There are many ways to get cannabis into your body, and there is a lot of confusion about which way is best for which conditions. There are also a lot of inaccuracies in the available information for patients making these decisions, so I would like to take this opportunity to set the record straight.
Cannabis is a weed that grows readily in a variety of climates. As a dried plant, or “flower”, it is able to be smoked in a paper wrapper–a joint, in a pipe, or through a water apparatus.
There are advantages and disadvantages of all of these. First of all, let’s discuss the safety involved. Although cannabis as a plant does not contain the various carcinogenic chemicals often found in tobacco cigarettes, burning the plant to smoke requires heating it to 600 degrees Fahrenheit. This temperature causes a lot of the naturally occurring cannabinoids like THC, CBD, and terpenes to burn off, at the same time leading to the inhalation of some undesirable carcinogens like tar, CO, and other irritants.
This must be considered as a risk factor, and smoking the flower should likely be avoided by people with underlying pulmonary disease, or those at high risk of developing a malignancy. If you are determined to “smoke” cannabis, as many “hard-core” afficianados feel to be the best way to appreciate it, it pays to consider the best way to do so.
Smoking a joint is convenient, portable, and inexpensive, but burning paper causes the amount of tar inhaled to increase.
Also, plant material is wasted as the joint burns. A metal, stone, or some other pipe is both quick and portable, but one runs the risk of inhaling lighter fluid and other gases this way. Water pipes are more cumbersome, but the smoke is less irritating after having been cooled through the water, there are no hot ash particles to inhale, and many toxins are removed as the smoke diffuses through the water. This is the cleanest way to smoke flower. Of note, studies show that smoking cannabis via combustion converts just 25% of the THC into inhalable vapor.
It is also possible to vaporize, or “vape” flower and oils. Studies show that vaping cannabis converts about 46% of the THC into inhalable vapor.
Vaping is the healthiest way to inhale cannabis as the vaping device quickly heats the material inside to a lower temperature than combustion, enough to release the THC and other cannabinoids without burning the material and releasing tar, carbon monoxide and other carcinogens. There was a big uproar in the media in 2019 about electronic cigarette or vaping associated lung injury (EVALI) but when the research was done it was determined that the flavored tobacco vape market and the black market cannabis vapes were the culprits. Additives were put into the tobacco vapes to give them flavors like bubblegum and fruit flavors, likely to appeal to the youth demographics, but these additives were found to be toxic to the lungs.
Also, people selling cannabis vapes on the black market were adding other liquids to dilute the cannabis oils, and therefore increase their profits, and some of the additives added such as Vitamin E acetate were toxic to the lungs. States with legal adult-use markets for cannabis (recreational use) were found to have the lowest incidence of this disorder, leading to the belief that full legalization, and the subsequent destruction of the black market, is the best solution for this health crisis.
Inhaling cannabis through smoking or vaping is the quickest way to feel its effects, with the onset of effects occurring in 90-120 seconds.
If the cannabis effects are desired very quickly, like in cases of pain and nausea, inhaling is a expedient way to get relief, and patients are able to better control the amount of medications taken in by waiting a minute or two between inhalations to determine whether they need more medicine or if their symptoms have resolved. When compared with waiting to digest a swallowed pill and see in 45 minutes to an hour if one has been given the proper dose, it is easy to see the advantages in using cannabis. Although we are all familiar with the pungent, unmistakable odor of burning cannabis, vaping cannabis has a subtle smell which dissipates within seconds and won’t linger in the room, or in clothing and hair, making vaping something that patients can do discreetly and allowing them to be out and about without fear of getting overwhelmed by symptoms. The effects of inhaled cannabis last from 2-4 hours.
In contrast, edible forms of cannabis, like infused candies, baked goods, and foods, have an onset of action that can take as long as 2 ½-3 hours, and are dependent on each individual’s absorption abilities.
This can lead to some amusing anecdotes. I had a patient tell me that she had eaten a cannabis brownie, “but nothing happened, so i ate 2-3 more.” Three hours later she was completely “wasted”, and the effects of edibles last much longer than inhaled cannabis, as long as 12-24 hours. Also, the Delta-10 THC that is formed in the digestive system may be more “psychedelic” than the Delta-9 THC formed while smoking or vaporizing, leaving the patients feeling more altered. Edibles are not going to be of much help to people needing a rapid onset of relief, and may not be a workable choice for patients whose diseases interfere with their ability to absorb things through their GI tract. Also, edibles are subject to the “first pass effect” where cannabinoids are partially broken down by the liver prior to reaching the target organs.
Tinctures and concentrated oils are usually taken sublingually (under the tongue).
This method of administration is much faster than swallowing the medication, with the onset of action in 5-15 minutes and the effects lasting as long as 5 hours. Medications administered this way show about 40% absorption, and avoid the first pass effect by going directly into the bloodstream, bypassing the liver. Cannabis oils can also be absorbed rectally or vaginally from suppositories, a direct and highly efficient way to absorb the medication. The rectum is highly vascular, which is why people get hemorrhoids. Medicine administered rectally is absorbed at an 80% efficiency, twice that of sublingually. It goes throughout the body as quickly as sublingual absorption. Also, evidence shows that suppositories lessen or eliminate the intoxication or psychoactive effects of cannabis medication which is desirable for patients wishing for symptom management without the “head high”. Vaginal suppositories have been shown to be helpful for menstrual cramps, endometriosis, post menopausal dryness and painful intercourse and enhancing of sexual pleasure. Rectal suppositories are used for local issues like anal fissures, inflammed hemorrhoids, and lower GI cancer pain as well as sciatica, lower back pain, restless leg syndrome, prostate disorders and post-operative pain.
Topical forms of cannabis are useful for fighting itching and inflammation in diseases like eczema and psoriasis, alleviating pain from superficial cuts and avoiding infection through cannabis’ antimicrobial properties, and working locally on aches and pains when massaged into local areas.
One of the most exciting uses I have seen while treating cancer patients is the ability of topical formulations to treat peripheral neuropathy, the numbness, burning and tingling often seen in patients with diabetes, spinal cord and nerve injuries, and as a side effect of chemotherapeutic agents. Unlike the medications more commonly used to treat this condition, like Gabapentin, Lyrica and Cymbalta, all of which have a lot of side effects, topical cannabis is very well tolerated. It can be spread all over your body without causing any psychoactive effects, and even if it is not successful in treating neuropathy, the worst the patient will experience is moist, supple skin because it is dispensed in a moisturizing base like shea butter and coconut oil.
Cannabis based medications are being explored more and more for the veterinary medicine market.
I have a lot of personal experience with this, and attribute the fact that my elderly goldendoodle is still alive to his use of CBD products. When Noah was two he was diagnosed with lymphangectasia, an autoimmune doggy colitis, and had several surgeries and was treated with a lot of expensive medication regimens. He survived against the odds, but has always had a very sensitive GI system and cannot eat fatty, or spicy, or many other sorts of foods without getting colitis effects. As he aged, he, like many large dogs, developed arthritis in his hips and back which imapired his mobility. I knew that he could never take the usual doggy pain medications which are non-steroidal anti inflammatory medications, as his GI tract would never tolerate them.
CBD, however, is used for pain relief as well as anti-inflammatory treatment of conditions like Crohn’s disease, a human autoimmune colitis. I started Noah on CBD and he is still plodding along, albeit slowly, at 12 ½ years of age! CBD is also helpful for animals struggling with anxiety, PTSD, and nausea, as well as topically for itching and helping to heal open wounds.
One also sees CBD and THC appearing in health and beauty products. Since cannabinoids have anti inflammatory and antimicrobial effects, it is easy to understand how they could be soothing and healing to skin, and prevent some of the visible signs of aging by nourishing and healing the skin. As the research into cannabis continues to develop, I am sure that we will discover many other exciting and useful ways to incorporate the healing powers of this amazing plant!