relaxation
• Seizures
• Cures of many diseases
• May fix opiate problem
• But.. No studies • Journal of Science and Medicine in sports 20(2017) 825-829)
MARIJUANA: FACTS• Good?
• Internet recommends cannabis• But.. No studies
• THC • bronchodilator• Journal of Science and Medicine in sports 20(2017) 825-829)
MARIJUANA: FACTS• Good?
• THC • Bronchodilator
• There are much better bronchodilators with lower side effects
• Induces tachycardia
• Lower blood pressure
• Cannabis decreases aerobic performance• Journal of Science and Medicine in sports 20(2017) 825-829)
MARIJUANA USE TIMELINE
2700 BCFirst Medical
Use Bob Newhart
1850 ADAdded to US
Pharmacopeia
1937 Marijuana
tax act
1988Schedule 1
1991 –Present
Medical MJ legalized 23
states
2006FDA statement
2014Medical
Recreational
POTENCY OVER THE YEARS
REMINDER OF THE CHEMICAL
• HCN: Hydrogen cyanide: It is a colorless liquid with a piercing, acrid smell. The smell of burnt fat is caused by glycerol in the burning fat breaking down into acrolein.
• Formaldehyde: Formaldehyde is a naturally occurring organic compound with the formula CH2O. It is the simplest of the aldehydes. The common name of this substance comes from its similarity and relation to formic acid
• Ammonia: The simplest pnictogen hydride, ammonia is a colorless gas with a characteristic pungent smell.
REMINDER OF THE CHEMICAL
• PAHs: Polycyclic aromatic hydrocarbons are hydrocarbons—organic compounds containing only carbon and hydrogen—that are composed of multiple aromatic rings. The simplest such chemicals are naphthalene, having two aromatic rings, and the three-ring compounds anthracene and phenanthrene.
• NO2: Nitrogen dioxide is the chemical compound with the formula. It is one of several nitrogen oxides. is an intermediate in the industrial synthesis of nitric acid, millions of tons of which are produced each year which uses is primary in production of fertilizers
• Acrolein: It is a colorless liquid with a piercing, acrid smell. The smell of burnt fat is caused by glycerol in the burning fat breaking down into acrolein.
SIMILARITIES TO TOBACCO
Cannabinoids Nicotine
TarAcrolein
FormaldehydeAmmonia
PAHsHCNNO2
ADVERSE EFFECTS OF TOBACCO SMOKING
• Cause of 1 in 5 deaths in the United States
ADVERSE EFFECTS OF TOBACCO SMOKING
• Cause of 1 in 5 deaths in the United States
• Coronary Artery Disease
ADVERSE EFFECTS OF TOBACCO SMOKING
• Cause of 1 in 5 deaths in the United States
• Coronary Artery Disease
• Cerebrovascular Accidents
ADVERSE EFFECTS OF TOBACCO SMOKING
• Cause of 1 in 5 deaths in the United States
• Coronary Artery Disease
• Cerebrovascular Accidents
• Lung Cancer (Bladder, blood/AML, Cervix, Colon/Rectal, Esophagus, Kidney, Ureter, Larynx, Liver, Oropharynx, Pancreas, Stomach, Trachea, Bronchus)
ADVERSE EFFECTS OF TOBACCO SMOKING
• Cause of 1 in 5 deaths in the United States
• Coronary Artery Disease
• Cerebrovascular Accidents
• Lung Cancer (Bladder, blood/AML, Cervix, Colon/Rectal, Esophagus, Kidney, Ureter, Larynx, Liver, Oropharynx, Pancreas, Stomach, Trachea, Bronchus)
• COPD
ADVERSE EFFECTS OF TOBACCO SMOKING
• Cause of 1 in 5 deaths in the United States
• Coronary Artery Disease
• Cerebrovascular Accidents
• Lung Cancer (Bladder, blood/AML, Cervix, Colon/Rectal, Esophagus, Kidney, Ureter, Larynx, Liver, Oropharynx, Pancreas, Stomach, Trachea, Bronchus)
• COPD
• Adverse effects on pregnancy
“UNDERSTANDING” TO DATE
Habitual Smoked
Cannabis Use
Airways Disease(1) Chronic Bronchitis(2) Abnormal
histopathology
Immunomodulation(1) Activation of cannabinoid
system(2) Upper and Lower airways
infections
HABITUAL INHALED CANNABIS RESULTS IN AIRWAY PATHOLOGY
Roth, Am J Respi Crit Care Medicine 1998
CHRONIC USE AND RESULTS
• Marijuana smoke contains particular matter that induces• oxidative stress
• inflammation
• Annals of Internal Medicine 2018; 169:106-115
CHRONIC USE AND RESULTS
• Marijuana smoke contains particular matter that induces• oxidative stress • inflammation
• Endobronchial biopsy data users v non-users• Chronic airway inflammation• Epithelial injury
• Basal cell hyperplasia• Goblet sell hyperplasia• Subepithelial inflammation
• Annals of Internal Medicine 2018; 169:106-115
ALTERED IMMUNE RESPONSES
Croxford, Journal of Neuroimmunology 2005
CANNABINOID EXPOSURE INCREASES OXIDATIVE STRESS INDICES IN VITRO
Murine lung epithelial cells2013
Human endothelial cells1999
INHALED CANNABIS EXPOSURE IS ASSOCIATED WITH IMPAIRED ALVEOLAR MACROPHAGE FUNCTION
AJRCCM 1997 1 μg/mL E coli LPS
DO ALTERATIONS IN IMMUNE RESPONSES AND OXIDATIVE STRESS AFFECT CLINICAL OUTCOMES?
INHALED CANNABIS USE IS ASSOCIATED WITH UPPER AND LOWER AIRWAY INFECTIONS
CANNABIS SMOKING ON LUNG FUNCTION AND INFECTION• Experimental
• Bronchodilator effect (THC)
• Analgesic effect
• npj Primary care Respiratory Medicine (2016)26 www.nature.com/npjcrm
CANNABIS SMOKING ON LUNG FUNCTION AND INFECTION CONTINUED• Reality
• Increased FVC with chronic use
• Similar reactions of tobacco• Additive affect if use both
• Cannabinoids• Varies with THC concentration
• Partial agonist
• Even be antagonist
• npj Primary care Respiratory Medicine (2016)26 www.nature.com/npjcrm
LIMITATIONS TO OUR KNOWLEDGE• Lack of homogeneity of exposure (type of marijuana/THC/CBD and
route of smoking such as vaping)
LIMITATIONS TO OUR KNOWLEDGE• Lack of homogeneity of exposure (type of marijuana/THC/CBD and
route of smoking such as vaping)• Confounding variables (tobacco or smoked WITH cannabis)
LIMITATIONS TO OUR KNOWLEDGE• Lack of homogeneity of exposure (type of marijuana/THC/CBD and
route of smoking such as vaping)• Confounding variables (tobacco or smoked WITH cannabis)• Limited longitudinal data
LIMITATIONS TO OUR KNOWLEDGE• Lack of homogeneity of exposure (type of marijuana/THC/CBD and
route of smoking such as vaping)• Confounding variables (tobacco or smoked WITH cannabis)• Limited longitudinal data• No funding due to status as schedule 1
LIMITATIONS TO OUR KNOWLEDGE
• Cannabis exposure is different• In vitro data exposure to only one cannabinoid (>60 in cannabis)• Human data THC content has significantly increased
• Honesty/Reliability of cannabis quantification• Quantification of cannabis exposure – “joint year?”
QUITTING MARIJUANA AND ASTHMA• Asthma associated with use of Cocaine, Heroin and Marijuana
• Bad
Journal of Asthma 54:7 714-722
QUITTING MARIJUANA AND ASTHMA
• Asthma associated with use of Cocaine, Heroin and Marijuana• Chronic Marijuana smokers
• Greater than 52 times over year
• Quit smoking
Journal of Asthma 54:7 714-722
QUITTING MARIJUANA AND ASTHMA
• Asthma associated with use of Cocaine, Heroin and Marijuana• Chronic Marijuana smokers
• Greater than 52 times over year
• Quit smoking • Returned to normal clinically
• Morning cough
• Sputum production
• Wheezing
Journal of Asthma 54:7 714-722
INCREASING THC CONTENT
Volkow et al NEJM 2014
SCHEDULE 1
THE TIDE MAY BE TURNING
THE TIDE MAY BE TURNING
MICHIGAN MEDICAL MARIJUANA PROGRAM
HTTPS://WWW.THORACIC.ORG/PATIENTS/PATIENT-RESOURCES/RESOURCES/MARIJUANA
FUTURE DIRECTIONS
• Advocate for change in the schedule 1 status
• Improve understanding of medicinal uses
• Opioid crisis
• Epilepsy
• Asthma?
FUTURE DIRECTIONS
• Advocate for change in the schedule 1 status
• Improve understanding of medicinal uses
• Opioid crisis
• Epilepsy
• Asthma?
• Improve our knowledge about – pulmonary – long term side effects
• Educate our patients and the public
CONCLUSIONS
• Use is INCREASING and will continue
• It is predominantly smoked and Vaped
CONCLUSIONS
• Use is INCREASING and will continue
• It is predominantly smoked and Vaped
• The medicinal benefit and long term effects are poorly understood
• Current “understanding” is outdated and inaccurate
CONCLUSIONS
• Use is INCREASING and will continue
• It is predominantly smoked and Vaped
• The medicinal benefit and long term effects are poorly understood
• Current “understanding” is outdated and inaccurate
• Limitations to studying it based on schedule 1 designation
• Lack of knowledge is a public health concern
• A unique opportunity for activist? For many of the reasons above Pulmonologists?
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