Sunday, September 29, 2019

Vaping Illness Update

This matters to me because I have found evidence--both in my clinic and in the scientific research (mostly from Britain)--that vaping is 1) less toxic than smoked tobacco, and 2) a means of achieving harm reduction in smokers.

Most people have heard about the 800+ Americans who have suffered from a mysterious lung illness, a kind of pneumonia that doesn't appear to be caused by some germ. It's an "inflammatory pneumonia" and some who have it have gotten so ill they've ended up on breathing machines, and a few have even died. The FDA and Centers for Disease Control have suggested that--until a cause can be found--vaping should be avoided.

What is vaping?  
A vape-pen and vape liquids.
Photo: U.S. Dept. of Defense.

For the unfamiliar, "vaping" is the use of electric vaporizers to heat a liquid so that the resulting vapor can be inhaled. "Vape juice" is usually based on some combination of vegetable glycerin and propylene glycol, a sugar alcohol, and this somewhat thickened base mixture is then flavored to recreate flavor experiences like "tobacco", "cigar", or novel flavor profiles like fruits or candies, or spiced profiles like menthol or clove. Vaping began with nicotine added to recreate the drug experience that tobaccos users seek, but in short order it was obvious that other drugs could be added, mainly THC from marijuana, to create a smokeless product, without the tars, carcinogens, and carbon monoxide of actual smoking.

History and Use

Tobacco smoking has been in decline for the last few decades. Smoking's out of fashion. So-called "e-cigarettes" were developed about two decades ago but never caught on. With time, the technology got better and e-cigs started to gain traction among consumers. Some used them as a some-time alternative to cigarettes. Some used them as a transition to quit. Others tied them but went back to tobacco. In the last 5 to 7 years their use has grown, especially among teenagers, who are attracted to the flavors (examples: "bubblegum" "pina colada" etc.) and then get hooked on the nicotine.

A lot of people don't know that vaping can be done without nicotine added. But then you ask, "why would anyone do that?" It's simple: it's an activity. It's a thing people can do together--sit around and puff out vaporous clouds, clouds that taste like cherry syrup or cinnamon donuts or Froot-Loops!

There's evidence that nicotine isn't great for teenage brains. And really, is 16 old enough to start making decisions about trying addictive substances? So there's one problem: regulation and control of the industry. But then there's a flip side. With more regulation and control, an industry consolidates, and when it does, it tends to be big players with lots of money who dominate, forcing consumers into a narrower array of product choices, and encouraging others to black market products that are cheaper, or that come in flavors and such that the big companies don't produce.

Public Health England, a research group in the UK, reported that e-cigs/vaping was 95% safer than smoking and could help smokers quit. The researchers admit that data are preliminary, but enough has been accumulated to make some early arguments that vaping should continue to exist and that it should be regulated for safety.

So What's the Problem?

Over the last several months, as doctors started to notice these weird cases of lung disease and their connection to vaping, reports mounted, leading to public health investigations. This article from Buzzfeed News in September suggests the 5 best theories that explain the current crisis. In reporting from the CDC we're now up to just over 800 cases and no single factor explains them all. The CDC has seemed to focus heavily on accounting for the active drug, and THC vaping has been implicated in over 3/4ths  of cases. However no single flavor, drug, or brand is marked in all cases.

My own theory? I think it's a contaminated or poor-quality ingredient, and researchers have reported that vitamin E acetate has been found in a very high number of the suspect vape juices they tested. Maybe heating up vitamin E acetate and getting it into one's lungs is a problem. What hasn't been reported on yet is how heavily the people afflicted with this illness vaped. I also wonder if it's a combination of factors.

After all, Americans have been vaping for over a decade. Millions have done this, and we're only really seeing this critical mass of cases now? Why doesn't smoking cause this illness? Is it that some people may be genetically predisposed to suffer from vaping illness? There is a gene group that could explain this, and it's one we've known a little about for a long time, but in the last five years we know a lot more about it. Is it the unregulated market? The internet is full of recipes for vape juices, and the ingredients are largely uncontrolled chemicals such a glycerin and propylene glycol, both used widely in foods and pharmaceuticals. Isn't it possible that with the vast array of do-it-yourselfers and entrepreneurs out there, and the equally vast array of ingredient sources, and the near-limitless combination of possible ingredients--both drug and flavoring--that there would be an outbreak of illness from contamination at some point?

What to do?

For many of my readers, this may not be an issue. A lot of my patients and readers don't smoke and don't vape. But what if you are a smoker and wish to vape to reduce or eliminate your dependence on cigarettes? What if you quit tobacco, but are habituated on vaping? Well, first off, the percentage of cases in the overall number of people who vape is small. Reputable products from above-board suppliers are causing a tiny minority of cases of vaping illness. Second, in no way is vaping as bad as smoking. If you've quit cigs but still vape, you are still far better off than if you still smoked. Third, why not use nicotine substitutes like patches or gum to wean yourself off? If you can, that's great, but vaping addresses a behavioral aspect of the habit of smoking that some people are as attracted to as the nicotine or THC itself--I hinted at this above when I noted that some people vape without any drugs in their vape juice. So if vaping satisfies that "puffing behavior"--often social or contemplative--and you would just go back to smoking cigarettes or cigars to avoid vaping illness while keeping the behavior, I think that's a bad idea.

Stay tuned, because at some point we're going to figure this out. I hope it doesn't lead to the widespread banning of vape products (it would just become a black market industry anyway, and then anything can happen!) Above I mentioned "harm reduction"--this is the drug management philosophy that argues that people are going to use drugs, no matter what. It's what we do (even if you personally don't), so why not make the thing as safe as possible? Encourage people to quit, but also give them a safer alternative to the worst effects of the use of a drug or behavior. 

Image result for how many people vape in the us
Cited in: BBC

If there are an estimated 42 million users worldwide (and the US has the vast majority of users) then this means even at now-800 cases, it still amounts to a risk of 0.0019%--or about 1 case for every 52,500 users. So the message: it's ultimately safer to not vape, but it's pretty safe compared to tobacco smoking, in which the numbers look much worse (I've noticed that acute pneumonias related to tobacco use haven't been mentioned in any of the press coverage!)

Interested in a longer discussion? From CBS News with public health expert David Abrams I share this video.

A Final Word

This article is not intended as medical advice, as all of my articles are educational in nature. If you vape and notice chest pain, increasing shortness of breath, or you require additional assistance, seek medical advice from your own provider. 

Friday, September 20, 2019

Herbs and Nutritionals Series: Medical Cannabis

"What do you think about CBD?" 
Photo by Sharon McCutcheon on Unsplash

This question comes up for me pretty much every week for me now. CBD--cannabidiol (CAN-uh-bi-DI-all)--is a chemical found in varieties of hemp or cannabis, the two plant names are essentially interchangable. Cannabis comes in three major species: sativa, indica, and ruderalis. The first two are the varieties that are most famously associated with their use for their mind-altering properties; the ruderalis--and not all botanists agree that it's a separate species--has not been subject to cultivation and selective breeding. It's considered "wild" cannabis, although even these are beginning to be bred by some cannabis horticulturists.

"Hemp"--a casual term for the plant--has come to specifically refer to industrial hemp grown for fiber that can be used in fabric, paper-making, and other consumer products. The species isn't as important as the strain of species when considering what a cannabis plant is to be used for. It's selective breeding that drives the end product in cannabis farming. This means that the Cannabis sativa grown in Iowa for fiber might be tall, with light foliage, few flowers, strong fibers, and almost none of the chemicals that make people "high." On the other hand, the C. sativa grown at a recreational marijuana farm in Washington State could be shorter, leafy, with plentiful, resinous flowers saturated with those chemicals. C. indica and C. ruderalis are shorter and less desirable as a source of industrial fiber, and so these are not bred for any purpose other than the psychoactive chemicals that people find desirable for medical or recreational use.
Industrial Hemp. Note the long, thin stems and lack of
significant flowers. Photo: "Valyxyz" on Pixabay
Psychoactive marijuana. Shorter, bushier, with many
resinous flowers. Photo: "futurefilmworks" on Pixabay

So it's breeding and strain that determines what's in a batch of marijuana. This has become a big business! Hundreds of nurseries, farms, growers, labs, and marketers form a new industry catering to both medical and recreational marijuana. So today I'll share a few points that my readers might find useful.

The chemicals that cause users to feel high are tetrahydrocannabinols (tet-ra-HYDRO-can-NA-bin-alls) or "THCs", mainly THC-9, and a lesser amount of THC-8. THCs resemble a naturally occurring brain chemical, or "neurotransmitter", called anandamide (ah-NAN-dah-mide), which comes from the Sanskrit word for "pleasure"--so it should come as no surprise that marijuana is something many people find pleasurable!

But activating anandamide circuits in the brain also comes with some sensations that some people find uncomfortable: It can raise emotional arousal, so it can feel like anxiety to some. It alters processing of sound and vision to a small extent, and while some find these experiences fun (or at least not bothersome), others can find the experience weird and unpleasant. So as I tell my pharmacology students: any drug that affects the mind can have unintended effects on susceptible brains. The THC in cannabis is no different. In some ways, psychiatric drugs and homeopathy are the same--one size never fits all!

There are several other psychoactive chemicals in marijuana. I won't go into all of them here, but the talk of the town these days is CBD.

CBD is a sedative, for the most part. It quiets the nervous system, which is why it was originally legalized in Pennsylvania, after parents of children with intractable seizures testified to the legislature. Since legalization in 2016, regulations have been developed and medical dispensaries have sprung up. To get it, a person has to be diagnosed with one of 21 medical conditions and see a PA-licensed physician who is authorized to write a recommendation letter for marijuana--so not all providers are in that program. The dispensaries distribute products in various forms (edibles, oils, resins, flowers, etc.) that contain various ratios of THC and CBD.

The other chemicals are usually not listed but are also less directly related to the therapeutic effects most people are aware of. More on this later.

Industrial hemp also contains varying amounts of CBD, and because it doesn't contain any significant THC, CBD is being sold--legally as far as everyone's concerned--in hemp oil-based products. So basically we have two industries: a highly regulated medical marijuana supply system that starts with a visit to a PA-licensed physician who is on the state's provider registry, and allows access to quality-validated, marijuana-derived products that contain various amounts of THC and CBD. And we have an unregulated, hemp oil supply system that starts with a visit to an online or local retailer--or even just a 7-Eleven! In this system let the buyer beware.

In my next installment, I'll talk about what CBD does, and a bit about some of the other features of medical marijuana that have effects on health and well-being.