MODERN CANNABIS AND LUNG HEALTH

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1 MODERN CANNABIS AND LUNG HEALTH JEFF CALLARD PA-C EMERGENCY PHYSICIANS MEDICAL GROUP ST JOSEPH MERCY HOSPITAL LEAD APP EMERGENCY MEDICINE FELLOWSHIP DIRECTOR EMERGENCY PHYSICIANS MEDICAL GROUP APRIL 28, 2018

2 KAHOOT! MOBILE APP Download our app for free: Found in App Store Apple App store and Google play

3 DISCLOSURES NONE But willing for the right price

4 SPECIAL THANKS Jason Biehl MD Spectrum Health Michigan State University College of Human Medicine

5 DEDICATED TO:

6 WHO CARES???

7 MAINE RESTAURANT SAYS THEY HUMANELY KILL LOBSTERS BY FIRST GETTING THEM HIGH ON MARIJUANA. BY BRIAN NEWLIN POSTED: 10:22 AM, SEPTEMBER 20, 2018 UPDATED: 10:22 AM, SEPTEMBER 20, FIRST-GETTING-THEM-HIGH-ON-MARIJUANA

8 MICHIGAN VOTERS TO DECIDE NOV. 6 WHETHER TO LEGALIZE RECREATIONAL MARIJUANA

9 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

15 SMOKING USE

16 SMOKING Water pipe and bongs: water filter

17 SMOKING Water pipe and bongs: water filter Equal amount drug No decrease smoking risk

18 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

19 SMOKING Vaporizer Heat to combustion point Lower tar level Fewer adverse respiratory symptoms BUT.. Increased ammonia Irritation increased CNS adverse effects Increase asthma/bronchospasms

20 WHAT DO WE THINK WE KNOW!

21 MARIJUANA: FACTS Cannabis comes from a flowering plant native to central Asia and the Indian sub continent.

22 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

23 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

25 MARIJUANA: FACTS Genus includes sativa-higher THC Indica-higher CBD Rudarlis- lowest THC Smells like skunk

26 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)

27 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) )

28 MARIJUANA: FACTS Good? Internet recommends cannabis THC But.. No studies bronchodilator Journal of Science and Medicine in sports 20(2017) )

29 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) )

31 MARIJUANA USE TIMELINE 2700 BC First Medical Use Bob Newhart 1850 AD Added to US Pharmacopeia 1937 Marijuana tax act 1988 Schedule Present Medical MJ legalized 23 states 2006 FDA statement 2014 Medical Recreational

32 POTENCY OVER THE YEARS

34 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.

35 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.

36 SIMILARITIES TO TOBACCO Cannabinoids Tar Acrolein Formaldehyde Ammonia PAHs HCN NO 2 Nicotine

37 ADVERSE EFFECTS OF TOBACCO SMOKING Cause of 1 in 5 deaths in the United States

38 ADVERSE EFFECTS OF TOBACCO SMOKING Cause of 1 in 5 deaths in the United States Coronary Artery Disease

39 ADVERSE EFFECTS OF TOBACCO SMOKING Cause of 1 in 5 deaths in the United States Coronary Artery Disease Cerebrovascular Accidents

40 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)

41 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

42 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

43 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

44 HABITUAL INHALED CANNABIS RESULTS IN AIRWAY PATHOLOGY Roth, Am J Respi Crit Care Medicine 1998

45 CHRONIC USE AND RESULTS Marijuana smoke contains particular matter that induces oxidative stress inflammation Annals of Internal Medicine 2018; 169:

46 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:

47 ALTERED IMMUNE RESPONSES Croxford, Journal of Neuroimmunology 2005

48 CANNABINOID EXPOSURE INCREASES OXIDATIVE STRESS INDICES IN VITRO Murine lung epithelial cells 2013 Human endothelial cells 1999

49 INHALED CANNABIS EXPOSURE IS ASSOCIATED WITH IMPAIRED ALVEOLAR MACROPHAGE FUNCTION AJRCCM μg/ml E coli LPS

50 DO ALTERATIONS IN IMMUNE RESPONSES AND OXIDATIVE STRESS AFFECT CLINICAL OUTCOMES?

51 INHALED CANNABIS USE IS ASSOCIATED WITH UPPER AND LOWER AIRWAY INFECTIONS

52 CANNABIS SMOKING ON LUNG FUNCTION AND INFECTION Experimental Bronchodilator effect (THC) Analgesic effect npj Primary care Respiratory Medicine (2016)26

53 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

54 LIMITATIONS TO OUR KNOWLEDGE Lack of homogeneity of exposure (type of marijuana/thc/cbd and route of smoking such as vaping)

55 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)

56 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

57 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

58 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?

59 QUITTING MARIJUANA AND ASTHMA Asthma associated with use of Cocaine, Heroin and Marijuana Bad Journal of Asthma 54:

60 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:

61 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:

62 INCREASING THC CONTENT Volkow et al NEJM 2014

63 SCHEDULE 1

64 THE TIDE MAY BE TURNING

65 THE TIDE MAY BE TURNING

66 MICHIGAN MEDICAL MARIJUANA PROGRAM

70 RESOURCES/RESOURCES/MARIJUANA

72 FUTURE DIRECTIONS Advocate for change in the schedule 1 status Improve understanding of medicinal uses Opioid crisis Epilepsy Asthma?

73 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

74 CONCLUSIONS Use is INCREASING and will continue It is predominantly smoked and Vaped

75 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

76 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?

78 KAHOOT a%3d

79 Questions?

Trichomes: Crystalline structures that coat parts of the cannabis plant that hold the majority of the cannabinoid content.

Trichomes: Crystalline structures that coat parts of the cannabis plant that hold the majority of the cannabinoid content. ESSENTIAL MARIJUANA TERMS To more fully understand marijuana, you have to know the language of marijuana. Marijuana has its own language. That s due in part to the complexity of marijuana as a plant, and