Medical Cannabis State and Federal Regulations: Implications for United States Health Care Entities

Cannabis use before and after metabolic and bariatric surgery: literature review

As accessibility and legalization of cannabis rise throughout the United States (US), programs have sought guidance about whether its use should be considered a contraindication or, if not a contraindication, what recommendations patients should receive regarding appropriate use before and after metabolic and bariatric surgery (MBS). In this review, medical, nutritional, pharmacological, and psychological considerations are presented by a multidisciplinary group of members of the American Society for Metabolic and Bariatric Surgery (ASMBS). Research suggests several risks associated with long-term cannabis use in the general population, but research in the MBS population, specifically, is limited. Cannabis use is not associated with most postoperative complications but is associated with mental health concerns and disordered eating in patients who have undergone MBS. Research regarding weight loss outcomes is mixed, with most studies showing no significant association. Severe cannabis use appears to have more clinical significance than mild to moderate use, as it is associated with longer lengths of stay and medical complications. While an active cannabis use disorder is considered a contraindication, requiring treatment and abstinence before proceeding with surgery, the state of the literature is not strong enough to suggest that occasional or medical cannabis use is an absolute contraindication to MBS. Decisions about cannabis protocols should be made at the MBS program level, and patients should be fully informed about the risks of ongoing use.

The Risk of Ventricular Septal Defects Associated With Prenatal Marijuana Exposure: A Systematic Review and Meta-Analysis

With the recent legalization of marijuana across the United States, its usage in pregnant women has increased. The aim of this meta-analysis was to determine if prenatal marijuana use increases the likelihood of ventricular septal defects. The analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The search strategy identified 4 case-control studies that were ultimately included in the analysis with a combined 381,621 infant records. Quantitative analysis demonstrated prenatal marijuana usage significantly increases the likelihood of ventricular septal defects (odds ratio = 2.39, 95% confidence interval = 1.11-5.18).

Marijuana Use, Vaping, and Preoperative Anesthetic and Surgical Considerations in Clinical Practice

In recent years, marijuana and vaping have acquired widespread popularity, with millions of people using them for a variety of reasons, including recreational purposes. However, these practices have often overlooked the implications on surgery and the preoperative anesthesia considerations. Marijuana can influence a patient's response to anesthesia, alter postoperative pain management, and increase the risk of complications, whereas vaping can have negative effects on the respiratory system and hinder the body's ability to recover after surgery.

Attitudes of Swiss psychiatrists towards cannabis regulation and medical use in psychiatry: a cross-sectional study

BACKGROUND

Changes in regulation for cannabis for nonmedical use (CNMU) are underway worldwide. Switzerland amended the law in 2021 allowing pilot trials evaluating regulative models for cannabis production and distribution. Simultaneously, cannabis for medical use (CMU) in psychiatry is a growing issue, asked for by patients and being discussed by medical professionals.

METHODS

From December 2021 to February 2022, we conducted an online survey of psychiatrists in Switzerland. The survey comprised questions on attitudes towards regulative models for CNMU and towards prescribing CMU for mental disorders.

RESULTS

We contacted 2010 psychiatrists in Switzerland. A total of 274 (14%) participated in the survey. Sixty-four percent agreed to a regulated legalization of CNMU, and 89% would welcome pilot trials in Switzerland assessing models for regulating CNMU with those from a French-speaking region being more skeptical. Forty-nine percent of psychiatrists agree that CMU might have a therapeutic effect in mental disorders, but 50% agree that there is not enough scientific evidence yet. Participants working in an inpatient setting or in a French-speaking region as well as those with a longer duration of practice were more skeptical on CMU for mental health.

CONCLUSIONS

Most surveyed Swiss psychiatrists favor the regulation of CNMU and the conduct of pilot trials. Despite little evidence and potential negative consequences, many participating Swiss psychiatrists agreed that cannabis could be efficacious in the treatment of some mental disorders advocating for more research in this topic.

How Are Patients Who Legally Use Medical Marijuana Treated When Hospitalized?

The majority of U.S. states have legalized marijuana for medical use and some states have legalized marijuana for recreational use; yet, marijuana remains illegal federally. Given the misalignment between state and federal policies, this paper seeks to explore how hospitals handle inpatients' medical marijuana use in states where medical marijuana is legal. To examine this phenomenon, we conducted an anonymous, online, cross-sectional survey of nurse leaders working in acute care inpatient settings in states that had legalized medical marijuana. Using descriptive statistics, we report on these nurse leaders' experiences. There were 811 survey responses-291 who worked in an acute care inpatient setting in a state that had legalized medical marijuana. Among those respondents, only a small percentage reported that inpatients had some access to their medical marijuana: 5.8% reported that the drug was kept in the pharmacy and dispensed like other prescriptions; another 3.4% indicated that patients kept the medical marijuana in their rooms and took it, as needed. Most respondents (55.6%) reported that patients were switched to an alternative medication during their inpatient hospital stays. Almost half (49.4%) of the nurse leaders who reported that alternative medications were used, reported that opioids were substituted, and the majority reported that the marijuana was safer than the opioids. These findings are concerning given the increase in opioid overdose deaths.

Argentination: A Silver Bullet for Cannabinoid Separation by Differential Mobility Spectrometry

As the legality of cannabis continues to evolve globally, there is a growing demand for methods that can accurately quantitate cannabinoids found in commercial products. However, the isobaric nature of many cannabinoids, along with variations in extraction methods and product formulations, makes cannabinoid quantitation by mass spectrometry (MS) challenging. Here, we demonstrate that differential mobility spectrometry (DMS) and tandem-MS can distinguish a set of seven cannabinoids, five of which are isobaric: Δ⁹-tetrahydrocannabinol (Δ⁹-THC), Δ⁸-THC, exo-THC, cannabidiol, cannabichromene, cannabinol, and cannabigerol. Analytes were detected as argentinated species ([M + Ag]⁺), which, when subjected to collision-induced dissociation, led to the unexpected discovery that argentination promotes distinct fragmentation patterns for each cannabinoid. The unique fragment ions formed were rationalized by discerning fragmentation mechanisms that follow each cannabinoid's MS³ behavior. The differing fragmentation behaviors between species suggest that argentination can distinguish cannabinoids by tandem-MS, although not quantitatively as some cannabinoids produce small amounts of a fragment ion that is isobaric with the major fragment generated by another cannabinoid. By adding DMS to the tandem-MS workflow, it becomes possible to resolve each cannabinoid in a pure N₂ environment by deconvoluting the contribution of each cannabinoid to a specific fragmentation channel. To this end, we used DMS in conjunction with a multiple reaction monitoring workflow to assess cannabinoid levels in two cannabis extracts. Our methodology exhibited excellent accuracy, limits of detection (10-20 ppb depending on the cannabinoid), and linearity during quantitation by standard addition (R² > 0.99).

Cannabinoids as a Potential Alternative to Opioids in the Management of Various Pain Subtypes: Benefits, Limitations, and Risks

INTRODUCTION

Pain is a global phenomenon encompassing many subtypes that include neuropathic, musculoskeletal, acute postoperative, cancer, and geriatric pain. Traditionally, opioids have been a mainstay pharmacological agent for managing many types of pain. However, opioids have been a subject of controversy with increased addiction, fatality rates, and cost burden on the US healthcare system. Cannabinoids have emerged as a potentially favorable alternative or adjunctive treatment for various types of acute and chronic pain. This narrative review seeks to describe the efficacy, risks, and benefits of cannabinoids as an adjunct or even potential replacement for opioids in the treatment of various subtypes of pain.

METHODS

In June of 2022, we performed a comprehensive search across multiple databases for English-language studies related to the use of cannabinoids in the treatment of various types pain: neuropathic pain, musculoskeletal pain, acute postoperative pain, cancer pain, and geriatric pain. Data from meta-analyses, systematic reviews, and randomized control trials (RCTs) were prioritized for reporting. We sought to focus our reported analysis on more recent literature as well as include older relevant studies with particularly notable findings.

RESULTS

There is conflicting evidence for the use of cannabinoids in the management of pain. While cannabinoids have shown efficacy in treating specific chronic pain subtypes such as neuropathic pain, fibromyalgia pain, and geriatric pain, they do not show as clear benefit in acute postoperative and the majority of musculoskeletal pain syndromes. Data trends towards cannabinoids having a positive effect in treating cancer pain, but results are not as conclusive. To date, there is a paucity of data comparing cannabinoids directly to opioids for pain relief. Overall, the side effects of cannabinoids appear to be relatively mild. However, there is still potential for addiction, altered brain development, psychiatric comorbidities, and drug-drug interactions.

CONCLUSION

Cannabinoids may be effective in specific subtypes of pain, but current evidence and guidelines do not yet support its use as the first-line treatment for any type of acute or chronic pain. Rather, it may be considered a good adjunct or alternative for patients who have failed more typical or conservative measures. Additional studies are needed with standardized forms of cannabinoids, route of delivery, and dosing for greater-powered analysis. Providers must weigh the individualized patient risks, benefits, and concurrent medication list in order to determine whether cannabinoids are appropriate for a patient's pain treatment plan.

Kratom-Associated Mixed Cholestatic-Hepatocellular Liver Injury in a Patient With Long COVID: A case Report

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Herbal Cannabis Use Is Not Associated with Changes in Levels of Endocannabinoids and Metabolic Profile Alterations among Older Adults

Simple Summary

The endocannabinoid system is a complex cell-signaling system that has numerous effects on the human body, including on the heart, blood vessels, and metabolism. In this study, we aimed to assess the effects of exogenous herbal medical cannabis use on the components of the endocannabinoid system among older adults with a diagnosis of hypertension. Medical cannabis is a product containing cannabinoids used for medical purposes. Herbal cannabis contains many types of cannabinoids, the most well-known of which are Δ⁹-tetrahydrocannabinol and cannabidiol. We followed people aged 60 years and older and conducted a number of tests, including endocannabinoids levels, before they started using cannabis and following three months of daily cannabis treatment. Fifteen patients (53.3% male; mean age, 69.5 years) underwent complete evaluations. We found positive correlations between the components of the endocannabinoid system and blood lipids, markers of inflammation, and blood pressure. On average, cannabis treatment for 3 months does not result in a significant change in the levels of endogenous cannabinoids and thus has a safe metabolic risk profile. This study provides additional evidence for the safety of medical cannabis use among older adults.

Abstract

Activation of the endocannabinoid system has various cardiovascular and metabolic expressions, including increased lipogenesis, decreased blood pressure, increased heart rate, and changes in cholesterol levels. There is a scarcity of data on the metabolic effects of exogenous cannabis in older adults; therefore, we aimed to assess the effect of exogenous cannabis on endocannabinoid levels and the association with changes in 24 h ambulatory blood pressure and lipid levels. We conducted a prospective study of patients aged 60 years or more with hypertension treated with a new prescription of herbal cannabis. We assessed changes in endocannabinoids, blood pressure, and metabolic parameters prior to and following three months of cannabis use. Fifteen patients with a mean age of 69.47 ± 5.83 years (53.3% male) underwent complete evaluations. Changes in 2-arachidonoylglycerol, an endocannabinoid, were significantly positively correlated with changes in triglycerides. Changes in arachidonic acid levels were significantly positively correlated with changes in C-reactive protein and with changes in mean diastolic blood pressure. Exogenous consumption of cannabidiol was negatively correlated with endogenous levels of palmitoylethanolamide and oleoylethanolamide. On average, cannabis treatment for 3 months does not result in a significant change in the levels of endogenous cannabinoids and thus has a safe metabolic risk profile.

Medical Marijuana Use for Cancer-Related Symptoms among Floridians: A Descriptive Study

Background: Thirty-six states, including Florida, have legalized marijuana for medical and/or recreational use, yet how it is used and perceived by persons with cancer is not well understood. Objectives: The purpose of this study was to identify patterns of use, perceived benefits, and side effects of medical marijuana (MMJ) among cancer patients in Florida. Methods: For this descriptive, cross-sectional study, anyone residing within the state of Florida who was diagnosed or treated for a malignancy within the last five years and had used MMJ was eligible. An online survey containing questions about dosing, side effects, perceived benefits, and barriers to use was used. Descriptive statistics including frequencies, percentages, means, and standard deviations were used to analyze quantitative data. Responses to open-ended questions were coded and categorized. Results: Sleep (n = 112), pain (n = 96), and anxiety (n = 82) were the most common symptoms participants used MMJ to relieve and overall felt it was highly effective. MMJ was well tolerated with a minority (10.3%) reporting any adverse effects. Cost was the most frequent barrier reported by participants (42.8%). A variety of legal, bureaucratic, and system-related barriers were described. Conclusion: Participants perceived MMJ to be helpful in alleviating cancer symptoms. They held negative perceptions of the way MMJ is implemented and integrated into their oncology treatment plan. Enhanced communication and patient/provider education on MMJ are needed to inform patient decision making.